Sign Alaska Banking RFP Secure

Industry sign banking alaska rfp secure

I want to jump right into our afternoon keynote speaker Laurie wing hire is the director of the Alaska Division of Insurance Laurie's been asked to testify back before the Senate health education labor and pensions committee has had a prominent role in terms of her speaking with in front of the National Governors Association this weekend at the National Association dress commissioners she's in high demand and we're really honored and appreciative of her being here so without further ado let's welcome Laurie wing hire thank you what a year it's been from where we were this time last year as we were looking at our rates after we did the reinsurance program we all know that the cost of health care in Alaska is very high and access is limited compared to mother most other states particularly for specialty services low population density and limited health care provider and facility competition in much of Alaska our primary contributors to alaska's high healthcare cost with a population of over seven hundred and thirty eight thousand spread across over five hundred and seventy thousand square miles we have a small population and are the largest and one of the most geographically isolated states in the nation access to care has been a challenge in Alaska for a very long time due to our large geographic size small population rural population and insufficient health care provider competition because of these challenges common managed care practices such as legislated network adequacy levels closed network plans and the development of health maintenance organizations have not been successful with the highest cost of health care in the nation Alaska also leads the state in the highest cost of health care insurance and is amongst the highest in workers compensation as intended the Affordable Care Act mandates increased health care insurance enrollment in Alaska prior to the ACA s in 2014 alaska's uninsured population was estimated at approximately 134 thousand residents mostly non-elderly adults after two years of ACA enrollment opportunities the number of uninsured residents in Alaska was approximately a hundred thousand Medicaid expansion has further reduced this number but the uncertainty of the future of the ACA may result in the number of uninsured rising again the unintended consequences of the ACA was that the high already high cost of health insurance in Alaska increased even further many Alaskans who do not qualify for an advanced premium tax credit or subsidies are unable to afford plans offered in the individual market according to the data of the Department of Health and Human Services premiums in the individual market have risen 203 percent since 2003 thirteen the year before the ACA was enacted on average this means that an Alaskan in the individual market who was paying a premium of 344 dollars per month in 2013 as a pain a thousand forty-one dollars per month in 2017 the high costs do not only affect those in the individual market participants in group markets employee sponsored plans are not eligible to receive subsidies or tax credits to those in the individual market even though many Alaskans are covered by an employee sponsored plan employer contributions typically do not extend to family members therefore many Alaskans families in the group market are unable to afford employee sponsored insurance that covers the entire family leaving spouses partners and children uninsured the ACA was a well intended piece of legislation that brought insurance to millions of Americans the expectation was that as provisions of the ACA alleviated insurance underwriting restrictions that previously made it impossible for many people with pre-existing conditions to obtain insurance those with chronic or civil severe illnesses would become eligible for insurance again soon second isms such as the advanced premium tax credits and cost-sharing reduction payments low and moderate-income individuals who would not otherwise be able to pay monthly premiums would also be able to fell obtain health insurance the insurance market would be stabilized by the 3 R's risk adjustment reinsurance and risk corridor the idea was that millions would enroll in the premiums generated would support the expenses of the whole however this well intended fundamental concept failed in most states forcing insurers to either withdraw from state states or increase premiums in the individual market to a point that a CPA plans were not affordable the three RS has had mixed impact on the markets and have not stabilized the ACA as intended which has also led to some of the turbulence in health insurance markets continue to face in Alaska it appeared that premiums could not be increased enough to cover cost of health care the cost of claims that were being submitted was above the premiums that were being charged some estimates indicate that for every $1 in premium a dollar 15 was being paid in claims we saw our individual markets struggle even with the stability mechanisms of the ACA and in May of 2016 we lost one of the last two insurers in the individual market to address the critical situation and stabilize the volatile market last year the division of insurance worked with Governor Walker to develop the Alaska reinsurance program HB 374 received overwhelming bipartisan support from the Alaska State Legislature the Alaska reinsurance program or ARP is intended to provide stability to the individual health insurance market mitigating rate increases by removing high-cost claims from