Vermont Legislature SmartTranscripts:

[Speaker 0]: Hi. Welcome back. We are moving back to 5 85. And let's I'm sorry, I'm doing a little housekeeping while we're on here. Do you think you should come up for we don't have any changes. We have changes? Or no?

[Speaker 1]: What? What are you I don't know if you're asking the language.

[Speaker 0]: Talk Okay. About the language. So, what I want to start with is I actually want to start with Blue Cross Blue Shield. Courtney. Oh. So, couple pieces in May. We're not going to do sections one and two again. I believe you've already testified on those.

[Speaker 2]: I did.

[Speaker 0]: You're clear on yours. I had asked Blue Cross to come in and share thoughts around the prescription drug app and sort of what their comments were around that since ultimately they are the ones that have to come up with the menu. Wanted get a little bit more information on the site neutral around Blue Cross Blue Shield. So Courtney, if you wanted to go ahead. Do have anything to share with us? Documents or slides or anything? No.

[Speaker 3]: Okay. I'll be, for the record, Courtney Harness, Blue Cross and Blue Shield of Vermont. Nice to see you. Thanks for not asking me to talk about sections one and two. It, spare you the same thing on repeat. On the prescription out of pocket maximum, I'm going to take my phone out because I want to read just a line or two from our chief actuary, only because she's much smarter than me, and it seems to make more sense to do that. Eva did submit written testimony for today. We would seem to align pretty closely with that testimony from the perspective of the timeline of 2028. Also, some good information that we've shared this morning around what those out of pocket maximums are, and it was nice that someone got to do all of that math. It wasn't me this morning, but we do have the math. And so I think when I was in a couple of weeks ago, what I did mention to the committee was that we don't see that there's actuarial value in this decision, nor would we see any movement on premiums. I think what I did share was that especially some of our large groups would appreciate the flexibility and plan design that this brings. And so what we would have to do essentially is navigate some of the cost share issues that come up with the out of pocket maximum to make sure that the actuarial values can be certified on plans. And so did have some conversation with the health care advocate. I do believe that we might be able to offer a few different plans. Again, a lot of that is up to our regulator. We can work with them to design plans that we do need to submit for approval. And so from that perspective, I would say the only issue that I would see, and this would be one for Vermonters that we worry about, if we're designing one plan with no out of pocket max and one plan with an out of pocket max. And again, this happens in other plans now, so I'm just laying it out there. We would potentially see someone choose a plan with no out of pocket max because of a current situation when they choose the plan where they're not using a lot of prescription drugs that then may end up with a $20,000 price tag. Again, that happens with plans that we offer now, so it's not like that doesn't currently exist. So, I think the language of the bill does offer some flexibility in plan design, the proposed language. Again, we see this as something that has an effect on premiums, but we do see it as something where Vermonters could potentially have some flexibility and plans that they could choose from and to Deva's written testimony looking out to 2028, probably.

[Speaker 0]: So, we talked earlier today with Ledged Counsel the bill as the latest version of the bill has essentially just striking out the requirements. What if we kept the requirements, but then we went in and we gave mission to not only do it for the bronze plan, but that you could create other plans at other metal levels that have an equivalent out of pocket for both prescription and medical. Would you pursue something like that?

[Speaker 3]: Yeah, good question. And we've had some meetings with DFR in the last couple of weeks where we shared some data and research around all metal level plans in New England and where Vermont falls and what some of the issues are, mostly in a conversation that we can walk down on how we get more creative or innovative with plan design, particularly to focus on affordability. And so I think that that was a good first meeting, but there would be no reason for us to say, no, don't let us have more flexibility in plan design.

[Speaker 4]: I think we would welcome that.

[Speaker 0]: Go ahead.

[Speaker 5]: I don't want to get into this today, but just thinking about it, is there any tracking of utilization in terms of these benefits? Is there any way to look at or for us over time to monitor, or does Green Mountain Care Board do this already? Just how people are utilizing prescription versus general. In other words, how many people are reaching their deductible? How many people are maxing out their cross sharing? And what is it on? Is that data collected and managed and reported in any way?

[Speaker 3]: Yeah, that's a great question. I think I saw in the healthcare advocates written testimony a couple of questions to that. So I think if the committee wants us to look through that specific set of questions, which, if I remember correctly, was around percent of people that reach their maximum. And there were some great questions in there. So if the committee wanted us to come back with that information, we could.

[Speaker 5]: I'm not asking that right now. I don't want to make people do work. It's just maybe someday it's worth looking at. But as you speak about plan design, let's say think about when we're designing these plans for people, how do we take into account how they're actually using them?

[Speaker 3]: Yeah, and I think this morning I heard a couple of folks on the committee say that it's kind of scratching around the edges, but the real need of it is in reducing the cost of And if we want to see real downward pressure on premiums, then we have to continue to focus on not just the cost of care, but the cost of prescription drugs themselves. Thank you. Well, I think that coupled with some flexibility and plan design would be really beneficial.

[Speaker 0]: And I

[Speaker 5]: think that's why it's about how they're using it, because then it's like, what are they actually spending money on? But I think in general, we need to reduce costs. I think we all agree with that.

