ALC-Arkansas Health Insurance Marketplace Oversight Subcommittee

Good morning members of the committee and our guests that are in the audience thank you for being here today just a few brief comments on the part of chair first of all I want to thank represented fortune she's actually been the driver of the work force on this and so I want to commend her thank her it's been a pleasure to be co chair with her I believe one of our recommendations that we're gonna make to leadership is that given the fact that the hi this is been moved over to the insurance department that we would recommend that this committee's responsibilities could be rolled over into the insurance and commerce committee make things a little bit to more lean and mean for the legislative branch and combine it into the Committee without it's been a pleasure to be in this position and we're going to cure the businesses forms expeditiously and I represent the Representative Ferguson co chair Frank homage. At notice it's been a pleasure and I thank the a committee that all of you being here three the last three four years it's for F. Frank would relate you know done good work and and moved to to the insurance department appropriately and they seem to be doing a good job with it so that may not think our work is done and I appreciate all of you. Okay with that we're gonna go on to a item C. on the agenda the report from the Arkansas insurance department a number person to purchase insurance under the health insurance marketplace trends over time because plan few graphical break down persons purchasing plan six cetera and you have exhibits member if you would to get those out and unless the presenters come to the table and if you all will please just to identify yourself and who you're with for the record please. Thank you Mr chair Alan Klein Insurance Commissioner I appreciate the work of the committee and as you know I'm I'm I'm new to the to the to the Department but I a lot of work been done well in advance to me that I appreciate and I am thankful for the work of the of this body and we look forward to it we have in the future you're familiar with Senthil all written and Bruce Dawson also over Arkansas health insurance marketplace program there the subject matter experts I'm gonna turn it over to them but I just want to bring you greetings. Thank you feel would just your name for the record again I know we in addition but destroy your voice please Chantelle open. Bruce Carlson. Okay one shall go ahead in making comments regarding the information you have force please. All right some of this you may have seen before we brought some of this information last but where an open enrollment now I thought it be a good time to refresh on it so let's look at the plan and right information first. We had a new entrant health advantage this year and you can see from. How many gold silver bronze expanded bronze is there are that each company is offering from twenty twenty one twenty twenty. And on the next page it shows you where the companies are in all of the areas every rating area that we have every County. The next pages will show you the silvers each each mental level and what the rates were for each year starting in two thousand and fourteen to current and that's going to be the Next few pages on the enrollments. I'm sorry the rights. And Several on page eight it will show you the plan year of twenty twenty one rates before the subsidies within each mental level. And they can can can be compared on our website we have a link where you can go in and you can actually choose your county treasurer age and what mental level you would like to look at and it'll show you a plan comparison. And it's just showing you and another snapshot of how that looks when you go into that link to be able to compare the plans. Anybody have questions about this information. Members or any questions. Jefferson. When we look at the. Yeah and I've I've been taking clasificados de I have much to appreciate these charts I mean in the work that goes into and I really appreciate all the work of it looks I know in eighteen we had that largest increase the twenty two point eight. Of and that was primarily the best I remember G. to the removal of the cost sharing reduction yes ma'am if that is reinstated could we think we could expect the a large decrease in premiums our actions next year yes I would imagine that would be the case okay of no this is great thank you I appreciate the information. Okay we can get to the enrollment report now. And this shows you from two thousand fifteen to present how that enrollment looks every time you see an up tick it's usually when people and roll and when you see the down see it going in the at the downward trend that usually because there are people who may not may not have paid their premiums for the plan so it's it's. This is very common and it happens every year. The bar graph on the next page will show you the difference and each month from two thousand nineteen to two thousand and twenty and as you can see here this year there's it's higher by about three percent and we. We think we can attribute that to covet nineteen and people wanting to hold on to their their coverage and maybe from people who have lost their jobs and needed that coverage. And then on the Page four it'll show you for the special enrollment periods that's an S. E. P.. compares from two thousand nineteen to two thousand and twenty it'll show you and how many there are per minute and the blue line is two thousand nineteen and oranges twenty twenty. We don't have the benefit of color is that is the blue line the darker the lighter of the two. I would say it's the darker okay. So it seven it's the one below if you start at the very okay got it first. Okay and so and as you may remember each year we would bring and. Seventy five counties worth of paper and so to be able to cut down on that paper we're actually showing you the link where you can go and look at all of this on our website. And that that'll be the information that's on page five. And then this is just kind of Pulang Washington County out for you to be able to see that visualisations that this is the sample of how the online visual visualization looks when Washington County is chosen for the past for the last twelve months. Do we have any questions about this in a moment the main issue you mentioned about those that have not paid what what's a specific number where's that information this that or how do you attract those that have been paid in wealth so if you see like for the very first of it starts and then it takes up that's open enrollment and so as it starts coming down. The very bottom of that grass each little point shows you how many plans are actually effectuated. So that will be the M. fifty thousand six hundred seventy three. Actually paid for their plans. That makes sense at the end I against and those that don't pay for the plan that just drop off they're not on here that's where it starts a decline okay. And they just show up as uncompensated care and up hospitals or what we. So. Okay. Yes. And how do we measure the impact of those that don't pay against uncompensated care to the providers. I'm not sure that we collect that kind of data. I don't we get a lot of our data from the insurance companies directly and I don't know that that is collected I can certainly find out for you and see if that is something we can look into I'd like to if you don't mind okay they beat international how may drop off don't. Don't pay and then translation uncompensated care providers. And see. I'm sorry Representative right. You're recognized yes Sir thank you Mister chairman ma'am on page four you were explaining about the different cost of the healthcare you know Mississippi seven six hundred one dollars a month. And Tennessee is it three hundred sixty five and then Arkansas Senate right at five hundred dollars can you tell us wine that there's such a difference in how much it is variation from state to state. And I don't have it do you know what that would be. possibly the the majority of the cost is the actual delivery of care in those states may be lower than ours we have some pretty high tech here in Little Rock as you will know and up in the north west and costs a little bit more deliver the care here. Yes follow up please sure do you think maybe it's because of accessibility is a little bit better in certain places and other places to. Yes that that has to utilization and usage has a big determining factor in those costs as well the people that access care more regularly than those that don't influence that cost