Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Everyone. Welcome back. Pivoting away from VFR and a couple of people want to speak to these sections, we have Chelsea Lewis.

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: Hey, wonderful to be here. Chelsea Bardo Lewis, Executive Director of Vermont Businesses for Social Responsibility. I think most of you know BBSR, although don't probably know me. I started my career here in Vermont about fifteen years ago, working across the street at the Agency of Agriculture. So I spent lots of time in this building, but never with this committee. So great to meet you. GBSR is a business membership association, comprised of business leaders who are working to align their business with their values. Our vision is a just thriving economy that works for all people in the planet. And I think, like the commissioner, we are just trying to figure out what tools in the toolbox we can put into play for our members. I know you've heard from many of your constituents about the challenges of this particular moment. And we certainly are hearing from many of our members of all scales and sizes about the child keep in health care right now. So thank you for taking those on. BBSR did have an AHP that we offered many years successfully. Had many of our members join BBSR because of the AHP. And in 2018, we actually gave it up before we were required to because, as was alluded to earlier, we advocated for the ACA, and we wanted people to be in the big pool. And our members employ 43% of the working population in the state. We wanted them to be in the pool. I think I fear not as an expert in health care policy, but just to roll up my sleeves alongside all of you and be part of this conversation about what we can do in this moment and a positive VFR for being in the same boat, that there's no silver bullet right now. To the point about volatility, it is already here. I was in a different committee and they were saying, well, we're hearing the commercial premiums are actually stabilized right now. We have members who did go self fully insured, self insured and self funded plans. And this year, they're seeing up to 48% increases in their premiums through Cigna. So they're looking for what can work so that businesses aren't paying for a health care system out of their margins is, I think, the conversation we're having today. I do want to double click on the notion of how what we want is for everyone to be covered. And particularly now that we have enhanced tax credits off the table, I know that we have many of our members and members of employees who are not covered right now. This includes our solopreneurs, which are really the backbone of Vermont's gig economy. People who, like my friend Lisa Mason down in Mooredown, who runs Fiddlehead Cuisine. She and her husband are both self employed. That self employed sector of our economy is so integral in Vermont. Lisa told me their premiums are going from $400 a month to $1,600 a month. And they have two kids. So it's not a choice between which plan. It's a choice between not being covered and not being covered. So our solopreneurs are struggling. We have small employers. I really want to point to the hospitality and restaurant sector right now, which is struggling on so many fronts. They have not traditionally many of those employers have not traditionally offered health insurance packages because until very recently, something on the exchange was better than something that a restaurant with restaurant margins was able to offer. Now, again, because of the economics of losing the enhanced tax premium credits, their employees are leaving even at a greater rate than they were previously so that they can go to an employer where they can get health benefits. I think that is the type of business that I think if they had something that they could access through an association health plan or another mechanism that was somehow either offered customized benefits or was less expensive than the exchange, it may make the difference between them being able to say, yes, let's offer some level of benefits so that our employees are covered so that we can retain employees in the restaurant sector, which is so important to Vermont stores in the economy, or not being covered at all. So the other thing that I did just want to touch on is that likely, as the federal law stands now, VBSR would not be eligible to offer an association health plan because we wouldn't pass the commonality test, which is what was referenced earlier. In order for an association to offer an AHP, the members have to be sufficiently pass a commonality standard. Our businesses are from all different sectors, all different parts of the state, very small to very large. So we likely wouldn't qualify for what's called the Pathway I under the Affordable Care Act. So I am, again, interested in what the opportunity might be for us to be part

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: of the

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: solution. But as it stands today, we would not be eligible from our meeting and understanding to offer this.

[Alyssa Black (Chair)]: Any questions? Just about a minute. We're we're in the bill to address this. Would this change help you? I guess is what I'm thinking about.

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: Yes. As I so this bill, although it would it

[Alyssa Black (Chair)]: it

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: allows Associations who would pass the requirement, the federal requirements to offer health insurance. So if it was an association that had that passed that commonality test. From a very similar sector, then it would allow them to offer an AHV.

[Alyssa Black (Chair)]: Is that federal or us? That's federal. The commonality test. We can't change that.

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: Changing this would allow those associations who do qualify to operate.

[Alyssa Black (Chair)]: Thank you. I'm thinking about just a couple of things that you said regarding So one thing that we know is that employers have been leaving the QHP market, the small group market, for self insured. And I would argue that, no, the rates are not stabilized left in the QHP market. Although this past year, we were able to hold them down in a lot of ways from some things that we levers we were able to pull around this committee table. But, I mean, one thing that we do understand is that around this table, we have very, very a very, very small part of the market that we can actually have levers to pull to stabilize. And the more that leave, those become more vulnerable to things like a 43% increase. And it seems to me by expanding association health plans, we're now taking an even greater number of people out of the market. You said how many members?

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: Our members employ 43% of the state's employment base.

[Alyssa Black (Chair)]: Okay. Actually, as a whole. Yes. And We would then have no control over the plans that they have, the contracts that they have with providers, which oftentimes shifts onto who's left, that 57% that's left in the QHP market. Don't know. Do I have a question on this? You said that the mission of your organization is a just thriving economy. This doesn't seem just. Our

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: position has always been to have more people covered. And I think the analysis is, is there a path for an association to offer something to members that would have people who are currently not covered at all to be able

[Alyssa Black (Chair)]: to afford something? And I guess the other thing that I would mention is that, yes, the enhanced tax credits did expire. However, if they are ever put back in place, these people are now offered coverage through their employer and would have no mechanism to be able to go and get those back. And then they would be at an even higher cost insurance. So by offering insurance, you're locking your employees into taking that insurance. So if things do become extended, and there is a bill, I mean, there is a three year extension that passed the House and is sitting in the Senate right now, not this House or Senate. So if something happened with that, those people no longer would be able to get that benefit.