[Speaker 0]: Okay, let's

[Speaker 2]: Oh! I'm just waiting to see if anyone else's paper. This section in the bill now, the way it reads, the health insurance plan shall not include the annual follow-up limit on prescription drug benefits. Does this have any impact on any of the contracts that have been negotiated through the unions?

[Speaker 3]: It's a good question, I have to go and find out, would say, and thanks for pointing it out, that language as it is right now, as you just read, doesn't give us an option. So that would just be we won't, we can't. So if there are any contracts that we would need to look at, it would be because of a change to the law. So I think we'd have a good reason to

[Speaker 4]: go back and do that.

[Speaker 0]: So actually, that's a great question, Doctor. Wasn't even thinking about it in the terms of, let's say, you administer the state employees, you administer education benefits. So with those plans right now, you're not able to offer a plan with a combined out of pocket, correct? You have to abide by the lower for prescription and generally higher for the medical. So if those self insured groups were able to offer an additional plan and maybe not so much state employees, although their cost share is also pretty minimal, but particularly the teachers where it's the school district who's actually picking up their out of pocket. Would that have an effect if teachers were able to choose different plans based upon their utilization of healthcare?

[Speaker 3]: Yeah, I think, like I said, not an impact on premium. And the large groups, and those are ones that you all named are large groups. They would certainly appreciate the flexibility. I think I did see a letter come in that was maybe not appreciative of the flexibility from a large group. But to that point, there's less flexibility in the way that Vice Chairman Fong has read the language around shall not. So that's not

[Speaker 0]: Well, got to thank

[Speaker 1]: you the legislative council. So the language around shall not is existing law around annual dollar limits. There is no affirmative shall not have an annual out of pocket max. It's just the language use of the word that strikes the requirement for But that's not what was suggested somewhat.

[Speaker 4]: Thank you.

[Speaker 0]: Okay, I think maybe I misinterpreted then. Okay, thank you. Any other questions for the panelists? Let's move to site neutral.

[Speaker 3]: Sure. So I had some good conversations with folks from rehab gym actually in here earlier during a break about their letter in addition of occupational therapy and athletic training, which are typically all grouped together under, I think, term was rehabilitative purposes. There's no issue from us if we wanted to go ahead and do that. I would say, too, probably easier to do it as a whole group of services than to try to pick out. I think that that's a great suggestion to do and probably gives us a little broader cross section for when we come back to committee with a report. Next I

[Speaker 0]: have a question for you. So let's say we Well, we're calling it quite punishment, but it's really sort of eliminating a hospital's facility fee, correct? In addition to their No. I don't think so,

[Speaker 1]: I think that's been

[Speaker 5]: the clarification. Okay.

[Speaker 0]: Jump in. No, jump in. So, how do we have it current in the new draft?

[Speaker 1]: I mean, I'm happy to let Courtney address that, but it's been in people's opinion different things when they say site neutral, and that's the version that isn't being billed, is saying the facility fee. It's saying it has to be the same professional fee based outpatient fee schedule. Okay.

[Speaker 3]: Yeah, my understanding of it was that the responsibility was put on the payer to determine a set fee schedule regardless of the location so that there would not be independent, professional, outpatient. There would be one.

[Speaker 0]: There would be one.

[Speaker 3]: Yep. I would say and I could be wrong, and so maybe I didn't look at the draft from this morning. I wouldn't suggest that we would ever do this. However, I think the current language gives a lot of flexibility to choose whatever we want. And if we, for some reason, did decide to do the thing that we don't always do, we could potentially set a price that doesn't really help anybody or set a reimbursement rate. So I'm not suggesting that we would. I'm just saying that the language in there currently does give a lot of latitude, which we appreciate.

[Speaker 0]: That was actually my question, which is if you're paying the same rate to everyone, the assumption would be that because right now you're paying one here and one here. Can we be assured that if everybody's coming to the same, that you're not gonna go from here to here? Can we assume that there is room that you're going if you're saving a tremendous amount Yep. Can it be assumed that you're going to amp up your reimbursement rates?

[Speaker 3]: Yeah, 100%. I think the assumption would be is we would look to find a place where we could bring up the independent professional fees a little bit and bring down the outpatient fee. I think that's the goal of the language of the bill. I think it would be safe to assume that we would do the right thing. So yeah.

[Speaker 0]: Get two new board members. I'm sorry, that was meant to be funny. It wasn't meant to be anything else. Okay. All right. Yeah, I mean, I think that the site neutral section, particularly around physical therapy is because the disparity is so great. And it's obvious the disparity is so great. And I don't think we're using this to try to save Blue Cross Blue Shield pockets of money. I think what we're trying to do is we're trying to set the precedent that these are equivalent services and they should be paid at equivalent levels. And the hope is that you would pay everybody adequately a fair reimbursement

[Speaker 3]: for services. Yeah, I think our goal from this and partnership with you all is to come back on the reporting date and show some really good positive results that can hopefully use this as a nice springboard into some other areas. So absolutely.

[Speaker 0]: Thank you. All right. Oh, Tucker's question.

[Speaker 2]: On page 19, line 12, is that just the plan that they reimburse different amounts for physical therapy items and services delivered in an inpatient setting. Is that going to stay in?

