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Luncheon Address

Steven B. Larsen, Commissioner
Maryland Insurance Administration

John Iglehart: Could we get started again, please? It’s my honor to introduce our luncheon speaker. His bio information is in your folder, so I won’t repeat that.

Steven Larsen is the Commissioner of the Maryland Insurance Administration and has been in that post for a number of years. One of the most fascinating activities he’s involved in that I assume the Blue Cross and Blue Shield system is watching with great interest, if not intensity, is the possible conversion of the D.C. and Maryland Blue Cross plans into a for-profit corporation.

Steve will talk for about a half an hour, and we’ll have an opportunity to ask him a few questions after that. Steve?

Steven Larsen: Thank you very much, and I’m glad to be here. I don’t have a PowerPoint presentation. I know how to watch TV and eat at the same time, but I thought that PowerPoint would be too much.

I counted up--I think I’m like the 14th or 15th speaker on the agenda, and the only question I have is what does the Center think I can possibly add at this point to the debate.

It reminds me--I have to tell the obligatory speaker’s joke, which is it reminds me of Elizabeth Taylor’s eighth husband on their wedding night: I know what I’m supposed to do. I’m not sure I can add anything new to the equation. [Laughter.]

Okay. As a state regulator and a bureaucrat, I get certain luxuries when I speak, particularly with academics and a lot of the learned people that preceded me. And one is that I can say anything I want to and I don’t have to back it up with any data whatsoever. So I’ll be doing a lot of that today, so don’t challenge me on what comes out.

Just in order to avoid any confusion up front, I will identify myself early on as in the camp of people who believe that the individual market as it’s currently constituted is a very poor vehicle for increasing the number and the access for people that don’t have insurance. The word kind of "crummy" comes to mind when I think about the individual market, and I could think of other adjectives, you know, if we spent more time here.

I know the beef industry had a motto when they were trying to get more people to buy beef, and it was, you know, "Beef--it’s what’s for dinner." And I think the motto for the individual market would be: "The individual market--it’s what’s left over." Because it’s really--you know, you’re not on Medicaid, Medicare, you want to be--you’re not in the large-group market or the small-group market. People don’t go out and say, hey, let’s go into that individual market, I’d like to be there. It’s a last resort, and I think it has all the characteristics of that type of market.

I do believe that many of the reforms that have been talked about--and I’ll talk about it a little more--that can solve some of these problems that I will also talk about, like community rating and rate limits, should be enacted, although I do agree that they have their own set of problems that come along with them. And I think a lot of those should be enacted, but ultimately I think there are only two big fixes that are going to solve the problems, and that’s either a significant infusion of public money--and there are many methods to do that--or the creation of a much, much broader risk-sharing mechanism than certainly what’s there now, and I think in many respects what’s been talked about.

Before I add a little flavor to this, I just want to spend a few minutes explaining some of the assumptions that I bring to the table. The other thing about being a state bureaucrat is you can make statements about things that are obvious, and people can’t hold that against you.

The assumptions that I bring are based on being Insurance Commissioner for five and a half years, looking at rate filings from small-group and individual carriers, five and a half years of dealing with actual complaints from consumers who operate in the individual market, and I guess I have the pleasure--or the misfortune, depending on the day--of dealing directly with the companies and listening to their actuaries and their underwriters come in and make the business case, listening to impassioned pleas about why they need higher rates in the individual market, and I’ve also heard the impassioned "please"--and I mean that literally, "please"--from people in the individual market who are on the receiving end of that business case.

Our agency handles thousands of health care complaints every year. We handle about a thousand appeals and grievance medical necessity cases, but we handle between five and seven thousand non-medical necessity complaints that involve things like denials and exclusions and rate increases.

Again, it probably goes without saying, but one of the things that I think we have to recognize is that health insurance really is completely different than almost all other types of insurance, even though we call it health insurance and we think about markets and there’s markets for auto insurance and homeowner’s insurance, and then there’s health insurance. But it’s a lot different. And I think these differences are what make it a tough market to solve problems in.

Hopefully anyone in this room that has a car has automobile insurance. And if you have automobile insurance and you are a normal person, then you would find it undesirable to be accessing your automobile insurance policy because it means either you’ve been hit by someone or you hit someone or something got stolen from your car. A lot of us go years without making any kind of claim under an auto policy or a homeowner’s policy. I had a claim last year, and it was my first one in 20 years, almost. And there are a lot of people like that. And you particularly hear from those people when they make one claim, and they say, "I’ve been paying my premiums to my auto insurance carrier for 20 years, and I hit someone and now they’re trying to surcharge me. What did they do with all that money that I gave them?"