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: We were helping our members through in November. Should we try to offer something? Is this going to help our employees? Is it not? What our members want is for their employees to have health insurance coverage. And the volatility right now is making it incredibly Lori? Okay. Thanks. Keep using

[Alyssa Black (Chair)]: volatility. Maybe I'm the one that mentioned it.

[Mike Fisher, Chief Health Care Advocate]: Mary

[Alyssa Black (Chair)]: Black? Yes. Go ahead, Mary. Yes,

[Mary Black, Department of Financial Regulation]: please. Mary Black from the Department of Financial Regulation. Just to be clear, AHP rates are reviewed by the Green Mountain Care Board, and the forms and policies are reviewed by DFR. So it doesn't take them completely out of our regulatory control. It just takes them out of the exchange.

[Alyssa Black (Chair)]: Yes. Except the things that we do around this cable have an effect on the exchange rates. The policies we put in place over prices, those really just some of them affect just the QHP market.

[Mary Black, Department of Financial Regulation]: Yes. Some of them do, but a lot because these are rates and forms that are still governed by us, a lot of the things you do around this table still affect them. Yeah. So It's a little bit different. It's not self insured where it's completely out of our hands.

[Alyssa Black (Chair)]: Okay. Thanks for the clarification. I appreciate that. Any other questions? Thank you. Thank you. Thank you. Thank you.

[Emma Paradise, Incoming Co-Director, Common Good Vermont]: Morning, committee. For the record, my name is Emma Paradise, and I'm with Common Good Vermont, the incoming co director. It's great to be here. I think this is my first time in your committee, so appreciate the opportunity to testify on page five eighty five in accolating to health insurance reforms, specifically on the section regarding expanding access to association health plans. For those who are not familiar, Common Good Vermont is a statewide statewide program of United Way of Northwest Vermont dedicated to advocating for, uniting, and strengthening Vermont's nonprofit sector. As of January 1, we're also the state association for Vermont's nonprofits, representing 200 members at the end of the year. Common Good Vermont is deeply invested in ensuring that health insurance markets are accessible, affordable, and equitable for nonprofits that rely on stable benefits to recruit and retain staff. In the face of rapidly rising health insurance costs, association health plans could potentially provide much needed relief for nonprofit employers and expand benefits to employees. However, while we support the expansion of AHPs in Vermont, we do feel strongly that appropriate guardrails need to be in place. Currently, of our members are small to medium sized organizations, with 55% having annual budgets under $500,000 These organizations range from being volunteer run to small teams of four to five staff, which are probably not the primary demographic for an association plan, as most do not currently offer health insurance benefit. But some of those on the larger end may be more likely to. And if a more affordable option came available, they may be able to offer those benefits in the future. Midsize organizations make up about 37% of our membership, and these have budgets between 500,000 and 5,000,000. And these organizations have more employees and are more likely to offer health insurance already, making them a prime audience for the association plan. And then approximately 9% of our members have budgets over 5,000,000, and these probably are more likely to manage their own benefits and spend more on benefits as a percent of wages than smaller organizations. But regardless of size, managing health insurance costs is a top priority for Vermont's nonprofits. For those who do provide insurance, it's a driving cost. For organizations participating in our 2024 wages and benefits survey, about 94% reported premium increases, and that's compared to 52% in 2022. So a really significant increase there. These increases were absorbed by employers and employees, and in some cases, mitigated by higher deductibles or decreased coverage. We are concerned that after seeing years of growth in the percent of organizations offering health insurance, 2024 showed a 2% decline, which may indicate emerging downward trend. For those who don't offer health insurance due to cost being a barrier, this can make recruitment and retention really difficult. And we're also seeing more organizations look for alternative arrangements like ICHRAs. And in both of these cases, the expiration of the ACA subsidies are going to have a really negative impact on both employers and employees. So no matter where you stand, health insurance costs are hurting our workforce and forcing skilled, mission driven workers to choose between a career supporting healthy communities and their family's health. As such, goods see expanding access to association plans as a real opportunity with the potential to provide affordable benefits and predictability to nonprofits and their employees in the face of a broken system. There's also the potential to reduce administrative burdens for small organizations through a shared system. We have seen associations in other states, such as Together South Carolina, have success with AHP's. And there's testimonials from their members on their website, including one from the United Way of Greenville County, who shares that in 2022, we joined Together South Carolina Association plans, saving $50,000 annually while gaining access to high quality benefits alongside nonprofits across South Carolina. This collaboration has strengthened our ability to support our team while keeping costs manageable. As early adopters of the Together South Carolina AHP, we're proud to show how nonprofits can leverage collective strength to create lasting impact for teens and our communities. However, we also urge caution. The Rural Suttering Association plans exist to protect against adverse selection, ensure fair market competition, and avoid situations where Vermonters are segmented into uneven risk pools that may raise costs for some or reduce benefits for others. You have to consider how association plans will impact the quality of benefits, organizations and nonprofit employees not covered by the AHP, and Vermonters at large. Recognizing that expanding AHPs is only one of the proposals in this bill, we really must look at the full picture when evaluating how these changes will affect the overall stability of the market. And then there are also questions about what cost savings would be achievable, given Vermont's small scale, and our demographics. So while nonprofits employ one in five Vermont workers, the vast majority of organizations are small, 68% of budgets under 100,000. And so with these considerations in mind, we would recommend that there be clear guidance and disclosure requirements to ensure that nonprofits understand the difference between the different options available to them for health care. That we require annual reporting on AHP enrollment, premiums and benefit design, and that we ensure parity in essential health benefits so that nonprofit workers are not offered substandard coverage. We see these recommendations as key to creating conditions that support the successful responsible expansion of AHP's while mitigating unintended consequences. With the proper guardrails in place, we're optimistic that the proposed expansion of AHP's could provide much needed relief for Vermont's nonprofit workforce and would support the committee exploring this further.