[Speaker 0]: Yes, because we're talking about outpatient services here. So that language allows them that if it's in an inpatient setting that it can actually because it's not an equivalent service to another outpatient. Because the person's

[Speaker 2]: So it's almost taken.

[Speaker 0]: Yeah. This just is making it clear that we're talking about outpatient equivalency Go ahead.

[Speaker 6]: So on-site neutral, how do we best determine what's the appropriate level? What's the process?

[Speaker 3]: So the goal, frankly, for us would be to find

[Speaker 4]: a happy

[Speaker 3]: medium where you all, by way of this bill and us in hopes of finding some cost of care savings to put downward pressure on premiums, can figure out a place where we're elevating the lower reimbursed services and bringing down the higher reimbursed services to realize the savings and also create some parity.

[Speaker 0]: Yeah. Any other questions?

[Speaker 6]: Just a clarification from what Tucker said. Inpatient is a nursing home. Where, like if you have a stroke and you go to a nursing home and get your rehab,

[Speaker 2]: how does that fit? Inpatient,

[Speaker 3]: so it's tricky because inpatient is not in the hospital technically, whereas outpatient can also be in the hospital. Inpatient might be a physical therapy service or a physical therapist providing a service post surgery in a hospital bedroom. Inpatient. Yeah, outpatient would be I go into a hospital or could be I go into a hospital to receive my physical therapy and services in a physical therapy office that's located in a hospital or some other site around the state.

[Speaker 0]: Great. Thank you.

[Speaker 3]: Thank you. Since

[Speaker 0]: we're talking about the Charlie. I'm working on an old schedule, so I'm just looking around the

[Speaker 2]: room. Thank you very much

[Speaker 3]: for having me in. And I'll try to be quick,

[Speaker 7]: because we a lot of people here that you need to hear from.

[Speaker 0]: Yeah. You're gonna talk about the out of pocket.

[Speaker 7]: I am correct. Yep. So I just have a little bit here.

[Speaker 4]: Thank you for reviewing Oh,

[Speaker 7]: for the record, Charles Becker, Office of the Healthcare Advocate. Thank you for taking the time to review our one pager and for allowing me a few minutes to speak with you today. I wanna acknowledge that with this bill that you're considering, $5.85, you're looking for ways to make health care less expensive for Vermonters. Health care is expensive. Vermonters are struggling, and they need relief. We all share that goal. And it's been identified that there's this thing that we have here in Vermont, this prescription drug out of pocket max, and it requires all or nearly all state regulated plans to cap prescription drug costs through this low threshold, currently $1,700 for an individual or $3,400 for a family. Whether or not a person thinks that they or their family need that type of benefit. And I sense that there is a perception that this cap is a benefit for some people, but not for all people, and yet it raises the price for everyone. I would say that this Rx prescription drug out of pocket max is a benefit for all Vermonters, actually, and for reasons that I'll get into in a little bit. And I would say as far as how much the prescription drug cap raises prices on everyone, I would say that that could be answered with an analysis, but that we don't know the answer to that already. And I think we just heard a bit of information from mister Harness that perhaps the the the impact on premiums are are not that significant after all. I also have a sense that there's a question lingering out there. Why is prescription drug spending different than medical spending? And why are we privileging prescription drugs over medical care when, after all, it's just costs to Vermonters? I And also wanted to make an attempt to answer that question. So and I wanna make a comparison to preventative care. I would say one of the greatest accomplishments of the Affordable Care Act was the preventative care mandate. Zero cost share preventative care, and not just for ACA plans, but all plans. Every non grandfathered health plan in the country must provide zero cost share preventative care to beneficiaries. Screening colonoscopies and mammograms, pap smears, lung cancer screenings, many other services. These benefits cost everyone money, though not may not though not everyone may use them in a year. And there's a very strong policy reason for that. Right? Because preventative care saves money in the long run. Keeping people healthy, catching disease early, those things save individuals money, and it saves the system money. So I'd like to suggest to you that the same concept applies to the prescription drug spending, and that this prescription drug out of pocket max, it serves an important function that does benefit all Vermonters. When a person is diagnosed with an illness, particularly a chronic illness, and maybe they've spent months or years and many thousands of dollars trying to figure out what condition it is that they have, and now they have this diagnosis. You have x, cancer, multiple sclerosis, HIV, Crohn's, diabetes, asthma, you name it. You have this condition. It's incurable, but there is good news. You can regain your health or you can preserve your health, prevent the progression of this disease. You can stay healthy longer. All you need is a prescription drug. And that's good news for the individual and their loved ones that if they can afford this prescription, they can stay healthy, and that cap helps people to afford their prescription drugs. But it's also good for the system. Ensuring that people diagnosed with chronic illnesses can afford their medications to maintain their health, to prevent complications, to avoid unnecessary hospitalization, that saves money for everyone. It's also the nature of the spending that's a little bit different too. Right? When you go to the when you pick up a prescription at the pharmacy, you have to pay right then and there for that service at the counter in cash or with a credit card. With a medical situation, you have a medical emergency, you break an arm, you have a heart attack, you'll go to the doctor, you'll receive your care, and you can sort out paying for it later. That is not the case with prescription drugs. And so that is why we think prescription drug spending is different and why preserving this prescription drug out of pocket out of pocket max for everyone makes good sense policy wise, at least, and at the very least, until Diva or the carriers, as they've said that they're willing to do, come forward with an analysis showing that repealing the cap will actually allow for meaningful, impactful plan design changes that would really make a difference in making health insurance more affordable for for Vermonters. Even then, we'd wanna preserve the cap for some, as I've heard you suggesting you're open to allowing, having some plans have the cap and have others not have the cap. We we would wanna preserve the cap in some form even even then. And so, really, that's our HCA re request. We don't think there's been a strong enough of an of analysis of this issue yet, and we'd urge the committee to request that additional analysis and then maybe come back and consider this matter in another legislative year.

