Transcripts For CSPAN Discussion On The Future Of Medicaid 20170707

Abrams with the Commonwealth Fund, and we thank them for their since medicaid was the medicareside program in 1965, it has grown into one of the most farreaching programs in our country, in terms of the number of people it serves as low as their health and life circumstances, and the cost of the program. It is run by the 50 states and territories within federal guidelines and financed by both the state and federal government. So while medicaid policy has National Implications it of course has major implications for states and their citizens as well. As we know, major changes to the Medicare Program have been at the forefront of recent Health Care Policy discussions and are included within legislative proposals in both the house and senate. Today we will talk about what those proposals are, how they would work, and what they would our in practice based on best evidence and projections. I just want to make a special note because while it is really easy for medicaid policy to get very wonky very fast, and as the old saying goes if you have seen one Medicaid Program you have seen one Medicaid Program, this obviously has been an issue in our conversation that hits home for many people. I think it speaks to the need for continued dialogue on the different perspectives that are brought to the Medicaid Program that is what the alliance for Health Policy is about in this briefing is about. We are pleased to have a terrific panel here today to help us with this discussion. Let me go ahead and introduce our panel and then i will turn it over to melinda. Today. Ann is joining us deputy been a administrator at the centers for medicare and medicaid services. She directed the Senate Center for medicaid and Chip Services at cms as well. O my left is josh he is a senior fellow at the foundation for government accountability, and prior to joining that foundation he served as director of the senator center for health care solutions. He also served as legislative director for scott brown in the Massachusetts State Senate and as a senior legislative aide for then governor mitt romney. I already introduced melinda, so next to melindas right is chuck, the ceo at the Community Health alliance in reno, nevada. He worked atg cha the school of medicine and worked as the nevada medicaid administrator. Isally, dr. Richard frank the professor in the department of Health Care Policy at Harvard Medical School and previously served as deputy at the health and human services. Welcome to our panel. Melinda has a few quick opening remarks and then we will turn it over to cindy. Melinda can you hear me . Hello . Great. Good afternoon, everyone, and welcome, and many thanks to the alliance for Health Policy and the panelists for joining us. I have been asked to briefly frame the conversation. As sarah mentioned, dedicate has aken center stage as we have number of proposals to repeal and replace the Affordable Care act have been introduced. These proposals do not just change the expansion, the recent expansion of the Medicaid Program but actually also address the underlying traditional Medicaid Program. Say, what isly to next for medicaid . Before we discuss the implications and hear a range of data and perspectives, it is good to be reminded of some of the basics. Next slide. Thank you. So the ones that are being projected, by the way, are not actually is good as the ones in your folder so if you want to pull out your folder then you can see some of the numbers. So just to be reminded, it is a federal and state program. There are federal standards but ,tates have an enormous amount an extensive amount of discretion on the design and administration of the program. It currently covers more than 74 Million People and that can be roughly, there is roughly four groups infants and children, people of all ages with disabilities, low income seniors, elderly, and other adults. Children represent the Largest Group but the elderly and disabled account for the largest proportion of expenditures. In terms of what it covers, medicaid covers a broad range of services to meet its very diverse population. There are a number of Optional Services that states can cover such as pt and eyeglasses and dental, that it is important to stress that medicaid covers nearly half of all births, 40 of all children. There is a comprehensive benefit whichren known as is particularly important for children with disabilities. Medicaid covers longterm care occluding nursing home care and communitybased Longterm Services and support. As of currently, more than half of the longterm care covered by medicaid is in home and communitybased, spent in the home and in the community, which is enabling seniors and people with disabilities to continue to live independently. The fund has, for a number of years, the Commonwealth Fund has supported research to examine the implications and the effective medicaid on people. So that is what is in this next slide, just some data from some of my colleagues off of our National Survey or by annual survey. Survey. Ual it shows people with medicaid