[Alyssa Black (Chair)]: I have a question which I should have asked Mary or Kai, but I will ask both you and Chelsea. We're making an assumption that somehow association health plans are cheaper, cost less. Do we have any evidence of that? I mean, realizing that we don't have them here in the state of Vermont, do we have the equivalent for other states and how those other states' costs compare to what their qualified health plans would be cost wise? I think we're making this big assumption that this is going to do we have any evidence that this will save associations any money whatsoever? We've Go ahead.

[Emma Paradise, Incoming Co-Director, Common Good Vermont]: What we've seen, at least from some of our partners in other states, there's nonprofit associations across the country. And those where they are allowed, at least the couple that I've talked to anecdotally, have seen cost savings largely from being able to have negotiating power. And then some have also mentioned that insurers might be more likely to underwrite them just because they don't want to deal with so many small non profits, which is administratively of more burdens on them.

[Alyssa Black (Chair)]: And I think the same question applies to the question applies to the self insured market right now. Do we have any idea if this, how much? Yeah, please. They

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: wouldn't do it if they weren't safe. Well, was a private question after the last testimony by Samson, Commissioner of Financial Regulation. I think the key point is to have that option and allow businesses and nonprofits to make a decision if the option is better for them. The thriving self insured market tells you that between better control over benefits offered and savings that yes, there is savings there. The AHP option from our perspective and making these proposals, at least put the option there and then it's up to the non profits or the organizations to say, hey would this work for us or not? And if it does and there's savings and it's not only about savings, it can be about benefit flexibility as well. But I do think certainly in the self insured realm, popularity of that option is not because it's more expensive.

[Alyssa Black (Chair)]: Do we have options of changing plans, expanding plans in the QHP market to have more options for people to choose from that might be more affordable, that would mirror, do we have options of, I hate throwing this out there on the table, but are there things that we cover in our benchmark plan that maybe we should be looking at whether we should still be covering them. Have we thought about these things?

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: If I can continue Yes, that, we should be thinking about that. Well, a benefit set is just as much not a win win as anything we're talking about and also but that is a driver of cost and I would say that if I wasn't persuasive enough age rating does provide some options for folks to stay in and afford rather than doing self insured or AHP. Is a real impact there. Again it's better online when you look at why an organization wants to join other organizations in AHP or why an organization wants to go self insured, it's some combination of benefit design and savings in terms of their risk characteristics. The age rating proposal we have better aligns the risk characteristics of the age cohort of our population with their premium.

[Alyssa Black (Chair)]: Any questions? Thank you Emma. You. Send us your materials. Much appreciated, thank you. Ever so helpful when a few weeks later you're like, what did she say? What did she say? Hi, Megan. Thanks for joining us.

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: Good morning. Still morning. Good morning. Megan Sullivan, Vice President of Government Affairs for the Vermont Chamber of Commerce. Thank you for having me in today. I will say I only prepared testimony on association health plans, not on the other two components that were reviewed today. Happy to look at if we want to add comments to those another time. So our president, Amy Spear, presented at the all member briefing on what Vermont businesses are facing in health care. That, I think, is the only time where we were told, only talk about the problem. We don't want to hear about solutions right now. So it was a glimmering time of saying, we're not at the table for solutions. We're just talking about the problem. And I'm sure you have all heard from your constituents about how challenging the health care market in Vermont is right now. I actually got a message from a member today whose business provides behavioral intervention services for kids on the autism spectrum, a critical business for Vermonters who just said, well, there goes another employee because of health care. Our businesses, especially on the border of New Hampshire, are really feeling pain. And our employers that rely on out of state remote workers, because we just don't have the people here to fill the jobs, are saying, because of health care, we cannot keep employees if we rely on people coming from other states. And so it's a matter of how are we dealing with the costs. The The work that you all did last year was monumental. We choose to get done in one session. And we are so appreciative of the impact that it immediately had on bringing rates down. We know that you are continuing to look at all of the options. We're looking at association health plans not as a silver bullet to fix what's going on in health care. But I think we can also acknowledge that it wasn't the thing that made our markets volatile either. When those went away in 2013, Vermont's health care did not become more affordable. They came back in 2018, and then went away again in 2019. Vermont's health care did not become more affordable. To the point of bringing more people out of the market, people are already leaving that market. We're seeing people move to self insurance products because it offers a lower rate but higher risk. And we're also seeing our entrepreneurs, our solopreneurs so not employers, but non employer businesses, of which Vermont is we're tied with Montana for the most solopreneurs in the nation. 15.7% of our businesses don't have any employees here. And they are hit incredibly hard, especially we know everyone is hit because of the loss of subsidies. But folks in this category are making really hard decisions to go without insurance for themselves, for their families. In 2019, Vermont Chamber, through our organization that we work with, 32 other chambers in the state called BASE, there's two BASEs. One has two Cs. One has one C. They're both related to these operants. They saw about 1,000 people join. So when this came back on, we got to work when the federal government said you can have association health plans again. Got to work, got this set up. About 1,000 people joined that. So that was 1,000 people coming in. 20%, or I should say, overall in all of the association health plans that came on board in 2018, there were about 1,000 lives covered under that. 20 weren't coming from the exchange. And so that was a time when I think we aren't seeing as many individuals leave individual coverage and don't see as many small businesses going into the shelf insurance. I would expect that if we brought this back online, that number would likely be higher of businesses that we see moving from self insurance into a plan, individuals, those non employer businesses moving into a product that they can hopefully afford. And we don't know what the plans will be offering. That's certainly something. If we get some indication that, yes, this committee would like to know more about that, we are more than willing to jump in and have those conversations with carriers to say, if this was to come back, what type of plan again, you're under DFR regulation.

