Charlie Arlinghaus

May 22, 2013

As originally published in the New Hampshire Union Leader

Like most states in the country, New Hampshire is having a difficult time answering the question about whether or not to expand Medicaid coverage. For the last decade politicians of both parties have not made any attempt to expand Medicaid coverage in New Hampshire. With the federal government dangling some initial money for the program, some are tempted but unsure. Today, with so many unanswered questions and reasons to be skeptical policymakers should avoid a rush to judgment and just say maybe.

The federal government, as part of its new healthcare law, has offered to borrow about a trillion dollars to help states expand Medicaid coverage. Supporters in New Hampshire say it’s too good a bargain to pass up: the feds say they’ll pay 100% of the new costs in the first few years, then 90% and then 50%.

Supporters are excited that Medicaid coverage might reduce the percentage of people without insurance and reduce the amount of charity care (to the uninsured and to Medicaid patients) currently provided by hospitals.

But there are many reasons to be skeptical. There is some reason to believe the federal government may not live up to its promises and the experience in other states suggests the outcomes may not be as promised.

It’s important to remember that no one in New Hampshire would think this was a good idea if we paid for it ourselves at the regular Medicaid match rate. Remember that during the four years of a Democratic governor and Democratic legislature none of them proposed any significant expansion of Medicaid. The same is true of Republican control and divided control. There has been no local thought of expanding Medicaid in decades.

The feds currently claim they will pay 100% of the initial costs but they’ve already hinted at backing away. President Obama is perhaps the biggest supporter of this among any federal politician – it was his idea after all. Yet his 2012 proposal retreated from 100% funding and switched to a blended reimbursed rate attacked by left wing think tanks. If the biggest cheerleader for expansion has signaled a willingness to cut back before the program has begun, we ought not expect the promised federal funds to materialize.

While we are told that expanding Medicaid will reduce the level of uninsured, experienced across the country proves exactly the opposite. In the last decade, two states significantly expanded Medicaid: Maine and Arizona. In Arizona, the percentage of the population uninsured went from 19% to 19% over the decade – no change at all.

Lest you think it has something to do with deserts or warm air, our neighbors in Maine had precisely the same experience. Their uninsured went from 12% to 12%. In both states, the percentage with private insurance declined by the same amount as the increase in Medicaid coverage.

The other supposed policy benefit of expanding Medicaid coverage is a decrease in the amount of charity care provided by hospitals. Hospitals have a small number of patients with no insurance for whom they write off all their costs and a larger number of Medicaid patients for whom they receive payment for less than 50% of costs.

One of the big drivers of Arizona’s expansion was the expectation that it would dramatically reduce charity care and hence cost-shifting to private insurance. Instead, post-expansion, charity care costs rose an average of 9% per year (remember that that the percentage of uninsured didn’t change).

In Maine, a state almost exactly the same size as our own, they too saw increases in charity care. In the first eight years of expansion, charity care has climbed from $61 million to $215 million (in Maine too there was no reduction in the uninsured).

At this point, there are too many questions to say yes to Medicaid expansion. We know the results won’t be as advertised. There is every reason to be concerned about costs and the ability or willingness of a destitute federal government to meet its promises.

Proponents suggest we can adopt the program and just opt out at any time later but practically that isn’t true. The federal could adopt a maintenance of effort requirement like they adopted with the stimulus package that precludes any changes. And rolling back any program is always problematic.

This year, in this budget, there are too many questions, too many reasons to be skeptical to say yes to expansion.

Josh Elliott-Traficante

A recent study published in the New England Journal of Medicine suggests that the expansion of Medicaid, which is currently being debated in many states, including here in New Hampshire, does little to improve the health of the newly covered.

Several years ago, researchers were recently given the rare opportunity to study the effectiveness of Medicaid Expansion in Oregon. The state opted to expand its Medicaid program to include some low income, uninsured adults. However, funds were only available to enroll only a portion of those eligible, so roughly 10,000 individuals were chosen by random lottery to receive coverage. While unintended as such, these conditions laid the groundwork to conduct a scientific study of the efficacy of the program by creating a randomly selected sample (those chosen) with an established control group (those not chosen).