[Speaker 0]: Go ahead.

[Speaker 5]: Last thing you said, did you just say, can you say it again, your final summary of your recommendation? Are you saying we should wait and study it more, or are you saying we should do it and study it more? I missed something.

[Speaker 3]: Okay.

[Speaker 7]: Our HCA position is that this cap has value for Vermonters, and we'd urge you to keep it.

[Speaker 5]: You mean, like, don't strike out with this language?

[Speaker 7]: Repeal it. Do not repeal

[Speaker 5]: it. Okay.

[Speaker 2]: Yes. It is.

[Speaker 5]: So other words, don't do the exception of the bill? Correct. Okay. Thank you. That was what was not I wasn't sure where we landed or where you landed.

[Speaker 7]: At the very least, come back, ask for more information, come back and look at this another time.

[Speaker 0]: Or change the section of the bill to say, come back to us.

[Speaker 5]: That's what I was thinking. Okay. I have another question. I just wanted to clarify it because as I was thinking of the other question, then I was like, what did he just Thank you. And this is what I thought you were saying. You mentioned in your testimony that the Affordable Care Act established a right or requirement around preventative care. Does that include your yearly physical or is that only the diagnostic testing?

[Speaker 7]: Preventative care is for screening.

[Speaker 5]: Screening.

[Speaker 7]: Screening, and I believe it includes an annual wellness exam. I'm not entirely sure if that

[Speaker 5]: Okay, the reason I ask is because when did the Affordable Care Act go into effect?

[Speaker 1]: That's '13 as well.

[Speaker 5]: I paid for every yearly exam, they charged me something, so they're clearly finding a way to bill for something. It's not free for everyone, but we don't need to get into it today. When you said that though, it kind of threw me for a loop. I'm like, wow, really? Okay. I'll talk to you

[Speaker 0]: about significance separately identifiable at some point. What's that? Never mind.

[Speaker 5]: Ways that people bill for things?

[Speaker 0]: To further Brian's question, because I've been We've been sick home and we've been under the Affordable Care Act for how many years now?

[Speaker 7]: Fifteen, sixteen years.

[Speaker 0]: And we have all these preventative services, all recommended, the aid from the US Preventative Services Task Force. Do we have any evidence whatsoever that our concentration in the last fifteen years or twenty years on providing preventative services has actually made Americans healthier and brought down the cost of care.

[Speaker 7]: I would have to come back to you with information on

[Speaker 3]: that, but

[Speaker 7]: I did provide two citations in our one pager to and I believe mister Page, in his letter to the committee as well, made citations to studies that suggest that when people are able to adhere to their medications, that their costs of care are lower, that they have better health outcomes, they have less unnecessary hospitalizations, and that their total cost of care is lower when people are able to adhere to their medications.

[Speaker 0]: Do you think people often or sometimes have a propensity to choose prescriptions that are higher cost ones because they know they're going to meet their out of pocket max anyways and that they won't be on the hook for that $2,000 a month prescription? I

[Speaker 7]: don't have any sense of whether or not that's something that people do. My sense is that people make decisions about the medications that they're going to take with their doctors based on their conditions that they have. I don't know that people are making decisions to take more expensive medications because they know it's going to get them to that point of pre health care. I don't know if people are making those decisions. I couldn't speculate.

[Speaker 0]: Go ahead, Would

[Speaker 1]: it raise costs for the chronic conditions, prescription patients for chronic

[Speaker 7]: conditions. Repealing this cap as proposed in May currently? Absolutely, it would. For the person with a chronic condition, they would potentially be exposed to those full out of pocket maxes that are referenced in Diva's written testimony that they submitted to you and that you've seen going around on this placemat that that potentially, you know, $10,000 for an individual, $20,000 for a family, that could be your exposure. You could go from being exposed to $1,700 in annual prescription drug costs to being exposed to $10,000 on an individual level. It absolutely would cost people with chronic illness money.