[Alyssa Black (Chair)]: What could it look like?

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: Could we be offering something that incentivizes the members who are using these plans to go to some of the lower cost providers, the work that Blue Cross is doing to indicate to people what is the cost of going for care here versus here? Is there incentives that could say, we're going to help you make those choices, see what those costs are up front? So there could be flexibility in that. I understand the concerns of taking more people out of the market. But I think the crisis that we're facing right now is that people are leaving that market anyways. We need to examine all of the tools to figure out how we can address this. Because businesses are leaving the state. Employees are choosing not to work here. We can't fix everything with one solution. And so looking at how do we bring in as many tools as possible is something we know you've been doing and we support. And we think this is one of those tools that could be helpful. Totally

[Rep. Lori Houghton (Member)]: appreciate where the businesses are coming from. As you know, we have a small business, and we don't provide health care. And appreciate that you said we need all the tools on the table. What we don't have on the table is a tool for helping all the individuals who are left behind who don't have the opportunity to join one of these other things we may be creating, and their costs now skyrocket. So I'm curious if all the stakeholders in the business community have thought about any tools for that population that we would negatively impact.

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: I am happy to be part of that conversation. Mike Fisher would like to have me there, happy to jump in to say, obviously, our focus is how do we support our members. That's where they join us. But I think we've shown conversations, whether it's around housing

[Mike Fisher, Chief Health Care Advocate]: or

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: employment laws, we want to be part of the conversation. We fully see the spectrum of Limoners that need help. And our members want us to be there for that. So as previous witnesses said, I'm not a health care expert, but I'm also always willing to be at the table. And I think later this afternoon, I'll be at the Healthcare Transformation Task Force. So think we have a good group talking about it there, too.

[Alyssa Black (Chair)]: And maybe more of a statement than a question. The recurring theme is that everybody wants to do something because it has become unsustainable. But maybe the focus should be on, again, cost of care. And if we can get the cost of care in, if we can rein in the cost of care, then we don't have these other issues and it feels like we're pulling it feels like we're rearranging deck chairs, And I I really appreciate you talking about how small businesses are struggling with this. I also have a small business where we are not able to afford to provide healthcare. Keeps me up at night, my guys who have no health insurance. And I'm pretty sure it's Chair Foster who's made this point, is that this is killing our high cost of healthcare is killing our communities. Cannibalizing us. Cannibalizing. What's this word? Families are not moving here. Families cannot fight. Housing can move here, healthcare workforce cannot even afford the cost of healthcare. And I just feel like we need to be really concentrating on reining in the cost of care for everybody instead of cannibalizing the market and shifting to those that are left behind that have no choice and their costs are going to skyrocket.

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: And we support, appreciate, and are at the table for how we rein in care. And with the analogy of rearranging deck chairs, I think the hard work is also happening in the very cold water and trying to fix the boat that is sinking. And I don't necessarily think this is rearranging deck chairs, but just offering some life vests while that work is underway. We need to keep people employed in Vermont, and we need to keep people able to start innovative new businesses here. And I appreciate the pull that that can have in saying, well, if they leave, who's left to take care of these folks? They are leaving anyways, and it's not always in a way that is It's often in a way that's not benefiting them or the state.

[Alyssa Black (Chair)]: I hope everyone does come to the table because we have been talking about the cost of care in this committee for years, and we've done some really significant things. And it would be nice if our entire business community would get on board and help us with that. So we appreciate that we're going to be at the table.

[Mike Fisher, Chief Health Care Advocate]: Do you

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: get our newsletters? We cheering you on for everything you did last year.

[Alyssa Black (Chair)]: We

[Megan Sullivan, Vice President of Government Affairs, Vermont Chamber of Commerce]: appreciate the work that has happened, the work that happened last year, and the

[Alyssa Black (Chair)]: work that people are getting ready to dig into this year. Thank you. Thanks, Megan. Alright, Mike Fisher. Healthcare advocate.

[Mike Fisher, Chief Health Care Advocate]: Good morning, still. Good morning,

[Alyssa Black (Chair)]: Mike Fisher, how's your day going?

[Mike Fisher, Chief Health Care Advocate]: I was thinking as I was sitting down here as I was preparing on the sideline for this that the chair likes to make fun of me for things I got wrong when I sat at the other end of the table.

[Alyssa Black (Chair)]: I do. I love when you're out. Yeah.