are less likely than those with private insurance or uninsured to skip services due to cost. Other analyses look at how medicaid beneficiaries, their satisfaction with their care and they rate the care fairly highly. But it is not just Commonwealth Fund data. There was recently a paper in the new england journal of medicine by ben summers and kate back andt did a look overview of the implications and effects of the Medicaid Program, and basically showed that those with medicaid had better access to care, more likely to have Early Detection of disease, more likely to be adhering to their magic dedication regimen, have better management of their chronic condition, and importantly but maybe not overly appreciated, peace of mind knowing that they had some coverage when they got sick. So moving on, another area that we tend to look at is not just the implications for the people and the state economies, but also the providers. This is the studied at the Commonwealth Fund did with the Kaiser Family foundation, and shows that among these primary care providers while they were seeing more patients with reported, most doctors no decline in their ability to provide quality care since the Medicaid Expansion. At the Commonwealth Fund, our role is to support rigorous analyses to understand the implications of the various Health Policy proposals. And really, we strive to look at the implications at multiple levels, whether it is on state economies, on providers, on people, or subsets of people. This next slide set a recent analysis done by al docton and his colleagues looking at medicare provisions and hospital finances. What we have seen is that for all hospitals, particularly those in expansion states, can anticipate over the next 10 years an increase in uncompensated care. That is a treatment or service for which there is no insurer and the patients are unable to pay. Anticipated increase of about 78 over the next 10 years. Billion, so a 114 big increase but also a lot of money. In the nonexpansion states, expect about a 10 increase in uncompensated care over the next 10 years, may sound smaller but still 17. 3 billion. Has done a number of analyses that pullout rural hospitals, look at it by state, just the safety net hospitals. There is a lot of analyses are you to turn to. For you to turn to. Another analysis we released yesterday was looking at the implications of the Better Care Reconciliation Act, the senate will, on state bill, on state economies and particularly on jobs. As it says on the slide, if it were to become law we anticipate about 1. 6 million jobs will be lost affecting grossed gross state products as well as the business output. And also, not just looking at this at the National Level but at the state level. Here is my little plug for some new fact sheets that we have pulled together and that are in the back for kentucky and nevada and california, are examples that we have available but actually there is one for all 50 states. Pieces, theed two hospital component and the job component because two of our thekers will look at implications for federal dollars to the state, that will be cindy , and richard will look at a subset of the population, people with opioid addictions. And so with that, i was just going to say, echo sarahs comment about how we really look forward to hearing a variety of perspectives and having data and evidence guide this conversation. Thank you. Thanks, linda. We are going to go right down the line cindy, josh, chuck, and richard. Aen we will have time q and and some discussion. Tag youuse thesh htag whats next for medicaid . It is great to be here. I am going to open up with a short overview of the key changes in the senate bill with respect to the Medicaid Program, and then really focus my remarks on the per capita cap implications its for states and the program and the people that the Medicaid Program serves. I just want to state my appreciation for the support of the Commonwealth Foundation for its support of our modeling work. We have looked at statebystate impacts of both the house bill. Nd senate bill i will draw on both of those analysis as i go through my presentation this morning. If we want to go to the next slide, here is an overview of some there is a variety of different provisions in the Better Care Reconciliation Act that affect medicaid, but here are some of the key changes. The house passed version of the and nobody quite know is you are supposed to pronounce the initials or just say them out loud. Converts medicaid essentially to a capped funding program, very fundamental change as they are identified in the basic structure of the Medicaid Programbcra, and really goes beyond any changes that the aca had with respect to the Medicare Program. 