[Speaker 0]: I Okay. So just be full transparency, I'm the one that put this in here. I've been talking about this for years. So right now, I'm looking at the menu. If I have Blue Cross Blue Shields and I am able to afford a Family Gold Plan. So a Family Gold Plan, I am paying $3,780 a month. Okay? So if I happen to have, if my costs are mainly incurred with a prescription, my out of pocket max for my family is $3,300 If my family incurs their medical care, their expenses through medical care, let's say your 12 year old child ends up with appendicitis and has to have surgery. That family's out of pocket is 11,400. So a difference of over $9,000 that one family would pay for their care as opposed to another family who equally health conditions or not equal health conditions. So to me, it's almost an unfair thing because it's almost like pivoting, it's pitting people's health care against each other and who's more valuable and who's less valuable. Would you be, I mean, would it make sense if we allowed, say, plan designs around gold to continue to have a cap on one plan and a more reasonable out of pocket because it wouldn't be $11,400 If you merge them together, it might be a little lower, same $3,800 a year, I mean a month. And we keep talking about age rating. From a family of four and I'm in my 30s and I've got two little kids, the odds of our medical care being generated from prescriptions is probably a lot lower than if I'm, say, my age. And as you get older, you have more chronic conditions. So aren't we sort of relegating younger people to pay more so that older people can have a lower prescription drug?

[Speaker 7]: Madam chair, I appreciate I understand what you're saying. I do understand what you're saying. And I've been listening to your committee's testimony about this throughout this entire time. I know this is one of the reasons why you've brought this section of the bill to this committee for you to consider. I I would say to you, I think it might make sense to do that. It might make sense to allow the flexibility to offer a gold plan that doesn't have the prescription drug out

[Speaker 4]: of pocket caps, out of pocket cap,

[Speaker 7]: but I don't think this committee has seen the information to say that that would be a good thing to do.

[Speaker 0]: I

[Speaker 7]: agree. And that's what I would say. And it would be the extra benefit to that family who has the medical expenses over the prescription drug expenses, I'd want to know what is the magnitude of that benefit? Are they going to get $5 in extra deductible protection or are they gonna get $50 of extra deductible protection? $500. How much more protection are they going to get for the sacrifice of giving up this benefit for all Vermonters of this prescription drug. Because it is, I would say, a benefit for all Vermonters, even if you do not take prescription drug medications. Again, because a healthier society is better for everyone. Great.

[Speaker 0]: Thank you. Thank you.

[Speaker 7]: Thank you.

[Speaker 0]: Thank you. Okay. So let's move on. Yeah. Not for you.

[Speaker 5]: I'm sorry.

[Speaker 8]: Thinking about our next steps.

[Speaker 0]: So what happens here with this language? What do we think? We're still talking about the bill. We're going to have a discussion later. You know what we're going do? We're going to have a long discussion tomorrow. We're going to put it in the morning because And I don't think Jen needs to be here. Yeah, I know. We're going to do committee discussion on this tomorrow,

[Speaker 1]: because we've got time. Unfortunately,

[Speaker 0]: we don't have time. All right, hi. You're here to talk about some of the things we heard, or some of the discussion that we had this morning.

[Speaker 2]: So

[Speaker 0]: let me ask you, first of all, if you are fine with us leaving that the governor gets two picks as originally written. Yes. Okay, thank you. In section one around the governance piece with Blue Cross Blue Shield, we had been going back and forth on whether the governor gets two picks. And it was originally written that the governor gets two picks and the new version has still the governor gets two picks. And Commissioner Sampson is fine with that, he just said.

[Speaker 2]: Correct.

[Speaker 0]: Great. Let's go to association health plans. Wondering if you were able to see any of our discussion committee discussion and the new language.

[Speaker 4]: Yes. So that's what I'm mostly here to talk about. But, obviously, any questions you have. I I did have I I did see portions or get summaries of this morning's discussion. Couple things I wanna point out. I'll definitely talk about the data, quest for for data. First is that the plan as we've presented it, has two components. One relies on, a change at the federal level or equips us to be ready to conform with what could be a change at the federal level around the commonality of who can form an association health plan. That may or may not happen. There's a second piece in there that I didn't hear talked about this morning that is about an association health plan must conform with what coverage benefit requirements. Currently, it's small group. We're saying so the second piece is to allow conformance in our law with large group for an association health plan. So the delay, if ultimately this committee decides they want to delay or go with this amended language, I think there's a second question of, like, are you what do you feel about the other part, the change in requirements of how an associated health plan complies with our law, small group or large group? So that's I'll pause there.

[Speaker 0]: We had discussion around not only the language around the pause, but additionally that the Department of Financial Regulation would come back to us with some, I guess I would say, data on the effects of this on the QHP market, effects of this on the large group marketplace, lots of other things we had and I can't remember all of them.

[Speaker 4]: So in regards to the data, what will be the impact of if you just took what what we proposed without any changes and passed it. To give you any level of useful data and certainty, I I think, is near impossible. As impossible as it is for me to ask you what will small group rates be in three years, and and here's why. And I did speak to one of my favorite actuaries that the department uses, and it brings up a a bigger point that understand that the additional flexibility for association health plans that we're proposing does not entirely just say, if you're on the small group, you can leave because of this. It allows current businesses that have not offered a plan to associate and now offer a plan. Maybe they're 50 paying a small penalty, I think, to the state, but they've done the math, and they're just not offering a plan. Or maybe they're they're doing ICRA and having their individuals on the individual market. But there is a population of small businesses that simply do not offer health insurance. This would prevent I'm sorry, but present an opportunity perhaps to do so. Then there are larger groups that are in ERISA currently, and that also presents an opportunity for them to if if it makes sense for them to save on their administrative fees and ERISA to associate. So just wanted to make sure the committee was aware that this this is not solely a plan that allowed that that the movement is not solely about people leaving the regulated exchange. There's other shuffling that could happen, because businesses want opportunities to save on administrative costs or otherwise. In terms of the data, so there's a lot of moving parts. Even if we change nothing in law, ERISA ERISA plans, self insured plans, self level funded plans are currently and always pulling people out and out of an exchange plan or people leaving those plans and going back in. Why would an actuary have difficulty giving us any level of certainty that I'd feel comfortable saying, yes. So here's what's gonna happen in the small group market, and it's gonna be in this range. And that's because you have to know everything about who the groups are that aren't insured, what their risk looks like, the claims experience, what the small group would look like by the time this the earliest this could take effect in two years, what the impact would be, the natural impact of people migrating between or in and out of these different markets, and also what the price sensitivity is. We can get some information around that just by past behavior, but at what point do you refinance your mortgage? At what point do you decide to go rate wise is an analogy versus at what point do you decide, I'm gonna leave the fully insured market? Can