What makes this study so relevant in today’s discourse is that the population covered by Oregon’s expansion is the same population that will be covered under the expansion of Medicaid as part of Affordable Care Act in the other states. The study of nearly 12,000 individuals’ health outcomes grants rare insight into what the benefits and shortfalls of expanded Medicaid would be.

When comparing the newly covered and non-covered groups in Oregon two years out, the study found that there was little difference in health outcomes. The study concluded:

This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years…

The study did find that expansion increased the use of health services, diabetes detection and management as well as reducing financial strain, all of which would be expected. Surprisingly it did lower rates of depression by about 30%, which could be related to the reduced financial strain.

Some have argued that all that the study shows is that insurance is working because people are getting some chronic conditions taken care of, or that just by virtue of having insurance coverage does not make one healthier.

To some extent both are true, however, the gains seen in the Oregon study can be achieved by means other than the expansion of a very expensive program like Medicaid.

Charles M. Arlinghaus

 March 2012

Summary: New Hampshire should join the Health Care Compact to allow different states to try different health care reforms. The results of those reform pilot programs may give New Hampshire the opportunity to replicate better or more efficient programs here if we choose. The compact has no cost associated with it and doesn’t require New Hampshire to expend any money or assume any liability but has the long term potential to uncover cost savings measures.

On February 15, 2012, the New Hampshire House of Representatives voted 253-92 for HB1560 to join a national Health Care Compact[1] of states asking the federal government to play a role as the federal government considers plans to change, among other things, Medicaid and Medicare.  The vote sends a clear message that states should be consulted and states should have options. As the proposal is considered by a second committee, some details are worth addressing. While any new proposal is open to misinformation and demagoguery, this isn’t nearly as complicated as it sounds. Much of the criticism and even some of the support for a compact is based on misunderstanding, or in some cases misrepresentation, of the structure and language of a compact.

The Health Care Compact that has been ratified by four other states in the form being considered in New Hampshire would only happen if the federal government and the state government both agreed. Then, only if it so chose, the state would assume administration and direction only of the specific programs it felt it would manage more effectively than the federal government, quite likely a subset of all federal programs. Although states would receive grants equivalent to the specific funding for the programs it chose to administer, they would assume no long term liabilities for federal programs that currently have long term liabilities.

The Basic Structure of this Health Care Compact

At its most basic level, the Health Care Compact being considered in New Hampshire is a petition to the federal government asking them to allow states the opportunity to take federal health care spending for specific programs and craft a state specific program to replace the federally administered program.

The Compact is a group of states who essentially sign a request to the federal government to grant them (and any other state) that authority. Importantly, the program could not take effect without the federal government granting the authority and with the state opting to administer specific program or perhaps none at all.

To administer a specific program, states would be granted the authority to replace the federal laws regarding a program (Medicaid for example) with state laws. This provision has led to the most misunderstanding. The Compact would provide that a state may “Suspend by legislation the operation of all federal laws, rules, regulations, and orders regarding Health Care….”[2] Critics prefer to end the sentence there to misleadingly suggest Compact supporters are nullifiers. Instead, the sentence continues “that are inconsistent with the laws and regulations adopted by the member state pursuant to this compact.[3]” In other words, new state laws would take the place of previous federal laws under authority granted by Congress.

What’s more, all rules would remain in effect unless suspended by state action in specific areas and for any area not suspended the state will still be “responsible for the associated funding obligations in the state.” In other words, federal laws are not “suspended” except to the extent that the state chooses to act under a compact expressly agreed to by the federal Congress.

There are three steps before New Hampshire would administer any specific health care program.

Step One: States Agree:  Although a compact could technically start “on its adoption by at least 2 Member States and consent of the United States Congress,[4]” Congress will likely pay little attention until a dozen or more states adopt the Compact in their legislature demonstrating a critical mass of support.

Step Two: Congressional Approval and Amendment: Compacts do not become effective without congressional approval. In area like this – a bit more complicated than compacts on things like mutual recognition of drivers’ licenses – that congressional debate will be fairly involved. The compact document specifically anticipates give and take with the federal government by outlining the broad structure which should underlie the final agreement — the authority to use the current federal funds in each state guided by state not federal regulation.

Step Three – Evaluation: Although a Compact would give each state the authority to act, each state would undergo an evaluation process. Different states have different skill sets and few states would immediately take over administering all health care programs. The next step would to evaluate skill levels and decide where we would most likely be able to add value in a cost-effective way.