the individual health market by removing high-cost claims from the pool the benefits of the ARP are shared by the entire individual health insurance market regardless of income ace rage ethnic group or any other demographic characteristic as we anticipated the program had an immediate impact on the rates an individual market prior to the enactment of the ARP indications were that the 2000 17 rate filing would include an increase of close to 40% after the enactment of the AARP however the 2000 individual rates had a moderate average increase of just over 7% still it should be noted that Alaskans who had to switch insurers had a rate increase of close to 35% above what they were paying in 2016 actuarial modeling indicates that the AARP will continue to help reduce the rates of insurers in Alaska and thus the premiums charged to Alaskans the slowing of the growth rate increases and potential for decreases may also draw additional Alaskans into the market independent actuarial analysis estimates the ARP will increase enrollment by over 1600 individuals in 2018 modeling also indicates that the AARP at RIT may attract healthier members to the individual market further reducing rates we believe the AARP will encourage competition in the state's insurance markets there is optimism that in subsequent years there may be interest from other insurers to provide health care plans if the market remains stabilized if additional companies moved into the Alaska individual market consumers will benefit from competition HB a 374 amended current statute expanding the responsibilities of the Alaska comprehensive health insurance Association or Chia to include the AARP the legislature appropriated 55 million dollars from various insurance premiums to fund AARP in 2017 Alaska is using the funds to reimburse the one insurer in the individual market for incurred high club cost claims the high-risk residents are defined as people have been diagnosed with one or more of the covered conditions identified in regulation the insurers still administers the claims a cheery deceive the state funding audits the claims request and upon acceptance the claim disperses the fund to the insurer due to the on states state of Alaska's ongoing fiscal concerns the state legislature gave no assurances that the AARP would be funded beyond 2017 putting the sustainability of the AARP and the stabilization of Alaska's health insurance mark in jeopardy if long-term funding sources of funding were not identified in early January 2017 Alaska submitted an application to the Department of Health and Human Services in the Department of Treasury for a section 1332 state innovation waiver as authorized under the ACA an innovation a waiver allows state-by-state amendments within specific parameters for instance coverage must be at least as comprehensive and as affordable as what existed prior to the waiver the number of state references must be of covered state Reavis residents must be comparable and the scenario must not increase the federal deficit Alaska's application waived the requirement of a single risk pool and proposed that the federal government provide pass-through funding for a period of five years to stabilize the ARP the pass-through funding is based on the savings generated as a result of the reduction in the advanced premium tax credits it is estimated that the ARP will save the federal government 51 point six million dollars in 2018 relative to what the tax liability would be absent the program premium tax credits associated with the ACA will continue to be based on the federal methodology but the growth of such payments is slowed by the ARP our waiver application included an actuarial analysis that showed the amounts in the apt cease paid by the federal government to Alaska's was significantly reduced when the RFP went into effect in July Governor Walker was notified that Alaska's waiver had been approved director Seema Verma's letter to the governor indicates that the state will receive approximately 323 million dollars over the next five years to fund the ARP after the federal past who funded our accounted for the state will be responsible for providing approximately fifteen percent of the funding needed to stabilize the individual market in 2018 federal funds will cover 48 million three hundred and sixty two thousand dollars in the state will cover approximately six point six million of the 55 million at least in part due to the P Alaska's 2018 premiums are expected to decrease by approximately 20% or more if federal funding of the cost-sharing reduction repayments continues the decrease will be higher than 26% bringing the cost to the individual market back to and within reach of many Alaskans the state will continue to pursue programs that would benefit Alaskans both in the individual and small group markets possibly including the second section 1332 state innovation waiver as we work with the king with the Trump administration our congressional delegation and other stakeholders the governor is very committed to affordable and accessible health care to Alaskans all Alaskans regardless of their income or where they choose to live our relationship with the Department of Health and Human Services Indian Health Services Indian Health Services and others continues to be an important part of the governor's initiatives safer Alaska stronger Alaska which recognized the importance of affordable and accessible health care but we recognize that the cost of health care is a discussion that needs to be had this cannot be limited to the fees of a doctor