2020, medicaid, instead of a program where the funding is jointly shared by the federal government, the governments part would be capped. Int would go into effect 2020. The bait the government also offers the states the per capita applies to virtually all spending in the program and all people. There are some carveouts for the caps but longterm care, acute care, i think the key point is not just the expansion population. People think we are talking about repeal and replace. The financing changes are pretty much walltowall with the Medicaid Program. The other big change in the bill is that it would phase out and ultimately eliminate the enhanced federal funding that the Affordable Care act made available for states to expand coverage to low income adults. You will see on the slide that 2021,ses out beginning in and has a threeyear dropdown of the match rate. In 2020 under the aca it would , and init goes to 85 2020 it goes back to the states regular match rate. Big changes in terms of federal financing. There is also some big provisions that would provide extra funding for the state that did not take up the option to do an expansion, some funds, 2 billion of funds to the states to be shared among the 19 states , and also it changes the dish cuts so that the expansion states continue to experience or will experience the dish cuts that are expected to go into effect dish means . Disproportionate hospital share payments. It provides funding on a match basis to help provide financing to hospitals that serve a disproportionate share of either medicaid or uninsured individuals. Aca cut the spending on the theory that we would have more coverage and there would be less uncompensated care. And what the senate bill would and notstore those cuts put those cuts into effect. They go in effect in september, for the nonexpansion states but for the expansion states they would go into effect even after the enhanced match goes away. Those are some of the major things. I need to get going on this so if you go to the next slide, it briefly shows you what the reductions are. If you go to the next slide, please. Next slide. No, back. Follow your booklets. It just shows the yearbyyear reductions that cbo has identified in the bcra. Overall and you are probably familiar with the cbo scores the cbo says it would produce a loss of 772 billion over 10 years for the Medicaid Program and of course very importantly, by 2026 cbo projects that 15 Million People covered by medicaid would lose their coverage, would no longer have that coverage. If you go to the next slide, i want to talk a little bit about how the cap works. I am not going to spend a lot of time explaining this. It is a wonderful diagram and hopefully it will teach you, but we can have some time during q and a. Spending isc trended forward by a trend rate and both of those factors are critical in terms of understanding the impact to a states Medicaid Program. What was that spending in the early years, if the state is locked into that spending over time in perpetuity except for the adjustment. What you see in this diagram is there is different trend rates the. Plus one toand cpi bring the caps forward yearbyyear until the year 2025. 2025, all the groups go down to the cpi which is a much lower trend rate. That builds up to an aggregate cap. You have your caps for the individual groups of people. You multiply the cap times the mole the number of people you covered in each of those groups and that builds up to an aggregate cap. That is what the state is going to be guided by in terms of its spending. If state spending those over the cap and it starts to draw down federal dollars beyond the cap, it will have to pay back, there will be a clawback to those federal dollars in the following year and all of the dollars spent over the cap will be 100 financed by the state. So very different notion from current law, where all financing, all costs that are legitimate medicaid costs are shared by the states and federal government. If you go to the next slide. This just looks at how those trend rates compare. I will not go through detail on this but let a just say the trend rates are designed intentionally to save the federal government dollars. They are pegged at a rate that is intentionally below what the states are expected to spend over the next 10 years, and that is one of the main ways in which some of achieves its, the savings and the 772 billion score. If we go to the next slide, please, this one you might want to look at, at your booklet. This shows the yearbyyear this is our modeling where we showed the yearbyyear, and we have this statebystate impact of the caps on this is just the caps, not the effect of the thension so just part of 772 billion and what you see here is the federal loss of dollars. But i also want to point out which is also forgotten often forgotten, is the state lofts of dollars. Loss of dollars. If the state says, i would only spend to the caps, which is what most of them do now. I could spend all their money on health care but they basically spend what they can spend to qualify for a match. If they only spend what qualifies for a match under a capped environment, their state spending will decrease so the total impact to the Medicaid Program is bigger than the impact of the federal cost. It is also the reduction in state dollars. The state does not have to reduce its dollars, it can simply spend dollars without getting a match. On the assumption here that a tote will keep below the cap avoid the clawback