The Fiscal Impact of a Health Care Compact

The biggest question mark for any proposal is fiscal but joining the compact itself entails no financial obligation at all. Further participation by choosing to administer some program involves limited financial risk and the potential for significant savings.

One of the most significant errors opponents make is in regard to liability and whether or not a state would have to assume any and all health care operations. The question is “if we assent to a compact, would we then have to assume all health operations, and we would not then be liable for unfunded Medicare liabilities?”

First, signing on to the Compact does not obligate us to be one of the state with a good idea. We could, and probably should, wait for promising approaches to develop.

Second, if we do opt to implement a better idea, we do not have to administer all currently federal programs. We can choose ones that make the most sense for us. For example, we might decide that since we currently administer Medicaid, we could craft our state specific rules in exchange for a block granted federal funding. This is essentially a version of how Rhode Island and Florida operate under a Medicaid waiver. Rather than the one set of rules and regulations designed to fit fifty states, they forego the regulation in exchange for a block grant.

Were we to choose to administer Medicaid, we would not also be compelled under the Compact to administer other programs (like Medicare). The federal program as it exists then would remain in effect

The False Liability Issue

If our pilot program didn’t work or didn’t yield the results we wished for, we could “withdraw from this Compact by adopting a law to that effect….[5]” The withdrawal would be effective six months after we gave notice of our intent to suspend. If we were able to administer the program more efficiently than the federal government had, we would benefit from the savings realized. On the other hand, if we discovered we were in over heads, or the program didn’t work as well as the pilot we’d observed in another state, our financial risk would be minimal because of the ability to stop with six months notice.

The liability language in the withdrawal mechanism, though, has led to some confusion. The compact provides “a withdrawing state shall be liable for any obligations that it may have incurred prior to the date on which its withdrawal.[6]

The liabilities mentioned are not long term liabilities of the kind associated with Medicare. They are the typical liabilities associated with any program of this sort. For example, an insurance company would still have an obligation for covered procedures that occurred prior to the termination date of a policy. Similarly, a state would not be able to walk away from bills already incurred but not yet reimbursed. New Hampshire’s own self-insurance plan for state workers includes a similar accounting provision.

In fact, the long term obligations associated with a program like Medicare are exactly what an approach like a Compact is designed to address. Nationally, many competing proposals are being considered. Allowing many states many different options allows greater experimentation with potential long-term solutions. That experimentation will allow states to learn from each with some states acting early and some watching the various pilot programs before deciding whether or not to act.

The Virtue of Doing Nothing

In fact, in New Hampshire’s case we should move cautiously forward. We should petition the federal government to give states authority if they choose to exercise it and then wait and see what other states do. Even though all fifty states would be granted the choice by Congress, only six or eight would exercise that choice but each of those states would amount to a pilot program – and very different pilot programs that should teach us something.

In fact, this is the whole point of a compact that gives each state the authority to try different things. “Laboratories of democracy” has become one of the most hackneyed phrases in American politics but Louis Brandeis’ original thought is at the heart of a health care compact. Brandeis said “It is one of the happy incidents of the federal system that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.[7]

New Hampshire may well not yet be up to the task of coming with useful reforms in all areas but other states may well be. Texas would probably try something more market-oriented, Vermont would almost certainly create a single-payer plan and become a teeny version of Canada.

Perhaps Vermont or Oregon or whoever tried single payer would prove it a failure but perhaps they would not. On the other hand, the New Hampshire way is to watch carefully what other states do and then import the best pieces into our system. Allowing other states to pilot innovative programs – only if they choose to do so –will help us all.

Who Decides What is a Good Idea?

Some will worry that nothing in a compact prevents states from doing something stupid but that’s just the point. We want to allow states to craft their own pilot program with as much latitude as possible. They should use their judgment to replace Washington’s. And New Hampshire should watch the results to reap the benefits.

Today, the federal government decides collectively what is and what isn’t a good idea. They then impose on all states that idea which might be good for New Jersey but not for New Hampshire. Under a multi-faceted approach, different states will evaluate what each other state does. The best experiments will be adopted by many other states. The less promising idea will be abandoned after a year or two. But those pilot programs which Brandeis anticipated are not possible under the current system without a Compact being adopted.