hospital lab pharmaceutical or other provider nor can it be limit to what an insurance insurer may pay balance billing or transparency while all of these are a piece of the puzzle and concerns that we've each had to confront at one time or another there is not one single solution to this the administration continues to explore a common ground a relize resolution to the debate on the 80th percentile the state's regulation that requires an insurer pay at the 80th percentile for receive services received from an out-of-network provider as you might imagine at our hearing this past January we had testimony in support and against the regulation the question we cannot answer at this time is the impact the 80th percentile would have on Alaska Alaskans that already pay the highest insurance premiums until balance billing is addressed insurers appear to believe that any balanced billing should incentivize providers to contract as in network providers and a providers appear to want payment to be based on objective information and related to market value the Division of Insurance has had numerous conversations and two presentations at the National Association of Insurance Commissioners with Fair Health to understand their statistics and data that we rely on to accept the usual and customary rates and to determine the 80th percentile we were surprised to find that our largest insurer does not submit their data to Fair health nor necessarily rely on them to determine the 80th percentile when paying claims this is not a criticism of either the insurer Fair health but a point that the application of the 80th percentile may not be uniformly determined throughout the state it also means that consumers that rely on fair helpful in determining the cost of health care may not necessarily be receiving data that applies to their health care plan it is worth noting that a version of the 80th percentile regulation is being considered by some states as an answer to balance billing insurers will tell you that there is a cost to any balance billing legislation just as they show cost for the 80th percentile again the question we are still trying to answer is what will provide protection to consumers at the best possible cost states that have enacted balanced billing legislation also had to address a dispute resolution process to make sure the legislation is being applied or healthcare bills paid as the legislation intended consumer notices are being drafted in some states that have adopted balanced billing legislation the issue around provider billed and insured bit paid presents confusion to even even the most knowledgeable consumer and is hard to quantify but new legislation calling for transparency may be a start as Alaskans become more aware of the cost of health care and accessing it in a cost-efficient manner that will bend the curve down later this month the alaska comprehensive health care plan will hold their first meeting the group consists of state legislators health care providers and a senior member of Governor Walker's administrator the guest speaker is a former Oregon Governor dr. John and I'm going to mispronounce this I'm sure kitzhaber who led the healthcare system transformation in Oregon that increased access to care while contain cost we should not expect immediate answers or solutions to the cost in Alaska well we should be open to coming change as an access or delivery and to invent innovative approaches that have been able to control the cost in other states or regions we continue to monitor other proposed federal federal legislation such as the proposal to sell health care insurance across state lines while this is a hot topic this week federal law does not prohibit an insurer from doing so and some states have looked into the benefits pros and cons we are concerned with the erosion of consumer protections as the insurer would not be in licensed in Alaska if the state of dumb domicile did not have strong consumer protections Alaska could suffer financial harm and have little to no recourse a quick example would be the 80th percentile or balance billing our regulation that protects consumers would not extend to a health care plan offered in another state other concerns we have are the healthy members of the pool may elect to cross state lines further eroding the small risk pool we have the ability of your reg to choose your regulator yet conduct operations in any state was a major factor in the financial collapse of banks an analogy could be made that selling insurance across state lines could have the same impact the Walker administration is concerned with open 2018 open enrollment beginning on November 1st the recent announcement of the reduction in federal funding to the navigators and the sisters could will have a detrimental effect throughout Alaska and may reduce an enrollment in the individual market and Medicaid expansion we are aware that of the federal Department of Health and Human Services reducing access to marketplace health care gov every Sunday a time when you might expect those that work during the week to enroll it will be unavailable as they perform maintenance we have spoken to the congressional deleg tion and senior in the Trump administration I'm possibly performing the admittance at a time when millions of Americans are not depending on access we are also cognizant than any rollout campaign for open enrollment will not include the federal Department of Health and Human Services I'm headed to Juneau tonight meeting with Commissioner lattic Deputy Commissioner parity and the staff to discuss