So, but, anyway, there’s a lot of incentive and desire not to use the policy. We’ve also learned that if you do access your policy, it can work against you. A lot of carriers, of course, will surcharge you if you make a claim, and that’s happening even more in the homeowner’s area. Carriers will count up your claims when it’s time for renewal. Although that doesn’t happen typically as much in the health insurance market, we did--and I may have--I missed some of this morning. They mentioned that there’s a movement for that type of renewal underwriting in the health insurance market. It was kind of beat back quickly because it was viewed as undesirable.

But, in short, something like auto insurance, it’s a policy you have, you hope you never use it. You might not use it for years, and if you do use it, you might lose it if you use it too much. And if you have a car, you also know that your insurance policy doesn’t pay for the regular maintenance, you know, every time you change your oil, $50,000--yeah, it’s almost $50,000 for a tune-up--50,000-mile tune-up, 100,000-mile tune-up. But that’s not at all part of your policy. That’s a whole different set of expenses that you incur to maintain your car, and the same goes for homeowner’s insurance. One of the biggest complaints I hear from homeowners’ insurers is these homeowners think that their homeowner’s policy is a home maintenance policy, and it’s not. It’s there for catastrophic things, and they want to use the policy to fix their gutters and all the things that go wrong.

Now, of course, health insurance is nothing like any of those things. You know you’re going to use the policy. You know that at some point during the year you’re going to have to go to the doctor or worse. If you have children, it is a mathematical certainty that you will be at the pediatrician a lot, usually on Sunday morning or Saturday night. And, clearly, your health insurance policy is a maintenance policy, and everyone understands that and expects that of the policy to cover that maintenance. But it also has the characteristics of kind of the more catastrophic coverage that other types of policies do solely. And, in fact, for many people that’s why they get it. They’re not so much worried about the maintenance stuff, but they’re more worried about preserving assets and their health if they have some major catastrophic illness like cancer or heart disease.

And then, in addition, there’s like everything in between that isn’t the maintenance stuff, and it’s not the catastrophic stuff. But if you end up developing conditions, arthritis or diabetes, it’s got to cover all of that, too. And it’s not, as I said, usually a bad thing to submit a claim under your health insurance policy, not bad in terms of an underwriting standpoint. Of course, it’s bad from an aggravation standpoint because often claims don’t go as smoothly as people would like to have them go.

So, in short, unlike a lot of the typical insurance that you’re familiar with that covers unexpected or unanticipated events that occur infrequently, health insurance is the opposite. It’s a combination of insurance and service and covers everything from A to Z. And so it has this huge, broad role, which makes it hard to deal with, certainly difficult to cut costs by thinking about reducing coverage, because if you talk about turning it into more of a maintenance policy and you cut out the catastrophic element, then people say, well, it’s illusory coverage because you’re not really covered for that much. And, conversely, if you cut out the maintenance stuff, then people say, well, what about preventive care? I mean, that’s so important and that’s cost-effective in the long run.

So it’s really a product that’s got to be all things to all people, and we need to recognize that it really is different than other products.

Which leads me into the second one, which is we really rely on the private marketplace, insurance marketplace, to perform at best a quasi-public and I would say really a public function, which is the provision of health care to as many people as we can.

Some national governments, of course, take on this role, universal health care coverage, and I’m not going to get into that. But I think that indicates how health care is viewed. It’s different. Governments don’t provide homeowner’s insurance to people directly, but they do provide health insurance to people, and our governments, both state and federal, have identified some populations that they thought it was equitable to deal with, whether it’s the Medicare or the Medicaid population.

But it’s this structure of private market delivering public function that creates all the tensions that we’re talking about and that we heard about this morning and that are in the papers. And it’s these really unavoidable tensions between private business practices and public benefits and public goods. Insuring high-risk groups is really good public policy, but it’s very bad for the bottom line, and it’s not a great business practice.

Now, I think we first saw a lot of the results of this tension back in the late ’80s and early ’90s in the small-group market. In many respects, the individual market today is a lot like what was going on in the small-group market 10 or 12 years ago. It’s interesting because before the enactment of small-group market reform, which is community rating and a lot of the other things that people are proposing we do in the individual market, religion played a very significant role in the small-group market. And that’s because people prayed that they didn’t get sick, because if you got a sick employee, you knew that you were going to get a rate spike. They might try to exclude that employee. Your group might be non-renewed.