[Mike Fisher, Chief Health Care Advocate]: Didn't didn't you do this? And hey, if I'm good at my job as the as an advocate for Vermonters, I should challenge things I did in my previous job. We do make mistakes. Legislators do make mistakes. That's why you come back every year. You have to redo them. But as I look at the proposals in front of you, I'm you know, I I I wanna give them a good you know, run them through their pieces and entertain them and understand the pros and cons, and I think the committee should. But I have I'm having a hard time landing at support of any of the three sections. Let me share my screen. Okay. First, let's see how good I am. Let me first turn on my

[Robert (committee member, full name unknown)]: Did you send this in? No,

[Mike Fisher, Chief Health Care Advocate]: because

[Alyssa Black (Chair)]: Where is Sam, Charlie, or Emma when you

[Mike Fisher, Chief Health Care Advocate]: need them? Because

[Alyssa Black (Chair)]: Okay. This is just my desk. And

[Mike Fisher, Chief Health Care Advocate]: I can pull it together on some slides to look at. But I wanted to do just a little bit of Healthcare 101, just a reminder of something you guys have heard a 100 times before, but just to say it, the distribution of spending across the population varies tremendously. I was making this point the other day. And so when we talk about a population and we use averages, this is 2019, it's incredibly old, it's the entire country, it's MEPS, which is a good data source, But I just wanna drive home the point when we talk about populations that that there's a tremendous amount of variation. And what's wrong with this chart is that this is 50% here. If you really did the whole chart, this line would come all the way out five more bars with next to zero all the way out. And so the game of insurance is to have your pool be healthier and the game of ensuring a whole population is recognizing that this true, that is not variation. Also just to make the point, it's been recently in the news, I think. I think we think about 6,000 people left, 6,600, I think, is the number left the individual group in this past open enrollment period. Even a small number of well sorted people can have a big impact. So I wanted to flash that in front of you. I wanted to flash in front of you one of Nolan's charts to remind us of who we're talking about. I kinda wish this chart had some numbers, Nolan. But just notice the individual group and the small group, and there's been a lot of reference to the self funded group just relative to each other who we're talking. I apologize. I do not have my thoughts really well organized, but I'm gonna muddle through a little bit. So age rating. Who are we talking about who is uninsured? Here is the last household health insurance survey, And I have to be honest, over the last number of years, I'm gonna go right to the page 22. Right to the uninsured section. I have to be honest, last couple of years when I've looked at the household health insurance survey, last couple of surveys, I've been like, okay, we're at three percent. We're kind of bouncing along at three percent for a while. That's probably significantly just the churn in the system. You know, at any given time, there's a certain number of people who are between things. But so I haven't spent a lot of time before today looking at the uninsured. I've been very focused on the underinsured, although the topic would be great to spend some time on. I just thought I would spend just a minute because there were some questions here about, this is just that demonstration of 3% over the last couple of surveys. A little look at who they are by age. I think arguably, you could make the point that this is, you know, the younger group that's that's uninsured. They are male, proportionally male. And they have an interesting distribution by income. There's no 4,000 in this survey. This is a really good survey. This is one of the best surveys we have. It's a representative sample, doing it the same way for a lot of years. I'm a strong advocate of this survey. I think we should do it more often. It's not cheap. I think one thing that was missed in the discussion earlier about relative cost is how those land, how those costs land with respect to premium tax credits. And so if you recognize the 4,400 estimated population who are Medicaid eligible here. So, hey, can't get lower cost than that. That's free. And again, I'm gonna just call it I'm a gonna recognize that some people, you know, are between things. Maybe they just went through a redetermination and they need to reapply, you know, and they they didn't respond and they need to reapply. But I wanted to flash that in front of you, and this is, of course, with enhanced tax credits. This was done this is the '25 report. And recognize the interesting jump in the number of people. It's a smaller percent of the population, but about 400% of the population. Well, they are in the Northeast. But I think that was the main thing I wanted to point out, that in this whole discussion about raising or lowering people's costs, that you have to think about how it affects their premium tax rates. And so, for a very low income person, if you drop their, whatever their age, if you drop their premiums by a little or a lot, it actually has no impact or increased it. Are scenarios where, maybe this is just a little funky, but there are scenarios based on meta level decisions today where you could reduce someone's premium and actually reduce their costs. Say say that again? Reduce their premiums, and therefore and and the the their impact would be could be increased costs to them. That's getting into the weeds about solar loading between metal levels. You know, let's you know, But make no mistake about it. This proposal shifts costs from younger people to older people. And it just sort of invites me to just say something that's been on my mind lately. When we saw the cost of the enhanced tax credits, the $65,000,000 estimated value of the enhanced tax credits, I thought that's just too much for me to come to the legislature and ask for. I know what the budget's like. I know how impossible it is. And then I hear, how much are we thinking about helping property taxpayers? Over I I don't even know what the number is now. 75, and now it's like over 100,000,000. I'm shaking my head a little bit at myself, honestly. The way to help people out is with an income sensitized subsidy.

[Alyssa Black (Chair)]: Just so I'm clear on this, okay, so if we're taking our uninsured population, first of all, of four them are actually eligible for Medicaid, which is no cost. That's an issue. So if we were to decrease, and I think, Commissioner, you indicated that if you're younger, obviously your income is probably more likely to be lower. So theoretically, and we don't have the actual numbers here broken down by age, but if we look at this under this uninsured population, they tend to lean heavily younger male. Their incomes are probably in the realm of under 400% FPL, which still it doesn't have the enhanced premium tax credits, but they still qualify for enhanced premium tax credits under ACA. That if we were to decrease their premium, it is likely that they actually wouldn't see any decrease whatsoever. And at the same time, we would be increasing the premium for the older population who most likely is above 400%, which isn't receiving any tax credit.