what we can do with our limited resources to effect successful open enrollment of course we are working closely with Commissioner Davidson at Department Health and Social Services and her staff as well as the governor's office on any course of action we may be able to take we have urged Congress to not disrupt the health insurance markets but intent to focus immediately on stabilization uncertainty to stabilizes the market committing to funding the cost-sharing reductions payments through at least 2019 will keep premiums rates from increasing and keep our curve headed in the right direction down our rate filings are approved subject to the funding of CSR and that's at a decrease of twenty six point five percent any decision could not fund the CSR could cause unintended unfavorable disruptions to insurance markets the individual employer mandates keep the market stable eliminating the most mandates would most likely result in fewer individuals participating in the market resulting in a smaller health care pool and higher cost to all enrollees until a viable alternative is provoked proposed on the national level or via state waivers the mandates are necessary in the short term we support collaborative reform developed in consultation with stakeholders that strengthens the markets with a goal of insurance not only being accessible but affordable amendments to the ACA must be carefully vetted to examine examine whether at expectations of the state are reasonable and how the structure potential programs may adversely impact States the shifting of program costs to the states creating undue financial burden needs to be carefully and thoroughly analyzed for impacts to consumers programs that allow states to accommodate the unique needs of their residents such as the 1332 waivers are vital to the long-term stability of the insurance markets further deliberation on the health insurance tax is needed in particular citizens of Alaska that already face extremely high cop health care costs may be unfairly penalized by the current structure of the Cadillac tax continuing the navigator and assistant foreign 'sister programs in rural alaska and urban alaska these programs are vital insurance brokers are not always available we have languages that where translation needs to occur so that people understand the benefits or what they may be entitled to these programs reduce the number of uninsured citizens and maximize market participation a review of regulations may reveal that some that are unnecessarily burdensome and costly to both medical providers and insurers the administration is also very interested in coordinated health care coordinated efforts with health care providers to address the underlying drivers of health care spending considering all aspects including pharmaceutical area ambulance inpatient and outpatient services last year Alaska established a healthcare Authority feasibility study to begin to look at cost controls with the support of the federal government a similar national effort could go a long way towards addressing the underlying market dynamics that are driving unsustainable increases in health care costs but it is important that we recognize that cost control must also begin at the state level any decision that is made going forward by Congress the Trump administration or here at the state level will affect access to health care and extremely and deeply personal subject to all Americans we need to make sure that the end result is better access to health care and that means affordable we all want a safer Alaska and a stronger Alaska thank you [Applause] all right Thank You Lori I appreciate it did I hear you say that you're thinking about another 1332 waiver we are we have kicked around as this debate over cost-sharing reductions if we would look at a waiver to fund the cost-sharing reductions using the same analogy basically that cost-sharing reductions are keeping premiums lower the federal government would be paying less premiums or premium tax credits to the state of Alaska and if they wanted to give us that as a pass-through funding it might work for Alaska yeah I think Massachusetts has also looked at it and I know other states are considering the same so the the 1332 waiver that was proposed by the Walker administration that was passed followed that logic just to sort of put a finer point on it that by providing the state of Alaska these funds the federal government will save more money compared to not providing these funds right in 2018 the premium tax credits are estimated prior to the waiver at about two hundred and thirty two million dollars with the reinsurance program it's about a hundred and eighty five million so that Delta is what we said could we have back mm-hmm because of the legislature and the governor's action to establish the reinsurance program if we could have that funding back as a pass-through funding it would give us a longer term or a more secure future for the reinsurance program spend essentially the same amount on the federal side but allow the state to do more interesting innovative things yes is that that the only sort of edge and nudge into a political question which you can handle delicately doesn't isn't that sort of an admission that the ACA is working that under the ACA states are allowed to innovate and spend the same or fewer dollars I think that in many aspects the ACA is work and people do have health care let's get let's keep in mind that this is new legislation it started in 2014 you know we're kind of in the infancy of this legislation so I think we're