So when we enacted small-group market reform, we took the religion out of small-group, and as I said, the individual market now looks a lot like the small-group looked years ago.

I think the papers and the materials sent out and some of the discussion today identified a lot of the tools that the private market uses to enable carriers to issue these individual policies, and these are either about managing risk, avoiding risk, or pricing for risk. And, again, kind of the same set of tools that were in place ten years ago in the individual market.

For example, the use of restrictive underwriting guidelines, which I’ll talk about in a minute, carriers can avoid the risk of people they think are really too sick or too risky; the exclusionary riders and waiting periods, which are other risk management or risk avoidance techniques; and the same applies to benefit limits, which often don’t get a lot of attention but, again, are becoming more and more prevalent. One of the areas that we see at the Insurance Department is the imposition of benefit levels on drug benefits.

In Maryland, the major players in the individual market have either a $500 or $1,000 maximum limit on their drug benefit, and they have a copayment of $25 for formulary brand drugs. And if you have a limit of $500 and you’ve got to pay $25, that benefit doesn’t get you very far.

I know there are probably some studies out there that show what percentage of people bump up against limits like that. The one example that we have in Maryland is we have a senior prescription drug program, and that has a $1,000 limit. Now, we are talking about seniors, and the utilization for senior citizens is going to be higher for the rest of the population.

But of that population, I think there are about 27,000 people that have this state-run senior prescription drug program. About 30 percent of the people every year bump up against that limit. And you normally think about large limits, lifetime maximums that are really just there almost to make sure that someone doesn’t really blow through the roof. But this type of limit is truly a limit when you’re getting to 30 percent of the population that used the service are not going to get possibly the full extent of the benefit that they need.

Age banding is another prevalent technique in the individual market, another technique to manage risk. Rates can vary by a factor of two or three between age bands, and this has, as carriers in Maryland know, been one of my particular pet peeves because of the huge disparity between young and old. And I know that someone mentioned that they’re not sure adverse selection occurs out there. I guess carriers haven’t heard that argument because they’re convinced that if they rate these things on a community basis, it’s going to get flooded with some of the older people. So they’ve got to charge the older people. The question is how much is enough. And when you look at rates that are $150 for one person and $600 for another person because someone happened to have gotten old, I’m glad I’m not going to get old because that would worry me. But if you have to get old, you know, you’ve got problems. You can’t control it, but you’re going to get old, and under the current rating practices that really is going to work against you.

I think the study that Karen Pollitz and others did on kind of the problems in the individual market really to me illustrates exactly what can happen in the individual market. I did ask my staff to look through some of the complaints that we got to just kind of add to that body of anecdote, which I will agree to some extent these are anecdotes. But to me, these anecdotes are actually people. They’re actually people that have problems. And so you can marginalize them by saying, well, it’s a small number of people, they’re just anecdotes. But at the end of the day, these are still people that are trying to get coverage for their family. I’ll just run through a couple of these.

In one case, the complainant applied for individual health insurance coverage with Plan X. I won’t identify who that is. Coverage was denied because she had respiratory allergies and uses the prescription drug Clarinex on a daily basis. We upheld the carrier because they have underwriting guidelines that say that’s what they’re going to do, and our law wouldn’t restrict that.

Another complainant applied for individual health insurance coverage, also with Plan X. Coverage was denied because he had a history of one seizure which was controlled by medication. The carrier was upheld.

Another case: Complainant applied for individual health insurance coverage with Plan Y. That’s to denote that this is a different plan than Plan X. Coverage was denied because he had been treated for a mental condition, diagnosis of narcissistic personality disorder in 1999, which was five years within the date of the application, and so the underwriting guidelines look back five years. We upheld that one because we don’t have a law that prohibits that.

Another case: Complainant applied for individual health insurance coverage with Plan Y. Coverage was denied because she was treated for liver disease within the last seven years.

Next one: Complainant applied for individual health insurance coverage with Plan Y. Coverage was denied because the complainant was treated for ulnar neuritis and a nervous disorder within five years.

And this is the last one: Complainant applied for individual health insurance coverage with Plan Z--different. Coverage was denied due to the diagnosis of herpes within the last three years of the application date. Carrier was upheld.

And then we have two examples of not where they were denied outright, but where coverage was partially excluded. Complainant applied for individual health insurance coverage from Plan X. Coverage was offered only if the applicant agreed to sign an exclusionary amendment for mitral valve prolapse. Carrier upheld.