New Hampshire should join in a compact with other states to at least allow the potential for any state which thinks it might have a better idea to experiment with it. There’s certainly no risk to our fiscal order by letting Texas or Vermont try something. At the end of the day, that’s the only commitment we make when we join a compact.

 


[1]This paper capitalizes Health Care Compact when referring to the specific proposal that is being considered in New Hampshire in 2012 as House Bill 1560, and has been passed in substantially similar forms by four other states as of this writing.

[2] Text of proposed HB1560 (2012) proposed RSA 137-L4

[3] Text of Proposed HB 1560 (2012), proposed RSA 137-L4, emphasis added

[4] Proposed HB 1560 (2012), proposed RSA 137-L7

[5] Text of proposed HB1560 (2012), RSA 135-L9

[6] Text of proposed HB1560 (2012), RSA 135-L9.

[7] Interestingly Brandeis never used the phrase laboratories of democracy. The quote is from the end of his dissent in the 1932 Supreme Court Opinion in New State Ice Co. v. Liebman. Brandeis would have allowed a state to keep Mr. Liebman from selling ice without a license.

Charlie Arlinghaus

February 22, 2012

As originally publish in the New Hampshire Union Leader

Contrary to some of the misinformation circulating in Concord, a state-run health insurance exchange bureaucracy operating on behalf of the federal government is a bad idea, is not required by any federal regulation, and would be an expensive strain on our state budget.

At the centerpiece of President Obama’s health care legislation is a mechanism known as an exchange — i.e., a new federal or state bureaucracy to be set up to administer the rules and regulations regarding health insurance under the so-called Affordable Care Act (ACA).

The ACA included hundreds of new regulations and federal mandates to govern health insurance once the law takes full effect. In addition, federal agencies are in the process of issuing thousands of new rules to implement the myriad provisions of the law. To administer those rules, there will be a state-level exchange in each of the 50 states.

The federal government had hoped each state would set up its own exchange and manage the regulations for it while assuming the operating costs of the new regulatory agency.

The law can’t require states to set up an exchange. It provides that the federal government will set up and fund a state-level exchange if the state government chooses not to. The majority of states around the country have balked.

Much of the information in this debate is easily misunderstood. One particular piece of information exists only in New Hampshire and is incorrect. Our HHS commissioner mistakenly claimed that not running the exchange ourselves will cause us to lose our federal Medicaid funding, decimating the state budget.

This claim has not been made in any other state. The Obama administration, which has been eager to have every state establish an exchange, has never alleged any such thing.

It seems unlikely that there is a condition attached to Medicaid that no one else in the country knows about except one lawyer in Concord.

The Cato Institute has published a more authoritative legal analysis to show why this claim just isn’t true. The misunderstanding stems from a problem with the original draft of the state bill. The debate in New Hampshire centers on Rep. Andrew Manuse’s House bill prohibiting a state-run exchange.The original version included language that could have cost significant Medicaid dollars based on requirements that new information be able to interface with the state exchange whether federally or state-run.

Rep. Manuse quickly changed the language to make the bill simply a prohibition on the state setting up an exchange, whether by itself or through contract. That’s a very sensible compromise.

Another big question mark has been the financing of a state-run exchange. While federal grants would cover the setup, no one is quite sure how much an exchange would cost the state to operate. The final rules haven’t come out. However, we have some hints in that the Massachusetts version costs $29 million to operate.

New Hampshire’s costs are likely to be in the neighborhood of $10 million annually.

Exchange supporters have taken to saying we pay either way. What they mean is that they believe that the federal government would likely tax participants (fees on insurance plans, brokers, insurers and businesses related to their policies) and that states, if forced to fund a program this expensive, would have to look at similar fees.

Although local exchange supporters believe the federal government can impose these taxes already, the federal government itself doesn’t agree with them. In the President’s budget proposal, he asked Congress for $860 million for the express purpose of funding federal exchanges. Mind you, the start-up money for state-established exchanges is elsewhere in the budget so the $860 million is just for the 20-30 states not creating a state bureaucracy.

So the administrative function of the federal health law isn’t funded unless we fund it for them.

They haven’t finished the rules, but they want us to create the administrative agency. They don’t have the money or the authority to raise it, so they want us to assume the financial cost.