trying to find our way through with waivers as to what this that perhaps the one side that's all from Washington isn't working but if we can take some of that and say okay well but in Alaska if we did this it would work much better for our residents and our costs so do you think the flip side of that argument that clearly it's not working that we've had 200 percent increases in premiums over last few years on the individual market that sure seems like a pretty reasonable argument that we're not containing costs do you think that that creates more room for state-based initiative I mean if the ACA is working not working it's difficult but if there's clearly success when Alaska takes the reins and does it itself at least in this example is the lesson that the state of Alaska the governor's administration the legislature should be more engaged in actively trying to solve Alaska state health care issues I think we should all be more engaged in trying to solve Alaskans health care issues or the cost of health care that are at their health care insurance it's not an easy solution yeah you know there's a lot of emotion in it there's certainly funding needs to be addressed legislation needs to be addressed we need to look at rural versus urban we've got stakeholders from Indian Health Service to that we are all part of the equation yeah and need to be listened to so the the idea of taking this year the cost-sharing reductions in how so to speak at the state level for to support the market is interesting I know at one point I recall at least one of the hearings I watched the the you were testifying before I think a year and a half ago I think he made this statement that among the 13 32 options that you were considering at the time could have included merging the individual and small group markets is that an accurate reflection that at least at the time we were thinking about it we did look at that we thought that perhaps that if we made the pool bigger but at this particular point in time and when we were looking at it our analysis indicated that we would be penalizing the small group market they were going to take a dramatic increase to bring down the cost of the individual and we just as we deal with individuals we deal with small employers that are trying to provide this to their employees and if we raise the cost too high we were defeating the purpose defeating the purpose in that it would undermine the small group market though would have had could it have helped to individual market it could have made it larger it strikes me that there's this sort of central kind of tension if you break down some of these lines of business and you broaden the risk pool it might stabilize things generally right we could maybe merge into Medicaid and at least the individual market it's a very similar demographic cohort then it was real market and Medicaid but doing that undermines things that are working relatively well like the small group market how do you navigate that tension between the natural carefully yeah interest in expanding the risk pool but it's trying to protect what's working well and I think that's the point that if we can get the individual market down to where it is affordable and that it would make sense to merge the two but right now it just doesn't make sense we would really be penalizing the small group market and we just I mean we all want economic development we want to see you know we're in a recession now and if we penalize them even further by increasing their healthcare costs three times what it is right we we have not accomplished anything so I hope in a small group it's not so I know that's your lane of the commercial space but let me serve ask the same question with a different lane which is what about merging the individual market with a Medicaid space and and asking for a 1332 waiver that might take those premium support dollars and those CSRs and funding some sort of expansion of the Medicaid benefit into the individual market well it has certainly been discussed you know the governor has the senior health care team and we have certainly looked at things of if we if we merged it and how would the funding work the federal funding and the state funding and who would administer it and what groups are in and what groups are out and said the state plan go in I mean how much how can we fund this because when you look at the state of Alaska and particularly at our fiscal you've got you know the state employees of various I mean regardless of your own state then you've got the programs we support now we have the individual market in the small group so how how much of that can we combine for economic savings that are going to benefit all the groups and you know and in that you've also got providers that you've got to talk to because right now they're being compensated on different fee schedules you've got the Medicaid schedule you've got negotiated rates and then you've got some that are out of pocket so you've got to work with your providers to to make this work it's not just it's unfortunately it's not you know an answer that we can just flip a switch and we'll all be in one pool and agree that the cost is this there's a lot of talk that needs to be done yet is there a horizon point that is called success in other words is there a target destination or is it really you just sort of take the incremental wins when you get any when you said twenty six and a half percent premium decrease sheer seems like a Herculean win and a big win and one that I think everybody deserves praise for because it was a lot of a