and avoid spending 100 federal dollars, you see the total cost. Because the cpi trend rate pops in, in the senate bill in 2025, you see a very deep, a significant jump in the cuts between 2025 and 2026 because of the change in that trend rate. That gives you a sense and cbo has looked at this also a sense of how the cuts will grow over time. They become deeper every year but they will become even deeper after that 2026 period. Let a just try to make one point, if you would go to the next slide. One of the things that we have certainty the lack of of what life will be like. The one thing that we know is that Health Care Costs are difficult to predict, but the other thing is that these trend rates are difficult to predict. So when we have done these analyses, we have taken cbos projections of the trend rates. Cbo says i think medical cpi will be 3. 7, i think it will be 2. 4 over the next period of time. It is as good a projection as anyone might make so i have no quibbles, but over this period of time as these trend rates go up and down. They are volatile so what matters a lot which trend rate congress picks. Whichever trend rate congress picks, we need to understand it is not set in stone and it will fluctuate. One of the things we did was look at what if the trend rate was not exactly what cbo projects . What if instead of 3. 7 for medical cpi it is 3. 2, half a percentage point lower . The total cost due to the cap would change between 2020 and billion, itout 267 would jump to all lost 400 billion just because that trend rate changed and did not turn out to be exactly what cbo thought it would be. Suggest a close, i think that is one of the most important points we want to make about the fundamental change of financing the cap. It produces significant reductions in federal dollars to states for their Medicaid Program, but it also introduces a great deal of uncertainty, and all of that risk of uncertainty of the trend rates were actual Health Care Costs will be borne by the states, the Medicaid Program, and the beneficiaries. Thank you. Thank you so much for the alliance for Health Policy and the Commonwealth Fund for inviting me. For those who are not familiar, fga is a think tank that runs in roughly 30 states. I want to start with a poll. Raise your hand if you think based on the Media Coverage at the end of the 10 year cpl budget window we will be spending less money on medicaid . Raise your hand. Raise you hand if you think we are spending more money at the end of the budget window . A couple people. I am just saying absolute dollar amount, if you compare what we are spending today versus the future. We have found around the country is the Media Coverage has used this language around cut, massive, severe cuts. What has what is interesting is that for years we have had agreement on the right and left it we want to slow the rate of growth in health care in general. Yet, we have a proposal on the table for the Medicaid Program to slow the rate of growth and the sky is falling. There is lots to unpack here so i want to start a little bit and talk about status quo. I want to make sure that anybody who is talking about the changes in the republican bills has to also talk about the status quo. From the standpoint of the thecaid expansion pits ablebodied adult against the traditional medicaid population, let me explain that. The federal government put extra money toward the Medicaid Expansion population to get it to expand. The challenge with that is if i am a state budget writer and i have to balance my budget every year which by the way, they do, unlike here they have to fund one dollar of savings, determine where they will try to take that one dollar a savings. They have a few different options. First and foremost, when it comes to medicaid it comes out of the traditional medicaid population, the elderly, kids, the disabled. They lose less federal dollars if they do so. If it does not come out there and it comes out of education spending, public safety, infrastructure. We cannot spend the same dollar twice. Secondly, as far as the status quo is concerned, we can assume that federally we can actually suspend this spending that we have. Cbo, whenk at gao, they look at fsi, at a care in medicaid they will eat the federal medicaid and medicare, a they will eat the federal budget alive. If we cannot do anything for reform it is naive. Is ieeper concern we have do not think the Medicaid Program in general has lived up to the promises that we made to the truly needy before making new promises to the expansion population. I also would say that the current openended structure actually leads to some pretty terrible state behavior. Fornew york budget director a long time had this somewhat glib statement saying if it moves and medicare can pay for so we can in medicaid pay for it, things like school services. If not, appreciate it. At the heart of what that is, is to say we are going to try to pull down as many federal dollars as possible. The focus is not about program integrity, coordination of care, Health Outcomes, and as i sure many of you are aware, whether it is the organ study or others looking at questionable outcomes on medicaid. If we have a program estimated to deliver about . 