[Mike Fisher, Chief Health Care Advocate]: Sir, think the answer is it's tremendously nuanced and will play out very different for children populations. And yes, on average, people have more income when they're older. I know lots of very low income seniors. Sorry, this isn't seniors. They're 65.

[Alyssa Black (Chair)]: Thank you for sharing that. So

[Mike Fisher, Chief Health Care Advocate]: anyway, I think it's just something to weigh, and I just wanted to put this on the table with it. It's true, Vermont and New York are the only ones who have a more pure community rating. If I believe that 5% reduction in costs to younger people would drive a different kind of behavior. And I think I would entertain it. Personally,

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: personally not convinced.

[Mike Fisher, Chief Health Care Advocate]: We're gonna move on to AHD and we'll switch more.

[Alyssa Black (Chair)]: I just wanted to, it's hard to believe that it would drive behavior when you have 4,400 people who qualify for Medicaid. I haven't done that.

[Mike Fisher, Chief Health Care Advocate]: Yeah, and all those people above the road.

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: Yes, of course. I stand

[Mike Fisher, Chief Health Care Advocate]: as a

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: commissioner, DFR, focusing on that, I mean, I'm focusing on 7,400 people above any subsidy level and the underlying fact that was presented that these are younger population. So I guess I'm having a different takeaway and I would also say to the question of what are we doing here in terms of subsidy would eliminate any benefit, the subsidy applies at all ages. And so in my mind, you take that population out of any behavioral calculation you're thinking of because they're insulated you know to different degrees at different poverty levels across the age spectrum. So I'm not claiming that this change serves that population. I'm talking about where the biggest number on that chart is, which is people that never had subsidies and even if passed in that world where they're not significant subsidies, less significant subsidies but they're gone now. That biggest number on that chart has no subsidies.

[Mike Fisher, Chief Health Care Advocate]: I just wanna recognize the second, none of us are prepared for this conversation, so we're figuring it out as we go. The left hand part of the chart is, I think, percent of that population. 2% of the population over 400% of poverty?

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: We'll get 7,400, I'm not sure.

[Mike Fisher, Chief Health Care Advocate]: Yeah, there's also a different group, there's a different number of people. Yes. Okay.

[Alyssa Black (Chair)]: Thank you.

[Mike Fisher, Chief Health Care Advocate]: I wanna talk just for a minute about association health plans and give you a little tiny bit of background. Yes, sat at this table when we promised the association health plan and there was a great uproar about it. I get it why the business community wants to be able to offer them. I get it why everybody is after the best rate they can for themselves. Know, they fix the whole thing, they just need to go survive. I totally make sense and I'm gonna cut everybody's a bunch of slack about that. We, somewhere in my attic is a box of papers that I still have, you don't have this chair, and I'm just remembering, I wish I could find it, a chart that showed the cost of the association health plans when we closed them. And one of the shocking things at that time, in my recollection, is just how expensive some of them were. There were a lot of Vermonters at the time who were spending more than the market or their association health plans. You know, they belonged to a group. You know, I don't know if it was the auto dealers or the chamber or the medical society or businesses for social responsibility or if it was a bunch of them. And they were being told by those groups that this is a big plan, and in many cases they were actually spending more money social media than what the rate became. Asked, I want to just give a little demonstration of sorting. This is not a presentation for a legislator. This is an answer to a healthcare advocate question in the 2024 QHP rate review with Blue Cross. We asked Blue Cross to tell us about three different cohorts of people because we believed we were seeing adverse selection. We believed that we were seeing the small group shrink and that the small group was, and that the sorting between the self funded and the small group was driving up the costs of the small group. And so we asked, you know, the first line cohort one there is just, you know, people who moved from within Blue Cross family from an ASO, from a self funded to a small group, and you can see that the per member per month costs of that group was 882, $883 per member per month. And then the same question in the other direction, who's moving from small group to ASO, and it's $522. So the problem with this chart is it's an incredibly small set of people. You know? 12 groups and 15 groups. Not the kind of thing you make policy about. But when we saw this, we said there's evidence of adverse selection between these two pools, and we and it really ought to be looked at. I think since then, we've seen more and more homely garden.

[Alyssa Black (Chair)]: Can you explain what you mean by adverse selection? And

[Mike Fisher, Chief Health Care Advocate]: I assume you described that a little bit more.

[Alyssa Black (Chair)]: It's a big difference. So

[Mike Fisher, Chief Health Care Advocate]: the people who left the self funded plan and came back to the QHP,

[Alyssa Black (Chair)]: small Same people.

[Mike Fisher, Chief Health Care Advocate]: Were expense, they were on average costing $883 a month. And so you find yourself, somebody said it earlier, somebody, you're self funded, got off at a great rate, go out there and you have a bad year because you have three and eight. One employee with a very, remember that other chart? One employee with a really bad outcome, a really bad illness, and your rates go through the roof. Suddenly your self funded plan, your Cina or whoever, your ex, your spouse, says, okay, next year, race are going through your roof. Here's 12 small groups that made the decision based on that to come back to the QHP. And at the same time, there's 15 other small businesses who looked at what they were offered in the individual, in the self funded world and said, oh, I can save a bunch of money if it's less expensive than the mortgage fee. So we are actively sorting small groups today between these two insurance options. When you give small businesses these kinds of options, they will make reasonable rational choices about how what will cost less for them. And the impact will be that, I think predictably, impact will be more sicker people being left in the small group. And anybody who can get out is gonna get out. So I wanna remind you, this is just part of our advocacy, saying this for years, I'll keep this, you know, in those places where the advocate shouts into the wind and it has no impact, but I'll just say it again, We do get to have an impact on the self funded world because we regulate stop loss insurance. The Department of Financial Regulation regulates loss insurance. And I know that they look at the stop loss rule every couple of years, and I think they're looking at it now. But the the ACA is always gonna advocate for preventing this kind of shopping between pools.