I think Rep. Manuse has things about exactly right.

Charles M. Arlinghaus is president of the Josiah Bartlett Center, a free-market think tank in Concord. His email address is arlinghaus@jbartlett.org.

This is our dedicated page to information on healthcare exchanges, which are a centerpiece to the Patient Protection and Affordable Care Act, more commonly known as ‘Obamacare’

It will be periodically updated.

JBC President Charlie Arlinghaus on Healthcare Exchanges and why they are bad for NH

Cato’s Director of Healthcare Studies Michael Cannon and John Adler on the all important Obamacare Glitch

Also from Michael Cannon, his article in the National Review on how Obamacare can’t be fixed

The New Hampshire House  Bill: HB1297, which seeks to ban the state from setting up a healthcare exchange

JBC President Charlie Arlinghaus on why HB1297 is a good idea

 

By Grant D. Bosse

Summary: Certificate of Need laws, or CONs, have been set up across the country under the assumption that rationing hospital construction and expansion would limit increases in health care costs. Four decades of experience have shown that CONs do not control costs, but do provide a significant barrier to entry to innovative health care facilities and limit competition in the health care marketplace. Faced with this evidence, CON supporters have created novel arguments to justify them, but these new rationales also fall under close scrutiny. New Hampshire should end its thirty-year experiment and repeal its Certificate of Need Law.

Click here to download a copy of the study

[pdf http://www.jbartlett.org/wp-content/uploads/2012/02/Irrational-Certificate-of-Need-Laws.pdf]

 

Charlie Arlinghaus

February 1, 2012

As originally published in the New Hampshire Union Leader

MOST PROPOSALS on health care are part of a highly charged ideological debate. One exception this year, the health care compact, is not a short-term solution but a longer-term project that will allow New Hampshire to benefit by letting other states craft proposals on the right and the left.

A health care compact is a proposal in the Legislature to have New Hampshire join with other states (four have already passed the compact language) to petition the federal government to grant states the authority to take federal health care spending in their state and craft their own program as a replacement for the federal program.

This is not some wacky theory like nullification, but rather states coming together and asking Congress to vote to give states an option. One option would be to stay in whatever system is created by reforms in Medicare and Medicaid.

Another option would be for an individual state to create its own reform. Very few states will undertake their own reforms, but we could all benefit from giving those few states that option.

We know that change is coming to the biggest federal health care programs. Rep. Paul Ryan, the leading conservative on health care issues, and Sen.

Ron Wyden, one of the leading liberals on health care issues, have put forth a compromise proposal. The merits of the proposal don’t matter for this discussion. When the leading liberal and leading conservative on health care both agree that change is coming — amid a half dozen other proposals floating around Washington — we know change is coming.

A health care compact would let states, if Congress agreed, craft their own experiments instead of accept whatever new federal proposal emerges in the next few years. Some states will do things that I support, others will do things that different people support and then we’ll see how each works.

At a hearing on the compact, Rep. Gary Richardson asked me what I actually wanted to see happen. The implication is that I have an end game in mind and want the federal government to let us make that happen in New Hampshire.

What I really want is for New Hampshire to wait. I want us to petition the federal government to give states authority if they choose and then wait and see what other states do. Even though all 50 states would be granted the choice by Congress, only six or eight would exercise that choice, but each of those states would amount to a pilot program — and very different pilot programs that should teach us something.

“Laboratories of democracy” has become one of the most hackneyed phrases in American politics, but Louis Brandeis’ original thought is at the heart of a health care compact.

Brandeis said “one of the happy incidents of the federal system is that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”

I don’t think New Hampshire is currently up to the task of coming up with useful reform but other states are. Texas would probably try something more market-oriented, Vermont would almost certainly create a single-payer plan and become a teeny version of Canada.

I think Vermont or Oregon or whoever tried single payer would prove it a failure, but it is possible that I’m wrong (unlikely, to be sure, but within the realm of possibility). On the other hand, the New Hampshire way is to watch carefully what other states do and then import the best pieces into our system. Allowing other states to pilot innovative programs, only if they choose to do so, will help us all.

Some will object that nothing in a compact prevents states from doing something stupid.