of those premiums thank you Sir thank you Mister chairman. But you bet your first comment about The higher tech here in central Arkansas and up north west in sexual expand on that thought a little bit more which me and how it relates to the cost. Well the that the tech is expensive you know the MRI machines that we have here and and it's concentrated in and The Little Rock area and that that determines those premiums into the delivery of those that care influences the premiums carries gotta pay more so they have to charge more. If your MRI machine sitting over for city you got one set in Little Rock why would cost more to provide that why would you charge more Little Rock for that MRI then you wouldn't for city. Just the general delivery of that that care would cost more maybe the nurses here and doctors charge more than that the nurses and doctors charging to get to give an MRI down in Forrest City so that the utilization of the actually the the highest cost areas in the north west of Arkansas the delivery of character is more expensive even though probably the sicker population is down south southeast southwest so it's it's the delivery of that care that influences the premium the most is that driven by labor rates or what goes into the cost of delivery of care absolutely labor rates the technology all that. Okay represent right you're done. Our. Members have any other questions. Did you mention about another did under it may be in in the report previous I was looking through a did you say something about a. Another carrier. Or did I just imagine I heard that. Yes yes we had a another entrance health advantage. And how may use that make them. Thirty four we've got or how many that might five five yes. Can you tell a direct impact by them coming in that it's lowering the cost by the adding another layer of competition at the bend in the market place long enough to. No I don't believe they've so the other companies don't know that information until they see them like into a approve rights and those types of things they hear about it just as soon as the public does okay so that at this. Or is there anything else on your presentation what we have the the financial one I know that the big. Part of. Let's see to. Yeah and I'm not sure where this is. Thank you. Okay so we have the financial report and you'll see on page two the this is The state fee that was collected from a him before it was moved over to a ID. So the the total of the fees were four million three hundred thirteen thousand. And we don't have that fee anymore so this this would also contribute to the rates. But we don't have that anymore so it It. impact positively. So on page three we have a historical look at a him expenses by fiscal year and we've taken a sampling here of the highest cost things that we assign the AM previously for supplies and equipment travel salaries and wages facility rentals and the contracts for a Hillman as you can see and twenty and twenty one and for all that. One of those It's not something that we are having to and do because it was already established we were already doing this work and I think your remember we were doing deployed that a helmet was doing deployable work that we were already doing that which is kind of pushing the button sending it on so that's a huge savings we do have the A. him contracts which with CJ R. W. and with AFMC and we have to have them for For the it's a federal requirement to have navigators call lines At a call center and marketing. Thirty huge cost savings. What did the what did the contract amount. Go down Hawaii project you need to go down from twenty to twenty one I mean that's almost a hundred thousand dollar dropping contract I'm just curious right so this is this is the fiscal year it's not a calendar year so we still have time to. And if you'll remember we had a five hundred thousand that is our our and. What we are allotted to be able to spend for those two contracts. Refresh my memory on that is that built in shelves budget or was that spending down that four million dollars there were some reserve funds that were carried forward that's what we're doing with the reserve funds okay so. To do the math we would take the offer the. Four million three hundred thirteen thousand that rolled over when a him was transferred over to all too real. Take the contract the actual contract price off of that and I think we project to be we think maybe ten fifteen years for you spend that money down my right on that I'm I think we figured about eight maybe maybe eight or ten years however as you can see and twenty twenty we didn't use all that was allocated. For those contracts otherwise that money's just sitting over there in the insurance department and well I think it goes back into our pot so that it it will you know sustain us right and. As far as actual additional cost that the insurance department has incurred by taking a him in other than the contract shall just rolled all the responsibilities and duties and your current staff right well because you know we were when we go in and we review the plans we are already doing that as of regulatory healthlink so we didn't have to hire anybody to do that for as those types of things So the salaries and wages were taken care of in the facility rental we already have with a him as a whole. Senator Stubblefield as that you down there in eighty seven. Yes Mister chairman okay go ahead Sir I thank you Mr chairman. At the end of this goes back to what you were talking about earlier do we do we have any type of a comparison numbers it in regard to interstate are interstate a. Question in regard to the test screens if ordered by physicians. Including X. rays MRI's what is the kind of comparisons within our own state of particular areas that order more tests more screenings more MRI's compared to other areas another state. the insurance department is not and I'm not sure but a high may collect all of that data I'm just not sure if they do or not and that is there anyway you could find that out absolutely. Three that you're wanting the comparison for a. For a test ordered by physicians including X. rays MRI's. Bloodwork. Okay or other particular areas that are higher. In other areas in order states it also maybe just rounding states such as Tennessee Mississippi Oklahoma. Okay I believe I believe and Dr Joe Thompson will have more information on this and if we need to we'll we'll figure it out for you okay thank you thank you Mr. Represent person. Thank you Mr chair of looking at the state user face hi I know there was some discussion you know back before we turned back over to the insurance department a lot of states actually kept that revenue and used it to stand at different health programs waivers or they use it for various things and other states. The do you have any real evidence that eliminating that state user fee is actually decreased insurance cost yes I would I would I have I have heard the companies say that it does. M.. I'm sorry I lost my train of thought that yes I've heard that the the companies have said that they're building that into their right incrementa right change the and you think yes absolutely affected that right and so when they file their rates they actually made a statement saying so so they they do have within their rate information that they sent to us to approve or disapprove that that is the case but that did help. In the end hello at any maybe don't know this is amended to your the exchange but how important are rates based on the fact that Medicaid expansion buys insurance a minute ago they're one of the if not the biggest buyer of insurance in the state how much does that affect the rights. That that the Medicaid is buying insurance. I can't tell you how much and I don't even really know that it does that they're buying it I do know that. I do not I don't know I don't know what and how much that would be yeah now we can find that out as well we have people who work with the rates I just stopped sure well maybe maybe maybe and maybe the next insurance rating will get the plans themselves to come in and talk thank you. When you say that the insurance companies say that it definitely helped they don't give you a specific carry like today did that. Lower the lower the rate Sir did they get what specifically how did they say it helped. I don't remember the wording that is on the information that they actually submitted with the rates but it was positive that it helped the rates come down that they didn't Have to do that okay it is in writing and our and and R. and rate filings you mentioned that to a family letter sent out