[Speaker 0]: I interrupt him? Of course. Isn't that exactly what actuarial science is?

[Speaker 4]: Actuarial science takes to Their

[Speaker 0]: job to Their

[Speaker 4]: job is to to well, I don't wanna I'm I don't wanna speak for actuaries. They can model scenarios. They can say it's hard to predict. First of all, they like I said, they need the data. Actual science is let's take data and determine what would happen. So I think more a great example is what you're talking about in in pharmacy out of pocket maximum. Right? There's actual avail values that need to be complied with. They can look at what kind of freedom and a plan what what type of space it gives in plan design to do other things to meet the actual value. But in terms of predicting where you as a small business at at that point, well, first of all, we need to give them the information. If you're not on the exchange as a small business or nonprofit or you're not offering insurance, we gotta go find that data, you know, and figure out what the what the overall market looks like.

[Speaker 0]: Did you have a question,

[Speaker 9]: Lori? Yes, it's great that there's going to be opportunities for people. I get that. The conversation we've had around this table is, though, specific to the QHPs.

[Speaker 4]: People leaving the QHPs.

[Speaker 9]: People leaving. So can there be any type of estimate, something done on what it would do? Would it truly help small businesses that are currently buying on the QHP? And if it does, what does it do to individuals? I don't care about these people over here because they're not in the QHP.

[Speaker 4]: I do. I know.

[Speaker 0]: I mean, that's what it means.

[Speaker 9]: They do care

[Speaker 0]: about that

[Speaker 9]: stuff. Right? Now, the point is, are we pulling people out of the QHP this proposal? And if we are, who does it hurt and who does it help and by how much?

[Speaker 4]: Yeah. I I still think that's a level of certainty in checking in with his actuary that would be hard to give a good a good reliable number on. It would at the end of the day, to to me, you do have to ask about the entire market, and you have to look at how much is it helping someone. And there what I've acknowledged in testifying on this from the get go is, yeah, there will be just like there is now every day, there's the opportunity for someone to leave the exchange and, you know, through a risk or whatever. There's gonna be a a continued pressure on leaving what's possibly the most expensive exchange market for businesses in the country. Where I started with my testimony on this, when it was introduced, is I'm no longer comfortable saying, no, you may not because it's better for the common good or it's better for these people here. I mean, we're we're choosing winners and losers in an environment where you're looking for me to quantify exactly what the winners and losers would be in an environment where we have current winners and losers. We talk about them every day, but I don't want us to forget about businesses that just aren't even offering health insurance.

[Speaker 9]: And I appreciate that.

[Speaker 0]: And I

[Speaker 9]: think that's where we have some key differences on how we

[Speaker 0]: move forward with that. So I appreciate that.

[Speaker 4]: I would say that in the language as amended, you're not actually compelling us to to do that study. If you right

[Speaker 0]: now. Yes.

[Speaker 4]: Yeah. Yeah. I I would appreciate that staying that way because I feel like that is I feel like that's not gonna give the certainty that we all would want in terms of what's gonna happen. They're just to put it very plainly, way too many variables to to to for me to slap a study on the table here next year and be like, this is what's gonna happen.

[Speaker 0]: Can can I ask a question of the committee? And and we're not doing this yet, but I just wanna get a sense because I have a question for you if I get a

[Speaker 2]: sense. Is

[Speaker 0]: there anyone in this committee that if there is not a study at least on the association plans that they will not be voting for this bill? Can I get a raise of the committee?

[Speaker 9]: If

[Speaker 0]: this bill contains exactly what is in this draft here, around association health plans, Does that give anyone pause on this bill?

[Speaker 9]: I won't go up there.

[Speaker 8]: I won't even.

[Speaker 2]: That's a bit of

[Speaker 0]: a poison pill. Here is my question. How do we move forward on this bill? Because there is some really good stuff in this bill and I want to see this bill make it out of this committee by Friday. I feel like, how do I do that? How can we come to a place where we can get this bill out of committee? Well, are you I'm asking I'm asking, are you willing to do this study?

[Speaker 4]: I can I'd need to get a little more detail than my fifteen minute conversation with an actuary at one third that I had at 01:30 to understand the art of what's possible here and the cost. This would not be a bill back. I I don't think I can bill this to an insurer. This is not a cost neutral thing to our budget. Furthermore, I I think think I think wanna be, I think it's fair to say that you guys don't like it anyway. I feel like I don't have this committee in terms of wanting to loosen up AHP. I think that's true.