bipartisan effort at federal state on the other hand critics would say look 26 is not 200 and we've already gone up 200 percent plus and so to get back to where maybe we were is takes it's gonna take a lot of effort and probably not feasible what do you think it's going to take a lot of effort and we we have to take our wins one day at a time yeah and certainly our hope is that we can have a healthy provider community I mean no one wants to go back to the days where we absolutely had to go outside to receive treatment you know we like to see our healthy we like to see the numbers specialists that Alaska has become we'd like to see you know the number of providers that are available so we've got to talk to they've got to be a part of the equation and then if we can get to a point where with the healthcare community with those of us that are purchasing be it through an employer-sponsored plan or in the individual market or you're accessing it through Medicaid that we can agree when and what common benefits might be what we want our health care to pay yeah we could get there at some point but when we have these discussions I mean even accessing we have a lot of people who think their primary care is ER yeah and so I think some of this is almost a generational of how we access healthcare it is not an overnight fix but so you kind have to take baby steps with it so one of the lessons that we heard about from Curtis Thayer and others about the state employees and retirees market is that with a little more any sophisticated network management a little more sophisticated consumer patient engagement and maybe some benefit redesign that there have been savings of a million dollars plus in that cohort Alaska is generally speaking not a market with a lot of care coordination I think that's a relative understatement if how do we get to increase care coordination in the commercial space if we have an 80th percentile rule that effectively mitigates against the need for contracting we struggle with this because we have providers who do not want to contract for whatever reason but we also when we look at consumers call and they receive a balanced billing and usually when they call they're calling from a plan that we don't regulate the division of insurance after all a sudden done regulates about 15 percent of Alaskans the rest of Murray they're in a self-insured plan or a plan that is actually under the regulation of the federal Department of Labor it's not the division of insurance so when we talk to people they'll call and if their claim has been paid they get a huge balanced billing these are some real horror stories of why wasn't I paid at the 80th percentile because they all assumed that all plans pay at the 80th percentile and we have to say no there's certain plans a lot of them where the plan designer is able to determine how you how your played and they are getting reimbursed at some times forty percent of what the charges were and if you're going through a chronic illness or a devastating a cancer of some sort that kind of reimbursement is devastating financially to a family yeah so it's it's finding that ground of is the when we talk to insurers they say well if you do balance billing legislation that's that's going to increase rates too well is it going to increase rates more than 80% off or how much if we take the 80 percentile out how much our freights really going to come down can you tell us and there's really no hard data because then they go back what we've heard is well we want it providers to contract well the division has no authority to make providers contract so there is this argument that what we do is not necessarily going to make providers contract and if providers want to be independent and if the market will bury their charges there it's a fine line to walk between to say we don't support from any industry earning a fair wage or earning what they what would like to earn and then getting in the middle of saying no we're only going to pay X that's that's it you mentioned the transparency topic and certainly that's been a long-standing discussion including at the municipality of Anchorage and the Health Care Commission what would you think would be the most appropriate fix politics aside to bring train increased transparency to the market I think that to bring transparency to the market we have to educate consumers that there's a difference between with most providers there's there's a cache if you're paying cash there's the negotiated rate when they're a provider in network and there's an outer provider right and so you have to know going in is your physician in your network or not and where we hear the horror stories are when someone shows up fo ER and they go to their their the facility your your contracted you know your your plan pays for the Providence or regional but the anesthesiologist is called in the middle of the night is not under contract is not a provider or an in-network provider so now of a sudden your hospital bill is paid at the 80th percentile but guess what's not the anesthesiologist or the nurse that happens to be on duty because she's independent and is on contract and that organization is not part of your network so there's these layers of how do you explain to a consumer when in some cases it's a very emotional time because it's your child or your spouse or what have you that's seeking emergency services that wait you have to stop and ask the anesthesiologist are you under contract and no you're not what could you get somebody else and people just aren't geared to have to make