to staff I'd like to see how they supported their claim okay. Placed. Any questions from any other members. On the presentation. Culture it. Okay thank you all for being here today Frank presentation. Thank you Mr thank you Committee hello merry Christmas. Next run the day which is a report of the survey health insurance marketplace rounded stage which shows health insurance rates paid by the market place and Dr Joe Thompson and Craig Wilson bill would or anybody else is coming with you would you. From the table officially induced self and who you're with for the record please. Thank you Mr chairman chair and Joe Thompson presently Arkansas center for health improvement and with me's Craig Wilson director of policy at the center correct. Craig Wilson health policy director at the Arkansas center for health improvement and Craig you got to Mike to don't have the windshield on it maybe to make a difference with your master but all right one exhibit the The Jungle hidden present please. Correct I don't you do the presentation and I'll make some comments this is if we work closely with the insurance department they have regulatory oversight responsibility for insurance sold in the state are centered looks broader than just the in private insurance so looks for the interactions between our Medicaid premium assistance Arkansas Works program also looks to other state see what's happening in the environment to the questions we had earlier we also with the insurance department run the healthcare transparency initiative so we have about eighty five percent of all claims that are paid in the states questions that you have through your bureau of legislative research we can offer some support to answer thank you Greg. All right thank you for the opportunity to present today Mister chair I'm going to get to probably what is the the meat of this which is that the kind of bubble graphic that shows the rate comparisons across the different states but I do want to get a little bit of context before we before we get there talk a little bit about some of the national trends that we've seen over time the last time I was before this committee was a couple years ago talking about some of these trends and I want to make a note that that Hey Craig let me introduce you staff is staff is handing out a colored version of what you're saying shall be easier follow so what was exhibit the black and white is being replaced by a colored version I think it's going to make sure slide deck okay go ahead thank you thank you. the affordable Care Act of course introduced of destruction in the in the market as any kind of health care policy normally does and as a result the individual market for the first three years really. Of due to those major changes was was rather turbulent and you saw rate changes from year to year sometimes that were doubling in nature there were some risk mitigation strategies built in temporarily risk corridors and reinsurance programs initially those went away in twenty seventeen and despite those programs going away as well as of elimination of the individual mandate expansion of short term limited duration plans and the association health plans and the cost sharing reduction that is a that is that protects people with in a plan the that was suspended despite those things actually the market has become very stable and that's just a matter of really the insurers gaining experience over time the more experience they have with the particular market and the regulations surrounding it the more stable it becomes Unfortunately marketplace enrollment nationally has decreased by about ten percent from twenty fifteen to twenty nineteen that's mostly among the unsubsidized populations. A and and as a result of the cost sharing reductions suspension that that happened in in twenty seventeen a lot of the insurers really just shifted that cost because they were nonetheless still required to protect consumers from from from higher exposure cost sharing and they did what's called silver loading moving those costs into the premiums themselves and that resulted in individuals who were unsubsidized moving out of the the individual market so that's probably a part of the reason for that reduction over time. in Arkansas enrollment reached a high of about sixty nine thousand in February twenty sixteen it normally ranges from about fifty five to sixty five thousand in the health insurance marketplace an in twenty nineteen about ninety percent of enrollees in the market receive subsidies to assist them with the purchase of insurance only a third of individuals eligible for subsidies actually in roles so we as a state actually but due to our lower income here in Arkansas have a higher number of individuals eligible for subsidies unfortunately only about a third of individuals take advantage of those subsidies and if we if they all did we have a an enrollment of of approximately a hundred sixty thousand. So this is the the bubble graphic that we have done now for the last several years on the right there all all orient you on the right it shows the number of states since twenty fourteen with premiums lower than Arkansas and you can see we have headed in a very positive direction at one point we were in the lower third of states and now we're in the in the top tier of states having the lowest premiums in the individual market and then the comparison to our surrounding states you can see Arkansas was third among all states there of beginning in twenty fourteen and now we have the lowest premiums hard for me to even see that at about three hundred sixty five dollars. Per month. And I'll I won't delve into the group market but I did want to show you this as a comparison in the group market we actually have the it let me orient you again this goes from from left to right twenty fourteen to twenty nineteen on the left in the teal bar that is Arkansas premiums on the bottom is for an individual and topics for family. And then on the right in the blue is for the national rates and you can see that we compare favorably favorably nationally. And actually in twenty nineteen have the lowest of the individual rate for health insurance premiums in the employer group market and and we're only second in the family. So part of the reason and I think this is what little bit what Chantelle was was trying to get at part of the reason for our stability in the individual market is is a decision that that you guys made now six seven years ago the Arkansas Works through Medicaid premium assistance is a large guaranteed purchaser for about eighty percent of the market place so that ensures that those premiums get paid on time from the state and so that's beneficial for stability also since twenty fourteen as a result of the affordable Care Act the there was funding for states and an Arkansas wisely invested in additional a rate review platforms and are able to do some of a pretty aggressive rate review prior to twenty fourteen insurers would would submit their actuarial justifications and there was really no kind of cross check on that information you just had to either you know take a sample and believe it now the insurance department has additional tools including the all payer claims database and they can they can look at the the utilization and prices and how how those things have migrated and changed over time so there's there's additional tools to check their also there's a budget neutrality cap of course in the in the the Medicaid waiver for Arkansas works so it can only increase by a certain amount from year to year and so that puts downward price pressure on the insurers who offer their rates for Arkansas Works there is of course as the insurance department just noted before continuing competition in the individual market we have consistently had more than three insurers participating in the health insurance marketplace since the beginning and if you were. Call there were some years in the in the early years were some states had one or sometimes nine and they had to recruit insurers to come into their state to offer in certain counties. And then there of course has been a shift to value based payments were insurers are more willing to pay for outcomes verses outputs or or volume and it's so that through the patient center medical home program that you have here the episode based care program that we've had and I know that's migrated a little bit too Today to different types of value based payments but those consistent and widespread use of value based payment strategies has resulted in stability as well the Craig let me hit the pause button for many get a few