[Speaker 0]: And hold on, though, because none of us said we didn't like it. We just haven't been presented with any clear information. So I feel like a lot of us are not even able to make the determination whether we like it or not because we don't have the data. And again, we're very concerned about what happens with the QHP market and that gives us pause. And we feel like we really need to understand what we're doing to destabilize if we're going to destabilize a market that we've worked tirelessly over the years to try to build and stabilize. So I don't think it's fair to say that we don't like it. Just you haven't, you need more information.

[Speaker 10]: And I could step in. Sebastian Erdwango for the Department of Financial Regulation. In 2019, the congressional budget office and joint committee of taxation at the federal level tried to study this. And what they estimated was that studying the first Trump era expansion of AHP is would nationwide in the aggregate result in small group market premiums rising by 3%. But they did note to the point that the commissioner is making that that estimate was in the middle of an extremely broad range of possible outcomes and that the projections were also both inherently uncertain because of legal and administrative questions, and also that there were some aspects to the study, how insurers, states, employers, and individuals all respond to the widening of AHP that just could not be answered definitively. So I think if the question is, could we do a study? The answer is probably yes, but the number of assumptions we would have to make to do a study would make the answer you would get less. Like, this is exactly how much premiums would rise in the small group market and more premiums would rise. It would be more like a Vermont snow forecast than Ten days out. Ten out.

[Speaker 9]: That's great. That's a great idea.

[Speaker 0]: I know I should have to say, but you could model it. You could very easily say, okay. What if 500 people left the market? What if a thousand people left market?

[Speaker 4]: You could do that.

[Speaker 0]: You could that.

[Speaker 4]: We could tell you what if the healthiest 5% of small group market left. Yeah. That I'm not opposed to studying, but or studying or or producing, because I think the cost of that is manageable and the uncertainties in that. What what you know, I understand as much as all of you the importance of data. I love data. I'm I guess my reaction to this overall is, like, kind of what Sebastian is pointing out here is there's gonna be such a variation in actually what will happen. So when I come back with data that says, if your healthiest 5% leave in 2028, here's what small group rates will be, There's still no idea whether that five percent is the right number or whether no one would leave because it takes two years to set up an AHP and agree and shake hands, etcetera.

[Speaker 0]: But at least we really have

[Speaker 4]: But it's something.

[Speaker 0]: Can I just say for the committee that I've asked, I know Lori has to go, but I've asked the speaker if we can have an extra ten minutes and she has given us that? So unless you feel like you need to go yourself on the screen, we have an exemption for ten minutes. Lori Houghton.

[Speaker 4]: Think the other point I wanna make, and I know I've made this before, like this is crushing. As you all know, everyone's working and you mentioned it this morning, that the only sustainable way to deal with these issues is cost of care, and there's frantic work happening on cost of care. I'm not insensitive at all to the idea that there will be an impact on the on the QHP market in terms of the risk this provides, but that is there's a lag on that. Right? An insurer is gonna have to see or or try their best to predict who might leave just like they did with, the advanced premium tax credits, incorporate that into rates, see what actually happens. I would not be proposing this if I didn't think that in the interim, as this takes time to roll out, if it even rolls out at the federal level, that I'm less worried about that because I know that we're dealing with the systemic and root cause issues at the same time. So to answer your question, if the study either gives us some flexibility in not breaking our budget and asking an actuary to predict human behavior, but just models certain scenarios like that, I do not I do not object to that. You know, I I don't have much of a budget for unreimbursable large actuarial studies. And frankly, because I think this is more of an issue of are we gonna offer this choice and help people now and and react later if we have to, or are we gonna need certainty in everything we do? I think that's a that's a threshold question that we're on different sides of. So I I anyway

[Speaker 0]: But can

[Speaker 2]: you talk

[Speaker 0]: a sense of who and what percentage of insurance is exactly who those insurances or TPAs would be that underwrite the AHP funds? Do who you we're talking about as far as the insured?

[Speaker 4]: We have one major one now and I believe they're with Blue Cross Blue Shield.

[Speaker 0]: Okay. We have one now, but we don't have do we have a sense of if other associations were formed, who the major underwriters are.

[Speaker 4]: Underwriters meaning administrators?

[Speaker 0]: Yeah, administrators. I'm worried about the rates that oftentimes are paid.

[Speaker 4]: Reimbursement rates to hospitals.

[Speaker 2]: Reimbursement rates

[Speaker 0]: to and providers. The hospital, non hospital, outpatient, inpatient?

[Speaker 4]: Blue Cross and Cigna do a lot of self insured business. Do you have other thoughts on the market?

[Speaker 10]: Yeah, mean, the self insured market, we see a lot of issuers that are not participating in our fully insured market, like Humana, Aetna, UnitedHealthcare. Even though their rates aren't subject to review by the Green Mountain Care Board, Vermont providers agreed to be in their networks.

[Speaker 0]: I agree with some loose words. Go ahead, Topper.