[Alyssa Black (Chair)]: We talk about cohort three there. So that's all of them together. So all of them together, and yet cohort two is dramatically less is the

[Mike Fisher, Chief Health Care Advocate]: The number of groups there.

[Alyssa Black (Chair)]: Yeah. Okay. I'm just wondering if the QHP market is actually subsidizing the self insured in any way? No, no, nevermind, forget it, forget it, forget it. Moving on.

[Mike Fisher, Chief Health Care Advocate]: So I have a very big fear.

[Alyssa Black (Chair)]: Lori, did you have

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: a great sight, sound that I do.

[Mike Fisher, Chief Health Care Advocate]: You're have a very big fear of adding another place for small businesses to shop between, and and I think a a a predictable outcome. Again, remember that chart. If an association The game of insurance is to have a good pool. There's a major, major factor you guys are raising, and I think it's worth looking at about what's covered. That's a big, big factor. But the biggest factor is how, you know, the morbidity of the pool, how sick the pool is. And, you know, Back in the day, insurance, there's all these stories from back in the day of what insurance companies would do in order to have a healthier pool. It's very clear that they can be good at making sure they get a good pool. So I have a lot of fear about the impact of adding an association health plan option. I understand why they want it. I think it'll be bad for the marketplace. Lori?

[Rep. Lori Houghton (Member)]: Question for you, but also general question for everyone in the room. I feel like these ideas are being presented again without any data behind I'm hearing a lot of potential possible from everyone on both sides. And so I'm curious if you have any ideas of how we ascertain with data what the impacts will be.

[Mike Fisher, Chief Health Care Advocate]: Yeah. That's a little bit why I like this this data

[Emma Paradise, Incoming Co-Director, Common Good Vermont]: is different.

[Rep. Lori Houghton (Member)]: Even even that, right, there's different opinions. So it just and I guess this is for the commissioner too. Right? I just we need we need more than potential impossible.

[Mike Fisher, Chief Health Care Advocate]: Yeah.

[Rep. Lori Houghton (Member)]: We need to help Vermonters, and we need to make sure what our impacts are gonna be if we help one group over here and herd a group over here.

[Mike Fisher, Chief Health Care Advocate]: So one thing about data and then one other thing I wanna mention. One thing about data is I heard the commissioner say, I need the actuaries to look at it. And as somebody who spends too much time at the part of my life with actuaries and talking to actuaries, and I hire an actuary myself for some of our work, I have some skepticism about predictive. They don't give us complete answers. They give us ranges, and they often opine on things that they're not experts in applying it. So I just want to give a caution about that. Many people were hearing Susan Glatkowski still representing MVP? I just have this memory of her actuarial pixie dust. Oh, say it is so. That's a Susan Gorkowski bill. So I just wanna It would interesting to see whether there is data from other states. I agree with you. The other thing I wanted to add just because I hadn't said it yet is that it would be interesting to know from the provider's perspective about any possible risks. This is not my world as much. Though consumers get caught up in this as well, when there are multiple different kinds of insurance companies with different, know, more details that vary through the population and providers get caught in more complexity there too.

[Rep. Lori Houghton (Member)]: Go ahead, Lori. And I'm sorry, this is more for the commissioner. If you can provide, I'm just having trouble in my head at time and relate that to the impact of the things we did last year, like reference based pricing. Like a timeline of all the things we're doing or suggesting would be helpful to see and the various things impact Vermonters M and A overlap.

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: Yeah, can, Kai Sanderson, Commissioner of DFR, we can work together with some of our partners at care board and the HS to make a grade of that. In regards to your prior question, we all want data. I feel very strongly in all these big policy questions that we have a bias towards fear of the unknown. Absolutely. Meaning we, and none of these are thoughtless policies, We can't predict the future. I agree with Fisher about actuarial magical powers or the limits to those. And the data that's really driving us where we've been in the last forty years and where we are today. Policies, the approaches show us that we are not on a sustainable path. So I feel very strongly that failure, thank you for entertaining this, failure to entertain this, whether these different options or other options, is acknowledgment that a path we're on is acceptable and it simply is not. So I mean that's something I think regardless of where you fall on these things, have to, we all have to acknowledge the data we do have, is where are premiums now, where are our uninsured now and so on. It's just something, hope that feels like a bit of a pep talk, but it's a pep talk, I'll forgive myself because I prefer data, I prefer but we've got big, difficult transformational choices that more of the same is not gonna get us out of this.

[Rep. Lori Houghton (Member)]: And I absolutely appreciate that. And I think everyone around the table appreciates that and all the years of work that we've been sitting at this table trying to get to the proper point, all the work this committee did last year. I would also say it would be helpful to have not just piecemeal plans, but a full plan for our health care system.

[Alyssa Black (Chair)]: Can Yeah. I expand on Lori's question just a little bit? If the legislature went back and we did something like made reference based pricing only available to the QHP market, do you think more employers would go back into the market as opposed to Planning Association health plans or self insured?