questions in order for move on Senator Hendren. Thank you Mr chairman of these the last couple slides have been fairly interesting to me and I know as we prepare for a session and looking back on the debate we had on fee for service versus the in subsidized insurance companies. there's a couple factors one of the things that would be good for me to understand is if you could go back to slides to the health employer health insurance premiums and as a guy who just did my renew a looks at every year it was amazing this year to see flat for the first time I've seen and in years so there's a tremendous savings out there to companies as we have as have a stable employer insurance market is there a way that you can quantifying it as we start looking at. Because some people think it's just about the cost to the state of providing the service and forget to realize it's also about the cost to the taxpayers in the term in the term of employer insurance so is there a way to quantify that data what the savings is to employers and employees because of the stable insurance market. Senator I think your question is is spot on and and you've pushed forward into what I was going to try to do that let me let me take over for create just for a minute. Yes this being the last meeting of the insurance marketplace I wanted to make sure that you all have the history and the impact that your decisions before on using premium assistance from Medicaid to buy private insurance in the individual market place that you have that those impacts whether we can specifically quantify to the dollar I think that would be difficult I think without question you can quantify the directionality and attribute some of the stability in insurance world you have you have self insured employers that basically they take the risk and they just rent the health insurance companies provider networks to pay you have employer sponsored insurance which you are purchasing is reflected on the slide here that insurance companies really want because you're buying for a group and you're making a commitment because you want to healthy work force or part of your compensation package the individual market place where individuals have to write a check every month to keep their insurance is the least attractive market for insurance for health insurance of any that's around if I know that I have chest pain and I don't have insurance I can sign up this month to get my Cather's ation next month and then I don't pay my insurance bill the third month and so that is unattractive to insurance companies so what you did in two thousand thirteen and let me just say that the Arkansas Works authorization expires at the end of next year so you will have to decide whether you want to continue it in the coming session or in a session at sometime in twenty twenty one the waiver also expire so DHS is gonna have to renew that waiver so that's why this becomes important from a policy consideration in the coming session but what you did is you took the money under the affordable Care Act and you bought the sensually individual premiums individual coverage on the. Market place which is not reflected in the insurance department's numbers because they are in the private insurance market place but eighty percent of that that is sold is bought by Medicaid and it's guaranteed insurance companies don't have to worry that Medicaid not to write the check next month and so it's it's guarantee payment. That stabilizes the risk pool which then lets the companies have more confidence in what they're going to have to pay which then makes it attractive for other companies to come in and we actually have had companies enter the market place since the Arkansas Works program was put in place so that now we do have competition in every county another policy decision you made is the insurance department does not require insurance companies to sell in every county they allow insurance companies to pick which counties they would sell and so you can have people want healthier parts of the state and they don't want less healthy parts of the state in the Arkansas Works was a requirement that if an insurance company participated they had to cover geographic areas of the state they can cherry pick this county and leave that county out see it state wide coverage we also think that you not only stabilize the insurance rates but that you also stabilize the healthcare system we've had fifty five rural hospitals close in states around us in the last seven years we've had only one which was probably mismanagement down into queen more than fiscal duress and so it's been a stabilization there you also transferred. Because of this change in match rates the affordable Care match rate is ninety ten the state Medicaid match rate is about seventy thirty so you used to pay for almost two thirds of all pregnancies you paid thirty percent of those cost now they've moved over into the ninety ten so you've saved in concert state resources and finally one that's difficult to quantify but I think it's present is we have fewer people applying for social security to get healthcare benefits as a part of disability because they can avail themselves of health insurance and not to clear themselves to be SSI disabled so all these are moving parts in the policy space center I think your issue it is a significant contributor both on the individual market and then also because those health care systems or stabilize their not having to cost shift onto other employer sponsored insurance the drives up the cost in other states it if I could just follow up Mr one sure so I guess what I'm asking for again is find the state that similar to Arkansas that did not implement a program like this what has happened to their employer sponsored insurance rates compared to what happened Arkansas and what that equates to basically as to you know tax relief for financial relief or whatever you wanna call it for the employers and employees of the state so we can have that information as your right to be especially again I wouldn't wear that we had to renew all this this year or the waiver expires and and so it's gonna be important have is going to be important policy issue will work to get you a regional picture because that's probably what's most pertinent to you know our population if there are other specific states that you want us to look at. Let us know which those are will be collected thank thank Mr. Of culture first. Yes and sort of to senator hindrance concern of one of the things that DHS is considering is to leave people in Medicaid until they actively choose an insurance plan. Do you have thoughts on how that would affect the insurance market in insurance rates and. and what do you know I'm not sure that I think people care if they're in Medicaid or an insurance plan I don't think there's any incentive for them to cheese one but if we start leaving these people in Medicaid decide the premiums what is that can do in terms of lease in the premium tax and also losing that actuarial community rating. It is again in excellent question I want to I want to. Position this. One of your challenges is going to be to see the how the moving parts all work together DHS obviously would like to minimize their budgetary expense and therefore if you keep people who are using health insurance or are using health care you don't pay the insurance premium for those individuals conversely through the transparency initiative we see about twenty percent of people that have insurance don't use it at any point in time that stabilizes the rates that's how insurance works people who don't need it are at that point in time paying for those who have very expensive costs and are using it so anything that is going to I would say destabilise but I would say change the risk pool needs to be looked at from the perspective of what does it do for the Medicaid budget what does it do for the insurance departments regulatory situation and what does it do for the private employers that are paying for health insurance on the open market place. Let me ask you. On The percentage of people. The percentage of people that are not signed up on a plan the conversation we're having previously within charge. Apartment. If. Is there a way to measure the impact of them not being on there how that might impact the rate and would lower it. More. For those non premium assistance Medicaid folks that are on and then fall off as they fail to pay their monthly payments yes we can look at that and and actually with the transparency initiative it's a little bit of a lag because but we get the hospital discharge and your