[Speaker 2]: Is there any appetite on this committee for studying what's actually happening. We leave the bill the way it was in the beginning and we study what happens if the federal government changes. Because what this does is set it up in case or when the federal government changes their mind on something. So if they do, we're ready to go. We go and then we look at, okay, what did happen? How many people did leave? Did the premiums go up for the people in the pool? Then we've got something concrete that we're studying. Right now we're talking about actuarial trying to figure something out. And we set up a model. How the hell do we know that that model is gonna be what actually happens? So to me, if you're gonna have a study, that's what I think you should be studying. And if it comes out really negative to the people in the pool, then we figure out how to help them. I gave one idea. I don't know how many times I've said it. It begins with a c and it ends with a t.

[Speaker 0]: I don't know. We

[Speaker 2]: could we could we could do something similar to that to provide a subsidy to those people in the pool if it was so bad that it was necessary. I wanna study something that's going on and what the results of that are as opposed to something that's fictional.

[Speaker 4]: And I would call that kind of just live reporting from DFR in terms of the establishment or the approval. Remember, we have to approve association health plans no matter what happens to this law currently in the future. So they come through us. And much like my testimony on short term limited durations, you know, we're not interested in approving things that don't make sense. But we it also gives us an opportunity to see, to to Brett McFaun's idea, what see and ask what the impact is. You know? What okay. You wanna form an AHP? What what's your risk pool look like? What's your administrator predicting for your rates or morbidity relative to what you're doing now individually on or off the exchange? It's likely we would see potentially AHPs that combine potentially folks that aren't offering insurance now, folks that are on the exchange now or coming together to form a plan, insured or self insured.

[Speaker 6]: Karen. So when I was meeting with folks before I was appointed, I met with lot of small businesses and nonprofits, and they were just really concerned about not being able to offer health care to their employees, building businesses, restaurants, things like that. Would those folks be able to afford? Like, what could you model? Like, what would it cost them? Would it be affordable? Could they offer them?

[Speaker 4]: It would

[Speaker 6]: Is that one aspect that you could

[Speaker 4]: Yeah. And I believe that's why you see the coalition of support from the nonprofit and the VBSR and the chamber, I believe, for this. But I'm not gonna tell you that it's gonna make such a big health because of the cost of care. Yes. You know? So going going being able to associate and have a different benefit and rate structure than the exchange can save you money. I would very loosely magnitude of making that decision five, ten, 20% over what you paid on the exchange. I think costs are so darn high. That's gonna make a difference for some to say, alright. Let's do it. Let's offer let's offer a plan. But for others, it's still so far out of reach.

[Speaker 6]: And then part of it is, learned today, we're not a shop. We don't have a shop situation, so what you offered on these plans wouldn't have to be the same as the Affordable Care Act. So, Is that

[Speaker 2]: correct? You raise the question?

[Speaker 6]: So the Affordable Care Act has certain requirements. These plans would not contain those same requirements necessarily unless we made them. Is that right? Or how would that work?

[Speaker 10]: Yeah. So if you think about the ACA markets as having three big submarkets, that is the individual, small group, and large group markets, What is being proposed in H585 is to take the AHP out of that small and individual market framework and into the large group market framework in terms of coverage of essential health benefits and annual and lifetime limits and other consumer protections like that, which isn't to say that the large group market is completely unregulated. It's just to say that they have different consumer protections that apply to the market because we assume that large groups are sophisticated purchasers who can make those kinds of granular decisions about the configuration of their health plans. Yep. Okay. Yes. I'm just trying to

[Speaker 8]: think realistically here. We had 700,000 people, less than 700,000 people in this state. Most people do get in four year sponsors. The rest of the people are probably and I don't mean the rest of

[Speaker 0]: the people, but if you

[Speaker 8]: take out all the Medicare and the people who are on supplemental and all the big business, it's not that many people. I'm skipping it if we keep adding, keep throwing stuff at this system that we're just saturating it in not good way. I think this would be the death now for the Affordable Care Act. And I worry that people who have preexisting conditions will no longer have the right to purchase health care.

[Speaker 4]: Well, would not change the preexisting conditions. I'm talking about the associated health plans. They would not preexisting condition protections. No.

[Speaker 8]: So they can They would

[Speaker 0]: have to have an ACA compliant they would have to design an ACA compliant Yes.

[Speaker 2]: Right.

[Speaker 10]: So an association health plan, just to be clear, cannot deny a prospective employer coverage of their employees because one of the employees has a preexisting condition. That's true. They can So an association health plan, like a large group health plan, could rate based on the morbidity of the group as a whole, but they couldn't deny coverage to a certain individual, which just to add some to the conversations that are being had here. In the self insured market, what we do see in the stop loss plans that that market relies on is that the stop loss coverage often does laser individual employees based on their health status.

[Speaker 4]: But that doesn't impact the individual. That impacts the willingness of the employer to take the risk to go self insured or to go or to stay in a fully insured or exchange

[Speaker 6]: So it would also have all

[Speaker 8]: the minimal essential cover So it's like yes she likes me out of the marketplace.

[Speaker 0]: We need to go. I'm so sorry, I completely forgot. We actually have a film on the floor today.

[Speaker 4]: Thank you for the time.

[Speaker 0]: Thank you. Thank you.