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: Create a preferred group that has better pricing, the insurance costs will follow. And that's a big proposal there as well.

[Chelsea Bardo Lewis, Executive Director, Vermont Businesses for Social Responsibility (VBSR)]: Like that pie.

[Mike Fisher, Chief Health Care Advocate]: Businesses and individuals will follow with reduced rates.

[Alyssa Black (Chair)]: Leslie has a question actually. I want to expand on what Lori said. I'm really agreeing with you and struggling with hearing yes, but, no, but, we don't know a lot, actuaries, blah, blah, blah. And we've had sunrise reports that come out of OPR, and I'm just wondering if, as a mechanism, can we and I'm not sure where needs conversation. But we need information before I think action or so I'm just wondering if we could think about a process of getting that information and making it Reliable. Actionable. Like, you came in with your last report and you were doing like, can't, and I was trying to find it, but I couldn't, and it was like A, B, C, D, and it was very clear and supported. But this is not very clear or supported yet. But how do we make it that way so that we can take action?

[Mike Fisher, Chief Health Care Advocate]: So let get me in a word about short term limited duration. We support full coverage. We think people get caught up in in other you know, when you give them other options, they end up without full coverage or with or sometimes with scam coverage, honestly. Some of the discussions about short about sort of the short term needs for people, to me, sounded like special enrollment period dynamics. Today, if you lose your coverage because of change of job or a move or a divorce or a life event like that, then there's a special enrollment period. If there is a hole in our special enrollment periods around active duty, that's a question for Diva. I would be very surprised if somebody who lost their coverage because they weren't active duty wouldn't have a special enrollment available for them. And then lastly, I just wanna echo there's a piece of this whole conversation from every witnesses that was desperation. This is not working. And so all of my criticisms or concerns about what we put on the table should not in any way be taken as me saying the status quo is working. No, it's not. We're in trouble, and the business community is in trouble, individuals, people in the market place are in trouble, and therefore our providers are in trouble. And so, you know, there's a lot of reasons why I just want to say it. You've heard other people say it, but I'll say it as simply as possible. So a lot of reasons why our costs are so high. There's a lot of details behind that that we can't change. But the bottom line is the prices are too high. And that is a much more a simpler way of saying.

[Alyssa Black (Chair)]: Really appreciate go ahead, Brian. Was just

[Rep. Brian Cina (Member)]: Is there any wiggle room within the existing confines of the Affordable Care Act where you could see Vermont adopting new practices in terms of the way we manage the market? We heard geographic rating is an option, we heard age rating, we heard association plan. Is there anything you can say? Because it seems like it all points at cost in the end, no matter what we do there, but is there anything you think?

[Mike Fisher, Chief Health Care Advocate]: I think I think it so we got the pool we've got, and any sort of like, oh, let's put these people over here and those people over there are gonna be winners and losers, but they're not gonna affect the cost. The only thing that's gonna affect the cost is the price or what's covered. And that's, I I wanna be honest, uncomfortable ground for me.

[Rep. Brian Cina (Member)]: Oh, you mean, like reducing benefits?

[Mike Fisher, Chief Health Care Advocate]: It's not a place that I wanna go, but I have to recognize it. When we defined our essential health benefits, We were generous. Are there places in what's covered that could be looked at. You know, I wanna say again, I I'm not a fan of that approach, but I think other people have said this today, desperate times. We have to look at everything, and and it will be a tough ground to really look at.

[Alyssa Black (Chair)]: Go ahead.

[Rep. Brian Cina (Member)]: When you speak of what's covered, it did make me think, so now I'm pushing it.

[Mike Fisher, Chief Health Care Advocate]: I know that.

[Rep. Brian Cina (Member)]: It's two minutes to lunch, why not? You already ate. I'm still you all over the age earlier too, I need to eat again, let's not go there. I am just as hangry as the rest. What I mean is, you talked about what's covered. Might there be a way of, I'm just going to cut to the chase, could creating some kind of universal primary care perhaps help because if we created a common risk pool and everyone shipped into that, could it lower? Is that a way we might be able to lower those insurance premiums? Or maybe it's something else, maybe it's universal hospital care. Is there some way to reorganize the money in terms of how we deliver the services and guarantee something? I think

[Mike Fisher, Chief Health Care Advocate]: at two minutes to noon, that's a hard for me to fully answer. Will think about it. I I and and there is clearly a conversation about how to organize our payments for primary care happening in this building this year. I'm sure that we'll visit this table Okay. In a in a real way. And hey, we have all been a part of reform efforts that had the theory of better care now to reduce costs later. I love the theory. I've yet to see it play out like we want it to. But that's a big conversation. Can't help myself. Nobody is saying Everyone is saying they want more money. The conversation about primary care is how do we drive more money to primary care, not where is it going to come from. And so as someone who's looking at this whole conversation about insurance premiums, there has to be savings.

[Alyssa Black (Chair)]: Robert gets the last one.

[Robert (committee member, full name unknown)]: I'm just gonna make a statement. Like Brian. It's right near the gun, so I'm gonna shoot

[Kai Sanderson, Commissioner, Vermont Department of Financial Regulation (DFR)]: it. If

[Robert (committee member, full name unknown)]: we cover people with Medicare, Medicaid, and then we have people left, and we add in the association plans, we have people left over, my recommendation would be, let's go back to Catamount Health where premiums are subsidized to cover the rest of them all done.

[Mike Fisher, Chief Health Care Advocate]: Can we do that compliant with the Affordable Care Act would be my Yeah, answer let's go eat, Tom.