20 to . 40 of value to anybody, why would we just defend the status quo . Why wouldnt we be open to trying something new . I do think from the state perspective we work with a lot of state legislators and governors and when it comes to medicaid, one of the things we hear is additional flexibility. They want and desperately need additional flexibility on medicaid. What does that mean . It can mean a few different things. The waiver process here in washington, it does allow in theory a lot of flexibility, but when your state legislator needing to balance your budget, your governor needing to balance but theget that year, average waiver takes over a year to get approved, it is not as helpful in the short run. Given the flexibility to grandfathered new eligibility changes Going Forward, to do more frequent eligibility checks , to reinstate asset taxes or things that governors are starting to look at, especially in light of some of the proposals on the table from Congress Going forward of what they want to do to move forward. I will just say that on a per capita cap proposal, this used to be bipartisan. President clinton had a proposal in 1995. There have been democratic top past whoats in the have talked about the need to bend the cost curve or reduce the cost of medicaid. I want to make sure were having an informed, intelligent discussion about what the actual changes are Going Forward. What is interesting to note is two things. One, or those in support of the aca, that was over 700 billion in reductions in payment of medicare. I do not recall the sky is falling rhetoric around that time. In fact, i went on the come along website to look and what i found is erin davis testifying this is positive. In fact, she said more is needed to have a sustainable program. She lay out a number of different proposals to do so. But i think it is just interesting that we have people that want to have it both ways. If you recall, in welfare reform in the 1990s, the sky was falling during that reform as well. What was missing from that discussion similarly to what is missing today is that there are two components here. There is a tax credit. In welfare reform, there is the earned income tax credit. And health care, there is a tax credit. There is a robust debate about how generous it is, who it is offered to, put in the medicaid space, when your state decides to move away from Medicaid Expansion, there is a tax credit available for those who do not have employerbased insurance. People who are not currently qualify for medicaid, the is a tax credit available newly available under the Republican Health care bill. That should be part of the conversation we are having about holistically looking at the decisions people are going to be making. I am not looking to poke cbo too much, however, i will make a couple comments about the coverage of losses we keep hearing about. What we need to understand about the process, it is very arcane, and i get why the public does not follow it, but they model off of 2016 numbers. I had a number of assumptions of how many people will sign up in an individual market and medicaid. They did a model often updated numbers in 2017. Lives4 or 15 million number that we hear about people losing medicaid numbe coverage t losing technically. It is changes. There are things that are just phantom. For instance, they say that 5 million of those are people who lose coverage in states that they thought would expand medicaid. If you are not on medicaid, i am not sure how you can lose it. They also make some assumptions around the individual mandate, 54 7 Million People who just decide from this year to for to seven millionllion people who justify from this year to next year they will not sign up. Thank you for the opportunity to share that. I look forward to the q a. I suspect i may be sharing a slightly different perspective at times than others in the panel. Thank you, josh. I know most of the people in this room are very familiar with the Medicaid Program and the policies, but since we have talked about the expansion population in medicaid and the per capita cap i want to kind of raising clarifying point as well for those who might be watching on sees and that on cspan that who was in the medicare expansion, can one of you give that quick overview of that . Sure. Happy to. A lot of people thought before aca that poor people got medicaid and old people get medicare. Years. D grew up over the congress changed it over the years, but there was always a missing group of people. Parents can get coverage. Pregnant women can get coverage. Children can get coverage. People with disabilities and the elderly. If you did not fit into those boxes but you are still poor, you did not qualify for medicaid. You would have to come and get a waiver, and it would be complicated. What the Affordable Care act did is say people should be capable o. By filling in that gap, it meant the Expansion Group our parents about the income level that a state with covering before the aca well below poverty