And two more. Complainant applied for health insurance. Coverage was offered only if the applicant agreed to sign an exclusionary amendment for back problems, lumbar spine problems. That person had had a back problem, which if you listen to other statistics, I think 40 percent of the population at some point has lower back problems. But this person now would not have coverage for lower back problems.

Last one: Complainant applied for individual health insurance coverage. Coverage was denied because he received a cholesterol reading of 253, and the standard acceptable level under the underwriting guidelines was 225. The carrier then offered the coverage after the complaint, but with the higher deductible.

These to me are some of the sad cases about why the individual market doesn’t work. I brought with me some of the underwriting criteria from one of the carriers that I will not identify, but basically if you’re not familiar with this--and they all use--sometimes it’s the same methodology, sometimes it’s different. But you add up a bunch of points. The points correspond to medical conditions. And if you have too many points, you don’t get the coverage. And if you’re underneath the threshold, you get the coverage.

And so for this particular plan, the limit to keep you from getting coverage was 3.1. If you had a 3.2 when you added up the stuff, then you were ought of luck. But if you were underneath the 3.1, you were an acceptable risk. And I just want to share with you some of the medical conditions and some of the points associated with those to show you how relatively, to me, easy it is to kind of get bumped out of the coverage box.

If you’re currently being treated for mono, that’s a 3. So you’re one-tenth of a point from the high-risk pool. Viral warts, 3. Lyme disease, if you’re currently being treated for Lyme disease, that’s a 2. So you are two-thirds of the way there.

Neurotic disorders, which in one of these cases involved someone who is obsessive-compulsive and being treated, taking medication for nail biting, that’s 2.9. So you’re two-tenths of a point away from being in the high-risk pool.

If you have any type of serious mental illness, forget about it, because all of those numbers are pretty high and you’re not going to get coverage if it’s anything serious. And that’s also very troubling that mental illness in particular is something that is going to knock you out of the box.

Joint derangement--now, I know what being deranged is, but a joint derangement is a 3. A back disorder, if it’s within the last two years and you had physical therapy for six months, that’s a 3. Rotator cuff syndrome, 3. Flat feet, 3.

So if you’ve had back problems and you have flat feet, I guess you’re in the high-risk pool. That’s why--and I’m not suggesting that this maybe is universal to all the carriers, but this is why I think anecdotes are important, because you can do surveys and you can generalize about what’s happening in the marketplace, but you actually need to look at how this is being implemented and how it’s impacting people.

If I’m not generating enough sympathy, then I will now read a letter, the type of letter that we get all the time from people that are trying to access to the marketplace. This is from a woman who’s trying to get coverage for a family. "I’m deeply disturbed by Company X’s decision. I cannot believe they would expect a parent to find it acceptable that they will provide partial coverage for a two-year-old child. My son’s health is very important to me, and he needs full coverage. Why should I accept less coverage for my son than I will for my car? Nowhere in the cardiologist’s report did he state that my son was a high-risk patient. He used the word `normal.’ You don’t have to be a doctor to read a report and know that my son’s medical condition is under control," blah, blah, blah, blah, blah.

One more. "I have been denied underwritten coverage three times, all because I have been diagnosed with lupus. I take martial arts, practice for biathlons, am in the gym three times a week. I’m not on any medication. I believe that it’s patently unfair that I’m being denied coverage when others who don’t have my level of fitness have no problems obtaining health insurance. I’m also extremely concerned that if my appeal is denied, I will be without insurance because of the prohibitive, for me, cost of obtaining insurance through the open enrollment system that was being offered to me."

Now, I guess in light of kind of dealing with that all the time, I have a different test for what is a functioning marketplace. And to me, a functioning insurance marketplace is how well it addresses the needs of the high-cost, high-risk sick individuals, not whether it covers the 80 percent of the people who are not really that sick, because that’s--we can do that. That’s probably the easy part. But in terms of measuring what we’re going to do as a society, we need to focus on the people that can’t get the coverage and that need the coverage.

I think those are the people that need it the most, and those are the people that we need to focus on. And I’m not suggesting that some people disagree with that, but there’s often a lot of talk about how for the large number of people, the market works pretty well. And I would say, well, wait until you’re one of the 20 percent, and then you will understand why it does not work that well and why people, I think, get so emotional about reform that’s going to bring everyone in and why you need to level prices and make accessibility a priority.

I think I mentioned this whole 80/20 split and back when HMOs were more in vogue, if they were ever in vogue, you know, people would do satisfaction surveys and 20 percent of the people didn’t like it, 80 percent did, and it was the 80 percent that were generally the healthy ones that liked it.