discharge data so we could look at those people who dropped off and see if they show up in the emergency room at with no payment source effectively becoming you know uninsured individuals that the healthcare system pays for but. Person who really pays for that as they shift those costs over on to private employers or others that that are paying those premiums so we could look at that as senator to the transparency in issue we have not done that yet but we could. Okay represent first. Add up I thought the insurance department is going to bring this information I'd ask him but maybe you can answer the question these What are the parameters around the short term limited duration plans in Arkansas I know in in many areas they're horrendous and other words they say they have a million dollar coverage but it's only five thousand dollars per episode the hospital or they have a daily limit of their very skimpy and don't you know not really adequate insurance due to we had does interest department have rules for those kind of things will turn to create for the rules for a second just to level set I think it's three years ago less than three hundred sixty five day coverage plans were allowed which which got you out of the essential health benefits and therefore you could compress what was covered to your issue that it's it's kind of a skinny plan that done last the whole year those are a less expensive option Craig on on requirements there and and it may be a better question for the insurance department to answer on the rules if we could let us differ an yeah at that I had asked them to bring that I didn't think about it to live richer slide. Mission you will come up in when you all want to weigh in on. We we work really closely in well with the insurance department so we're pretty sure who knows what went and that if you've got the expert in we need to let them answer the question. Yes the. Sorry of the short term plans can now go up to three years guarantee renewable they are under written so you have to be reasonably healthy to get on those plans that's why their premiums are lower. And sometimes their their deductibles and co pays are lower as well than on the marketplace plan. Bottom line though is you have to be healthy to get under that plan so not everybody is eligible. I guess but do we have any requirements for a daily limit or a hospital stay limit or mean can they sell anything they want in terms of limited duration plans I have to refer to somebody else in compliance on that I don't have those details of what they will allow or not allow. Yeah well I mean yeah because I mean even for young people if they have a mental. K. cancer an episode of me just being healthy to start with you you know course maybe they'll go away I hope. Thank you yet you can actually go on Blue Cross is website and look at those short duration plans they have plans to go for up to eighty eight days they have won your plans or less than one year plan and then they can go three years and then you can see all the benefits there so the public can see the benefits and the rates and know what they're getting into but you're absolutely right they they can be skimpy. But we don't have any idea how many are sold in the state no ma'am I don't have that those numbers okay thank you thank you get that and send it to staff please what pushed up to committee okay. All right let me ask you one other question will move on with the rest presentation if there's no other questions the comment was made a while ago and they were looking at you want would be made about you know the cost of deliverable like for MRI and Central Arkansas northwest versus a four city or you know somewhere over in maybe not as thriving of an area how does that factor into the rates that are charged and what is that is that the labor of what is it that drives the cost up in those areas versus a you know a five hundred dollar MRI in Forrest City versus five hundred dollar MRI in literature sometimes a little rocky in the block apart and Amorites be significantly different. So the. The state has actual insurance department allows the insurance companies by different regions I think we've seven seven insurance regions so they submit rates for each region and those rates are built off of the underlying cost of care in those regions and the utilization of services by residents of those regions so there's a little variation across the state here in in central Arkansas it is almost always the highest rate and in that is both because of cost and utilization or little bit higher here for folks that are in central Arkansas that's probably driven by the doctor's order and more stuff and more accessibility here in the states in the central part of the state northwestern Arkansas not dissimilar but I would say within a region for two services that are side by side the cost don't really make any sense it's what's negotiated in the contract price with the insurance companies and that's why the transparency initiative that that you passed in that with the insurance department we're putting in place trying to make these price differentials more publicly available so that if you're paying twice as much for the same thing somebody at least ours ask the question why your question is directly on target I will tell you the the variations we see in the private market place there's not much variation in Medicare Medicare puts at a freeze fee structure and says here's what we're going to pay there's not much variation Medicaid Medicaid puts out a fee structure and says here's what we're going to pay but in the private sector their private contracts between the insurance companies and the providers and there's a significant amount of variation that we see in the all payer claims database and that can increasingly be revealed we've got a data user That is got publicly facing pricing information for different different procedures of arthroscopy of your knee an MRI of your hand those are increasingly publicly available as individuals have a co pay or deductible and they can shop more readily for the same service at a lower cost so the rates that are on the handout is that kind of a smoothing effect of the different of the of the overall cost when you when you throw the yes March the shady and and it's a weighted average across the state of the of the of the policies that are on the marketplace with there being a rationale to you said seven regions while ago taking a look at it region by region and the rates being set by region an apar reason thinking is it might be a you know center Hendren support at this may be good or bad but I'm he may be disadvantaged in his or somebody else's advantage in another area or is that make it too complicated for the insurance companies want to come in and bid on a market that's broken down by seven regions versus just the overall cost. Yeah I I think what what you're. Some of you in your predecessors did through the private option Arkansas Works Medicaid premium assistance issue forced the insurance companies to have a little more of a level playing field remembered the before that an insurance company could come in and say I only want to cover Pulaski County I don't want to cover Salim county or Washington County or and so with the guaranteed with the with the Medicaid premium assistance. In that original legislation is also the requirement that they cover regions of the state so we could revisit whether the regions are drawn in the right way or how they compare to each other but that's in your policy space and to the upcoming re authorization should you so choose for the premium assistance represent persons are created you have to yeah I I just add on the regional differences some of it's just basic supply and demand you know in in in Northwest Arkansas we've got a lot of population growth that that health care system structure up there is just trying to catch up on their supply is is is there from you know twenty years ago when it wasn't as as populated similarly in other parts of the state their supply is greater than what it was twenty years ago due to population out migration so that the healthcare system and their ability to the provider's ability to negotiate under those circumstances varies quite a bit across the state are represent version will add at I would think that and you might say if this is correct I would think that if you're looking at Little Rock in Northwest Arkansas being higher cost it's because they're tertiary care centers I mean you have trauma centers you have a higher level of care in those areas that are being fed into from rural counties in