or want to make that decision at that time and so if if providers would say all our anesthesiologists are not in our independence or all the specialty so that they could call perhaps assuming that this isn't an emergency situation but call and make sure how much is actually going to be in network and how much is out an hour but in some cases that could be contacting three or four different providers yeah let me make an oversimplified statement and and and I know it's not quite right but I think it also reflects some some view which is that the trade-off in the 80th percentile is between costs and access that we keep the 80th percentile rule we have improved access because we're able to recruit and retain more providers particularly specialists if we were remove the 80th percentile rule will have a sensibly a lower-cost trend and and probably lose providers do you think that's a fair trade-off I don't know that it's necessarily a fair trade-off I don't know of any provider that comes into Alaska saying well because of the 80th percentile I'm going to come in and set up shop in Alaska but they say I can make a good living they absolutely say they can make a good living yeah so I mean that's arguably connect let's keep in mind - that's not every provider yeah yeah you're going to hear you know primary care which is not necessarily overcompensated let's say yeah and then you have your specialties and and the issue is in the specialties or what we have seen of where the cost where the insurers will tell us that where you're looking is it in your specialty providers so let me make another oversimplify simplification statement like saving that the Department raised the issue of the 80th percentile held public hearings got a lot of emotional mixed feedback at best but a number of opponents to the idea of changing that rule and that while this is an administrative role in that the administration can change it on their own that it is so politically fraught it's probably best left to the legislature to change I don't know if it's best left to the legislature to change it or if we just need to come through legislation or through regulation as to how how do we guarantee that someone who is paying right now the highest health care insurance premium in the nation probably has a deductible $7,500 is going to have a co-payment - or coinsurance and then still make sure that they're adequately compensated for their claim that it's not paid at such a low level that it makes having the insurance basically worthless yeah and that's where we struggle yeah are we gonna get a second plan on the individual market anytime soon I would have told you a few months ago that I would expect somebody in 2019 I think right now it's dependent upon what happens in DC in 2019 or 2018 2019 we won't have anybody for 2008 a few months ago no way either no I did I did not expect to see anybody in 2018 we were hopeful for 2019 but I think a lot of it is going to be dependent on what happens in Washington let me sort of make another statement you can tell me whether you find you think this is accurate the instability and lack of predictability out of Washington DC and particularly particularly the Trump administration is harmful to Alaska health care yes well I think that any time you have uncertainty even if it's with the best of intentions of approving the ACA not knowing our cost rate and cost-sharing reductions right now being funded on a month month basis mm-hmm so that type of instability just creates uncertainty with insurers uncertainty with consumers we're concerned that because of the publicity and and all the conversations and stuff about the Affordable Care Act and where it's going that we'll see even a decrease in enrollment because people are concerned that while I'm not going to get a premium tax product I read that they were taking him away and I can't have cost-sharing reductions I read they were taking it away and we can't even tell them at the division that at this point at 2018 they're going to be funded so you should enroll because this is what your premiums going to be and this is how much you can expect to pay out of pocket we cannot give that certainty to one consumer at this point let me make another declaratory oversimplified statement see if you agree with this if the CSRs are not funded at any point the Alaska individual market will collapse I think we will always have an individual market we did before I think what's going to happen is we're going to have a lot of people who just cannot afford it and we're going to have a lot of people receiving uncompensated care yeah interesting last question what counsel or advice would you give to this community that is trying to navigate the healthcare sector in a time of boy really incredible predictability I I think we all have to be open to change I don't think that the Affordable Care Act is going to continue the way it is you know we're hopeful that our involvement in DC and we have been in very involved with the congressional administration this this entire year that it will be better for Alaskans now that doesn't mean it's going to be the same and it might mean there's a period where it hurts a little because we're not going to have everything funded to the level it is today or we may see some changes in benefits or we may see other changes that hurt a little but I think in the end we hope that it's a better product and it's it is accessible and affordable and that's that's our end goal but I think we've got some work to do or a thank you very much the boss [Applause] you you