I think also my little discussion on the underwriting guidelines might illustrate that I’m not sure there’s at this point a lot of agreement on who are the high-risk individuals and who we need to be helping and who we don’t need to be helping.

In setting up our high-risk pool in Maryland that we just started--and I will talk about that in a minute--we looked at other high-risk pools and the factors or the conditions that gave people a free pass into the high-risk pool. For example, if you have cancer, you know, you don’t have to worry about trying to get turned down from another company. We’ll take you because you have cancer. We all acknowledge that’s expensive, and most carriers aren’t going to cover you. Things like AIDS and cystic fibrosis, cirrhosis of the liver are all generally views as free passes into the high-risk pools.

But there is a broad area of dispute, I think, about what is a high-risk person, who should we be helping with the high-risk pools, who are the companies excluding when they don’t need to be excluding them. Some of the examples like the Clarinex are things that I’m not sure are folks that need to be in the high-risk pool.

No states have bulimia on their list, although I think that the carriers that we looked at will not write bulimia. Only one state had hepatitis C on their free-pass list, although, again, I think most carriers would exclude that.

Only three of ten of the high-risk pools had Lou Gehrig’s disease on its list of free passes, but carriers are not going to cover that. Same with spina bifida. I think only one high-risk pool had that, but carriers aren’t going to cover that.

So, you know, what happens in the middle I think is--my only point is that at some point we also need to have a clearer understanding of who goes where, who do we think the market ought to cover, and who goes into the high-risk pools, because my sense is in a lot of cases the carriers will put as much as they can into the high-risk pool. And if you don’t have an effective mechanisms for funding that high-risk pool, then that overburdens the high-risk pool and distorts the market.

Well, to me a lot of this is obvious because this is what we deal with every day, and I think we’re all familiar with kind of the basic problems. If you keep the sick people in the pool with everyone else, assuming we can agree on who the sick people are, that’s step one. Step two, watch all the rates rise. Step three, watch the healthy people jump out of the pool because now it’s too expensive. And step four, stay clear as the death spiral, you know, goes into full force.

I was going through the articles in preparation for today, and there were two comments that I thought were just great. One was in Mark Hall’s concluding comments, and he said this: "Crafting a set of rules and institutions that will allow the individual market to function as an acceptable alternative to the group market requires sophistication, intricacy, and difficult tradeoffs." In other words, we’re doomed, because I’m not sure we’ve ever accomplished any of those things as public policy.

Scott Siroda was almost as optimistic: "A delicate balance must be achieved regarding the risk of the covered individuals, the rates charges, and the regulations adopted. Relatively small miscalculations in any of these can result in spiraling premiums and plummeting coverage rates." And so the translation to that is: Be afraid, be very afraid, because it’s not easy.

Okay. I’m running out of time, and so let me just comment on a couple solutions.

As I said, I think health insurance, work under the assumption it’s got to have a full range of benefits. There’s a lot of talk about stripped-down benefit packages. If we need to deal with health care costs, we need to deal with costs, but I don’t think we should do it through stripping down coverage.

Health insurance is a quasi-public or public function. It’s delivered by the private marketplace. But if we acknowledge that it’s a public function, then maybe we’re more comfortable with a much greater level of regulation than we have today.

But the key is better risk spreading. The individual market is already a segmented market, and to expect that market to be able to balance the risks of its high-risk individuals is ridiculous. I think that’s acknowledged through the creation of high-risk pools, but we have to spread those costs much more broadly than we are today.

I wasn’t here for Katherine Swartz’s reinsurance proposal, but it sounds like that’s the type of thing. The key is risk spreading. You’ve got to spread the risk. And you’ve also got to acknowledge that--I haven’t heard about it. Even if you pull what we would agree are the sicker people out of the individual market, the individual market that’s left is still way more expensive. It’s still a problem. You haven’t solved that problem because there are a lot of people that can’t afford even what’s there. And so you can deal with the sick people, but for a whole lot of reasons--one is the administrative costs that go along with that, although I sometimes take issue with the administrative load on individual health insurance products. Often that is done by carriers through an expense allocation formula that may or may not reflect the actual expenses that are incurred.

We’ve done some studies comparing basically a comparable policy in the individual market and the small-group market, and it was one and a half or two times greater in the individual market for the same set of benefits.