other places so I think it's more that the type of care they're delivering is more expensive than maybe a rural hospital with a family practice doctor but. I I would agree just one of the the insurers are going to pay for care based upon the county of residence so even if you are in rural Arkansas and you come to Baptists are you a mess here in central Arkansas that that cost is going to reflect back on the on the region of residence for the individual so it's you're correct in that those of us who live in high cost areas every time we go we're going to have high cost those who may live in a lower cost area they're going to pay the same cost when they come to the tertiary care center that that others would. But you know what is that the moral hazard if you have it available it's going to be used more often so you're if you have a tertiary care center you're gonna have more usage than you would in a real place. Check Hey buddy. R. one shouldn't forty ways to rest the slide deck please all right now this is gonna this is gonna go pretty fast once I hit the button but this is just to orient you a little bit this is a small here small area health insurance estimates on is based on on county here and this is health care coverage from twenty two thousand eight to to twenty eighteen you can see the the legend over there that the darker blue areas are I can see it at closer to twenty five percent uninsured in those areas and yet this is just a demonstration of the change that happened as a result of of of your actions here expanding coverage to to more individuals it's the gets pretty pretty dark before twenty fourteen and then there's a massive change rates have debt for an insurance across the state to about twelve percent we were at about twenty five percent of the population prior to expansion of coverage in twenty fourteen and I like to note here the distinction in the in the surrounding states with the exception of Louisiana that expanded the Medicaid coverage in in twenty fifteen just a year after we did but there's a pretty significant difference right around the Arkansas boundary for Missouri Tennessee Mississippi Oklahoma and Texas is there. it's important that are occurring yes just for a does this have a hard time seeing. A in the two thousand the health insurance coverage in the two thousand eight to two thousand eighteen the last slide deck work shows Arkansas. Lighter as far as more of the blocks being white yes that indicates that we progress toward greater coverage of the citizens of the State of Arkansas mark in my right eye yes roughly cutting the uninsured population in half right and. The overlay of the states around us that are darker. And maybe you get to this on the deck the number rural hospitals that were closed yes it's gonna be significant in the states that have the darker Bloxham it's it's yes it's it's been devastating in some of those communities it's roughly fifty fifty fifty five of rural hospitals in our surrounding states of close since twenty ten okay all right thank you go. so important to the safety net is is critically important particularly now it's estimated from from the beginning of the covered nineteen pandemic that nearly fifteen million nationally have lost their employer sponsored coverage enrollment and traditional Medicaid and and and the Arkansas Works program has grown by nearly a hundred thousand since since March so that that safety net has been critical critically important for individuals who who are in need of care it part of that is because the the federal laws that were passed at the beginning of the pandemic inhibited states ability to descend role during the pandemic which is understandable so some of that is lack of disinterment but much of it is from people gaining coverage where they for they previously lost it and in job based coverage. there's been a significant disruption in a utilization patterns of courses is the insurance department mentioned there's a lot of delayed care for preventive services particularly vaccinations care for chronic disease management and elective surgeries there have been though considerable expenditures for coca nineteen related care we know that those who progress in the illness and have to be hospitalized can be hospitalized for long periods of time there been flexible telemedicine options which we've seen and in across the state and particularly and some of the data that we seen from state and public school employees that the uptake on telemedicine particularly for mental health services as I mentioned there the uptick in demand for for those during this time you know almost all of the. Mental health services at the outset of the pandemic we're delivered by telemedicine so it has become a critically important access point for folks getting care particularly mental health care and and I've I've heard it from they run at the Arkansas medical society and we've seen it in the data we really jumped about five years ahead of where we were on on telemedicine and hopefully as we move ahead it will become a more natural and integral part of how our physician clinics deliver care to patients. Some potential changes impacting the individual market place in the in the next administration I do suspect that That there will be a return to more limited application of an availability of those short term limited duration plans it is likely that they will go back to. Being a truly I think short term as they work with a prior to about twenty seventeen probably more likely around three months uh verses nearly a full year and renewable for three years. and those association health plans as well there was some litigation that that really it limited those and and and it might not be an executive action that occurs there there could be expanded open enrollment periods are open enrollment is currently at forty five days in previous years it has been three sometimes four months Unfortunately the the the plans that are on the market place are becoming less attractive due to out of pocket maximum costs which for an for an individual if if they don't have cost hearing protection in the plan can be as much as nine thousand dollars for an individual and seventeen thousand dollars for a family so the the out of pocket maximums within a plan are making the plans themselves much less attractive and then of course there is still pending litigation on the affordable Care Act before the Supreme Court and we should hear something from the court by June on that. Of. Go to address this one I just put these are things that are centers looking at you know the enabling legislation renewal in the preparation for Arkansas works in the coming session we anticipate the need for some telemedicine framework because we've kind of thrown the door wide open and there's going to be a need for some new approach to that the potential for surprise billing I think we're going to see with the number of air ambulance transfers that were having potential there for some surprise billing issues and then we've been working closely with the executive branch in the governor's team on assessing the impact of the crisis stabilization units these of the four units that you authorize around the state to allow an individual in mental health crises that has an interaction with law enforcement to not be taken to jail but to be able to be taken to a mental health crisis stabilization unit some of the early assessment that we have it's not so much a benefit on the health care costs side but it is a reduction in the subsequent incarceration days that these individuals have so it's a it's a it's a savings to the jeep the. Correction facility side of the equation so I thank you for the opportunity glad to take questions and taking the number don't take too much of your time but we're available if other questions come up. Telemedicine the only one that you're looking at because or a lot of other doors that swung wide open. There's some of those doors that we try to not go through. We would be we'll be glad to provide a framework on on scope of practice in the political battle that that will will have but the that largely yeah the evidence around scope of practice is is not as strong the things that that we try to bring to you that we see have good evidence that either other states found to work or that other states found not to work if if if we can find those who want to offer those to you for your deliberations and consideration in the coming session are apply right. Thank you Mr chairman on page nine. Of under potential on changes. It mentions nine thousand for individual and seventeen thousand