But that’s just the point. We want to allow states to craft their own pilot programs with as much latitude as possible. They should use their judgment to replace Washington’s. And New Hampshire should watch the results to reap the benefits.

Make no mistake, this is a long-term, cautious project. It won’t go before Congress until many states have joined together to ask. Even then, it will require debate and congressional approval. Even at that point, New Hampshire should let other states lead the way and watch cautiously. But their pilot programs will teach us lessons and teach the federal government lessons. This is a health care proposal that doesn’t presuppose a program or an ideology. It will be a tool for liberals and conservatives alike. The longterm future of health care will demand more than just yes or no answers to the question of the month. We should put other states to work for us.

Charlie Arlinghaus

January 25, 2012

As originally published in the New Hampshire Union Leader

 

At the center of the debate over the federal law known as ObamaCare is a debate over whether or not states should administer the federal rules and regulations in a supposedly state-run Exchange. New Hampshire would make a mistake with significant financial consequences if it allowed itself to be seduced into this foolish idea.

When the federal government adopted health care reform known as ObamaCare or the Affordable Care Act (ACA), the rules and regulations included a plan that each state should set up an Exchange, a new bureaucracy to administer the significant rules already adopted and the forthcoming regulations envisioned by the bill. States are encouraged to set up their own federally regulated bureaucracy – the state as federal extension agents – or else the federal government will administer an exchange itself.

As details have become apparent over the last year or so, it is clear that whether the federal government runs the exchange or the state administers its rules for it amounts to the same thing, that the costs of running an exchange will impose a significant burden on the state, and that not setting up a state-based exchange is likely to force the law to be re-opened and hence renegotiated.

In early days, some opponents of Obamacare nevertheless thought perhaps states themselves could blunt its impact by setting up their own exchanges. The Heritage Foundation, opponents of the federal law, had helped Massachusetts establish its pre-ObamaCare exchange called the connector and initially thought maybe other states should follow suit. After a few months looking into the rules and regulations, they concluded “a state would now have no more real control over an exchange it set up than one HHS established.”

The conclusion is obvious and at the heart of the exchange debate. Whether run directly by the federal government or mandated by the federal government and carried out by local agents is immaterial. The regulations and decisions come from Washington with perhaps a few window dressing exceptions. As such, we are not deciding between regulation and autonomy, we are deciding whether or not we want a puppet government.

If it’s all the same, why not run our own exchange even for those few admittedly insignificant rules we can control? The difference is money. The Massachusetts connector, although the prototype, administers a less complex system than the new federal law and its annual budget is $29 million. No one knows what a New Hampshire exchange would cost but it would be somewhere between $10 and $20 million.

Federally collected tax dollars would pay for the start up costs but after start up the state would pay for the exchange itself. With state government on the hook, the federal regulations would pay less heed to their costs so there would be more of them. With a federally run exchange, the federal government – which hasn’t the budget authority for them yet – would have to weigh financial costs.

I have written often of the folly of a federal bailout of state governments. I don’t think any of us wants to see a state bailout of the federal government.

By the way, the obvious decision to hold our fire on establishing an exchange is not irreversible. The state may at any point if it so chooses reverse course and implement one.

The last reason to avoid a state run exchange is what’s known as The Glitch. Michael Cannon and Jonathan Adler writing in the Wall Street Journal discovered that the health law provides for premium assistance programs in state run exchanges but not federal ones. This was an error drafting a bill which requires the bill to be reopened to correct. If only 20 or 25 states adopt exchanges, as looks likely, the law would have to be opened up if it isn’t repealed next year.

By not adopting an exchange, we increase the pressure to open the law to fix the glitch. We also increase the financial pressure on a law that counted on passing the cost of running the exchanges to the states.

But regardless of the pressure we may wish to exert, setting up a state exchange is a bad idea. A state exchange is a fig leaf layer of bureaucracy between us and the people who really make the rules. Setting up a puppet government to put a happy face on federal regulation does no one any favors, and it would cost us tens of millions of dollars each year that we don’t have.

 

UPDATE: Attached below is a letter from HHS Commissioner Toumpas to House Commerce Chairman Hunt, which lays out his objections to HB1297.

HB1297 would ban the State of New Hampshire from setting up a healthcare exchange.

Toumpas Letter to House Committee on Exchanges