What we’ve done in Maryland to fund our high-risk pool is I think kind of interesting. We’re funding it on hospital-based assessments so that we are going broader than just the individual health insurance market or the private insurance market. To avoid problems with ERISA, we’re collecting assessments through hospital payments so we don’t run into the ERISA problem. We get it on every user in the health care system, and I think that’s one of the ways to go because ERISA really can be a barrier to spreading the costs evenly.

Finally, I would just say that along with whatever package of reforms that you would look at, there’s got to be some standardization among individual products. In many states there is not, and it is almost impossible for consumers to shop intelligently because they’re trying to weigh different elements of a benefit package, none of which are quite the same. You should have variation in the market, but you’ve got to have at least one product that you can have an apples-to-apples comparison so that people can understand what they’re getting and what they’re not.

As to tax credits, it’s a fine idea, but I think you have to fix some elements of the individual market before you do it. And I know there’s some talk about defined contribution and this consumerism, consumer-focused health care, and I’m very skeptical of that. I think to a large extent it’s just cost shifting from the employer down to the employee, and I’m not convinced, based on the people that I deal with, that there’s that level of sophistication to navigate the health care system that people would like to think is out there.

So I will stop there and--I don’t know--I guess answer any questions if we have time.

John Iglehart: We have time for a question or two. If you would identify yourself, that would be helpful. Yes, sir?

Question: Turner Campbell, resident of Montgomery County, private individual. I was impressed and delighted with your comment and candidness about the current system of insurance in the State of Maryland, principally. And I’ve been amazed that no one today has mentioned the Department of Veterans Affairs Health System Administration, which to me is pretty much of a real net. Twenty-five million living veterans, two years ago the Congress mandated that they be entitled to medical care and did not promptly appropriate the money to anticipate the increased workload. So they set up a category after they enroll, one through seven, and I’ll deal mostly with the seven. That’s the relatively well-to-do veteran who is not service-connected. And if you don’t know what service-connected means, that means you’re rated from an illness or injury that occurred during service, and now just recently includes the two-week reservists, incidentally. You don’t have to be on extended duty as a reservist.

So the question is: Has this had an impact on your impression of the private insurance load? Because the category seven with $500 and $600 prescriptions a month now can go to the VA and with a $7 copay and a $50 outpatient can get that done repeatedly. And if I was in that category, I would do it. I happen to be category one. So did that influence your insurance load privately?

Second was TRICARE for life, which I was surprised that it finally happened. TRICARE for life, if you don’t know--and principally the change is over 65. You have to have Medicare. If you have a private payer, they’re the second payer insurance. And then if there’s any additional cost, TRICARE will pay for it. For example, my wife, who is not a veteran--I’m retired Reserve--they suddenly started paying her prescriptions, which hadn’t been covered.

So to repeat, this vast increase in coverage in my opinion for the veteran population, has that had any impact on private insurance as far as Maryland is concerned?

Steven Larsen: I guess the short answer is I don’t know. Like a lot of state officials, I’m probably not as tuned in as I should be to, you know, what some of the programs are at the federal level like the ones that deal with veterans. But I can tell you none of my actuaries nor have any of the companies come to me and said, you know, we’re seeing this change in the trend or this difference, you know, because of, for example, the program that you’re talking about. So I guess I have a shorter answer. I guess the answer is on.

John Iglehart: Thank you, Steve. Oh, excuse me. We’ve got one more. One more question.

Question: Chris Connell. I’m a writer. I’m interested, did your bleak view of the individual market affect your stance on the Care First takeover, and could you update us on that?

Steven Larsen: The short version is because we haven’t made a decision yet, I can’t tell you whether it’s influenced that decision. I know the answer to that question, but I’m not going to tell you. [Laughter.]

We are pretty far along in doing the analysis. We have all of our experts working, investment bankers, we have actuaries, lawyers. We have done hundreds of pages of depositions which are on our website. If you want some interesting reading, go to our website. We’ve got a lot of reports, and like I said, about 800 pages of depositions and five days of public hearings.

We will have a decision from the Maryland perspective by the end of January, maybe early February, and then the legislature in Maryland will pass on whatever decision I make. I can’t really speak to what the other jurisdictions are doing, and if it were approved, for example--it couldn’t go anywhere until all the jurisdictions got to the same point. If it’s disapproved, there’s some dispute about what that means. I personally believe that that’s the end of the process. But, of course, I’m going to say that because I’m the Maryland Commissioner.

So we will have a decision, I think, in the next, you know, six months.

John Iglehart: Thank you. It’s now time for Len Nichols to tell us what we’ve heard today with his summary.

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The Center for Studying Health System Change Ceased operation on Dec. 31, 2013.