for family and in twenty twenty one. Of. Is there a quite a bit comparable from twenty to twenty one. Yeah that's that's for a bronze plan date date the federal government re assesses that every year and there is a calculation that they do based on actuarial analysis it is up quite a bit it's it's it's going to be up a little more in twenty twenty two then then the change from this year from last year to this year on and that's just because they're they're changing the way that they calculate that it's a pretty complicated methodology it has gone up I would say from about sixty five hundred in twenty fourteen to now nine thousand and twenty twenty so. That that to me is that a pretty hefty increase over that time if I can just add you'll remember yep bronze silver gold plans on the exchange the bronze plan has the highest deductible that nine thousand dollar deductible but it also has the lowest premium so you can buy a. A plan with a smaller. Out of pocket maximum but you're going to pay more per month on the premium and so this is this is the least expensive plan has these levels of out of pocket expenses you can buy up if you say if you will and and reduce these out of pockets but your monthly premiums is going to be more. Are gonna be more okay follow please. The covert that came through this let this year. We're always behind a little bit when we start figuring the cost of things is that going to have an impact on the insurance for the next couple years. It it very well could you got some some balancing factors that I mentioned there are a lot of people delaying care that they would otherwise get due to coca nineteen so they're avoiding looking going and and get their blood pressure checks they're avoiding going to get there there you know annual wellness visit and and check out so. It's unclear right now what what that balance will look like I think it's important to understand. when when the insurers come with rates for the next year they're looking across multiple years to to develop those rates so they're looking at experience three sometimes even as far back as as five years so so the development of the rates takes a lot more into consideration that just of a particular period of time within a year and and that'll be important to smooth out the the the change in costs from year to year. I would just a with our window of in in pretty much real time has been the State and Public School employees plan where we can see those expenditures each month and we did see a pretty significant I mean things just shut down in March and April so you aren't spending anything in March and April it is come back to now be about the same level that we would have expected before course the other thing that's important you know your for your federal tax dollars have gone to pay for the billions for the vaccines development and deployments of those baxeen cost should not be in your health insurance premium but what we don't know yet is what the downstream. Comorbidities the downstream impact of Kobe nineteen is going to be on the health of our population we've got some in evidence that it not only causes your pneumonia and your long issues but we have some other organ systems that it can target and have some damage to that shows up to three months after you have code. Thank you represent first. Well and and that brings up the issue of pre existing conditions I I mean I know what think we cross that bridge now where everybody thinks preexisting condition should be covered but has that not been the biggest driver of the increasing cost of insurance. There's there's no question that the way insurance works is if the way it used to work and in many of you will remember this you could be uninsurable the insurance company would say you have so many. Problems we don't even want to offer you coverage at any price the affordable Care Act eliminated that and required insurance companies to cover you regardless of your pre existing condition you heard Mr Donaldson earlier say that the skinny plans the less than a full benefit plans under wrote you they they cause you to have to take a healthcare questionnaire and if you have a pre existing condition they can say we don't want to offer you a skinny plan and that's what he alluded to so yet the the pre existing conditions I think socially we all believe that you should be able to get health insurance The business model for health insurance is complex you don't get to by car insurance after you wreck your car but we think you ought to be able to buy health insurance after you have your heart attack and that's what is going to be a difficult you know ongoing challenge forced to balance cost coverage and then the quality access that we all expect. And we think it's okay to mandate car insurance but not health insurance. I would assume that was not a question. Well I guess my my bigger question is really for the individual I mean this is the biggest concern I hear from constituents if you don't qualify for subsidies on the market place and you don't have employer insurance it has become unsustainable for. While working at their age it is there anything as we can do from a state or is that all going to come from federal maybe increasing the subsidy limit and the percentage you pay out of pocket I mean water what are the solutions for that population of people who are buying individual insurance so if. This is going out a little bit on the the then I expect it is not just those for for individual coverage it's for employer sponsored coverage and self insured companies to that the cost of health care has grown faster than the average consumer price index for almost any other area over the history of time when we are in a relatively stable situation centre Hendren mention now but I guarantee it's going to start going back up we've got to find ways to eliminate inefficiencies in the system we've got to find ways that we actually understand why something costs what it costs and then I think you do have an opportunity in the original legislation for a the private option Arkansas Works was a requirement that the health insurance companies would participate in a value based purchasing strategy that's where the patient center medical home shared incentive scheme that's in the original legislation I think is there something new you can think about putting in the renewal legislation I think that's a point for discussion with the Department Human Services insurance department in the carriers to say are there new things we can do to actually try to contain the increases in costs that ultimately we all pay for. At a we didn't think that this to you mentioned that the risk corridor did the insurance companies ever receive risk corridor payments did that ever happen. I'm not sure that that they did at that I haven't and I'm not sure if if it happened locally. another person I think there were some litigation over over that issue as well recorder was the payment between plans no that's the risk adjustments that was about risk assessment did happen the risk adjustment is it is a permanent program and and if a certain insurer tracks more risk in the market their their payment transfers that go on after after the years and but the risk corridor was you know if they didn't price their product accurately and the a and the it cost them more they could they could receive a some funds from the from the federal government and I have to check on that yeah and a because it was so difficult to predict actuarial early on a all right I know at one time Blue Cross had not been paid at I don't know thank you. Members have a question. I guess last one I have is that you know it was mentioned while ago about individuals have subsidies on the you know health insurance marketplace and yet they don't sign up. Is that just human behavior or do we know the total number of people and maybe that goes back to question Lago how many how many are missing or how many or attributed to that group and how would it impact the overall cost of the insurance if they were in there would that lower that rate down sherry waited now that. So I think correct your number was a hundred and sixty seven thousand eligible for subsidies and right now the insurance department's number was somewhere in the hi sixty thousands of those that were participating on the market place and with a majority those getting a subsidy so you've got a hundred hundred twenty thousand people that are for forgoing a federal subsidy to help them buy health insurance on the market place it is a voluntary choice of of at this point in time with with no penalty for not being an insured and it's a it's a human nature decision based upon their individual financial situation and risk tolerance and probably health if those hundred thousand people are healthy and they got put in the risk pool it would bring the rates down if those hundred thousand people are unhealthy and hitting the emergency room right now and the hospitals with emergency departments or cost shifting on to those that are paying then it's going to cause rates to go up I think that's one of the questions we could look at project on those that start off and then drop their policy because they failed to continue their payment we can we can try to do some analysis with the transparency initiative to see are those healthy or unhealthy individuals and are we really paying for them in a different way through cost shifting on by them being uninsured I think the with which you generally see is is the people who decide not to take advantage of the opportunity to enroll or Julie those people who don't don't feel like they have a need for the insurance and and that's the that's the nature of of human beings so I think there's there's quite the possibility that the people who don't enroll are likely healthier than those who enroll because because the individuals who enroll are protecting themselves from what they what they see is a good risk to represent Ferguson's comment while ago though you you're required to have car insurance because you can't predict. When you're gonna have your car wreck and and with somebody else health insurance kind of the same way you can't predict when you're going to have your health need in advance so so that's that's just it's a moral hazard that is present in our system is is that. It is part of that because if they they're they're feeling healthy don't see the need to have insurance and even though they may qualify for the subsidies they may still be a hundred Bucks out of pocket or not and and that's bottom line is there is there any way to collect data on that missing population as far as what their income levels are and measured against what the subsidies would be if they were to sign up or is that too down the weeds or do we have the systems in place to get a good analogy of that population. That we could determine that if they were in the plan. It might reduce the overall cost everybody let us let us see what we can find a job I don't think we're going to get to the granularity that you would desire but we may be able to get some more information that we were able to give you this morning okay to be very good Senator Stubblefield. Thank you Mr Dr Thompson I just wanna ask you would question of. To the Medicare reimbursement rates vary between patients to have a consultation with the doctor in regard to cove even though that patient may not be tested for covert. R. or even treated for COPD to those reimbursement rates for Medicaid very on a patient that has at consultation. Purchase one who doesn't. Senate centers for Medicaid or Medicare or both I guess both both. I there are some supplemental funds that go for providers that are caring for Covin positive patients particularly those that are in the hospital or in the nursing home you've done that it cares Act had I think Federal government did Craig help me here one of them did the long term care workers and one of that the hospital workers and flipped on which one with. And then I. But I I think to your general question you know a regular doctor's visit or something else for cove it is not paid a differential rate. Okay. There is there is no difference in the reimbursement rate not to my knowledge okay and I know that's been a concern was there a is there a financial incentive to effectively up code the code diagnoses or or have those be more frequently kind of put in play which would cause the number of individuals with cove it to be misrepresented on a higher scale I've not seen evidence for that and I don't think the rate reimbursement for a regular doctor's visit is different it's still a and it's still the same CPT code that you do for a doctor's visit on other purposes. All right thank you Mr chairman. Represent right. Thank you Mr. Of these hundred twenty four thousand people Mr Jones that are uninsured and Arkansas. Now we've probably shown that may be in certain cases are healthy or they don't think they need a plan of some top okay but let's just say that they did out of that hundred twenty thousand if you had. Ten thousand that actually. Needed to go to the hospital or a doctor or something like that this year. They would not be paying for a plan and they would not fall. What excuse me they they actually would fall under a ten percent cost if they were in a plan but they did not choose the plan. What date in certain cases if they were not making a lot of money or something like that. And they fail within the Medicaid range. What does not cost. Senate so if for some. So if you have an individual in let's let's break people by income eligibility those that are below a hundred thirty three percent of the federal poverty level and therefore would be eligible for Arkansas Works there is not an open enrollment period so that if you were uninsured and then suddenly fell into need you could sign up and get coverage through the Arkansas Works program for the poorest individuals in our state is those individuals that are just above that line a hundred thirty three percent and above that the private carriers have an open enrollment we're in now the end of November first of December that if you don't sign up during that period of time you can't get into the insurance coverage in your uninsured so so that the door opens here at the end of the year for most of us with our employers are on the individual market place to buy or sign up for insurance and then it closes because the insurance companies don't want us to do that wait out until I'm having chest pain and say what I need insurance tomorrow and go sign up for the healthy have to pay and when they're healthy to cover the six people that are in the plan and these healthy people unfortunately all of us are going need to be in that that plan at some point in need some healthcare. Sure. But Mr Joe if let's just say they didn't sign up and I got out into the year I don't know what percentage of those folks actually would fall within. The property right well let's just say twenty percent. Overall would not cost the taxpayers more money if they did not choose to get into a plan it does cost the taxpayers more in a few different ways because when they get sick and go to the emergency room well it cost the taxpayers more but also because the private sector more because when they get sick or they get in a car wreck and they use the emergency room those are real costs and those costs get turned back either through cost shifting to those of us who do have health insurance that will pay in some for that uninsured individual that's how the private sector pays more or gets turned back on to taxpayers by the hospitals and others you know claiming uncompensated care credit on their on their tax base and other strategies. Thank you Mr chairman you're welcome. Like cashier date one bit information that you're looking for when you deal with that missing hundred thousand if there's any way for you to determine that after open enrollment closes that of those hundred thousand how many have actually ended up having medical events that had they had insurance you know it would have been a different outcome addition can you grab that number see if you could we'll try to put a package together for you that looks at the questions that we've heard this morning if we don't answer them all or if it would if we find a question that we cannot find an answer for will try to flag that for you also and if you might just send that to Emily and she consented up to everybody so everybody will have the benefit of it but we carry snow how may those ran the risk and then everybody else ended up paying for the risk so any other questions for members. Anything else you all want to share a hope everybody has a safe and and and merry Christmas happy holidays the the code is that the the vaccines come in we got a couple more months that we need to buckle down and do the right thing. All right thank you just a reminder that the chairs are in unison recommending to leadership this committee just be absolved into up absorbed into the insurance and commerce and thanks to work to be done there and help make you a more efficient less costly to the state culturing thank. We're good calendar Christmas thank you only for the good work helping us.