on lessage and socalled child adult. I am a parent but not a childless. In medicaid lingwood, i would be a childless adult because my kids are 19 and 20. It is adults that are not pregnant, are not disabled, are not elderly. Up to 138 of the poverty line. Just one more quick clarifying question. That is 15 million, the number in the cbo score, is that mostly related to that expansion in population or related to other populations covered under medicaid . The cbo does not identify it that precisely. We think it is mostly related to the expansion population, but there will be some implications because of the reductions in the federal funding that we went through the cap. But exactly how any given state might address those reductions i speculative. Ewhat i think it is mostly the expansion, but it is the combination. A point of contact. 75 of the growth in medicaid is not do to underlying Health Care Costs or other things going on. When we are talking about savings Going Forward, it is related to enrollment a of some sort. That is are we have seen the expansion. Great. Thanks. We will get to the intersection of the Medicaid Program, the expansion changes, and the tax credit that josh mentioned. Before we get to that, which i wanted to get to in the q a, we will give a chance for our other panelists to share their remarks. Good afternoon, everybody. I want to thank the alliance and Commonwealth Fund for having me here. My name is chuck. I am the ceo of Community Health alliance. By way of background, i wanted to tell you a little bit about myself besides running a Community Health center in nevada. I spent 15 years running Medicaid Programs on the frontline as an administrator. 12 years in nevada. Three years in hawaii. Before that, i ran Community Health centers in hawaii. I started a managed care organization, a Nonprofit Company in hawaii. I worked at hospitals and laboratories and a number of other things. I will start with a poll. How many of you touched a patient as a professional practitioner . How many . I am glad to see a lot of hands going up. That is wonderful because one of the things i warned sarah about is i will wear my heart on my sleeve. One of the things that i am going to borrow a line from a friend of mine in the audience today. She said, you cannot only break heads with data. You have to break hearts because there is a patient at the end of your decision. That is important to keep in mind. Part of my job is to tell you about that, but also happened in nevada. Nevada being a very pivotal state in this discussion. And also as a medicaid administrator, former administrator, what i see as the tough decisions coming up for medicaid administrators and governors throughout the nation. Again, my name is chuck. If you would not mind changing the slide. I run Community Health alliance, a Nonprofit Organization in nevada. It is a Community Health center. We have six in the county. We have mobile services, medical, dental, and additional services. We provide health care as well as dental, pharmacy, and nutrition programs for our patients. Next slide. We serve about 30,000 unduplicated patients a year, 44 of whom are children. 60 of our patients indicate they are of hispanic origin. 95 of our patients are below poverty. Of medicare, medicaid, or are uninsured. Next slide. What i would also like to do is tell you a little bit about nevada and give you a snapshot. The first thing you have to learn how to do it to say nevada. After me, nevada. Ada. S not nav waiters will refuse to serve you and dealers will deal from the bottom of the deck. Do not do that. Nevada is in the crosshairs. What people do not understand about the state is you think about las vegas, and nevada is really a frontier state. Islands,o population las vegas and reno. Reno is in the north. Las vegas is in the south. They are 500 miles apart. You can go across the state the other way, and it is 500 miles. 14 of the 17 counties in nevada, pardon me, have about 10 of the population. Excuse me. And so they have benefited lately from the medicaid. If you look at the population in the snapshot, 35 of nevadans are low income. 2 3 indicate they are obese or overweight. 1 3 indicate they have a Mental Health condition. 10 have diabetes. Deaths, we opioid are ahead of the national average. We are seventh in terms of the hiv diagnosis. Next slide. This one slide kind of tells the story. Mind going back one . Looks like it is not going to work. If you can go to your handout, hopefully you have this in your handout. There is a slide that shows you the change in the uninsured rate in nevada between 2013 and it says 2017, but it is actually 2015. One year after governor brian sandoval, our governor, and limited the Medicaid Expansion the experience exchange, we saw a drop in the insurance rate from on in one yr from 19 to 11 . Nevada posted the second highest uninsured rate behind texas at that point. It changed dramatically with implementation of the Affordable Care act. I saw a recent statistic that for nonelderly hispanic adults, the uninsured rate has dropped from 34 to 19 . That is the slide i was referring to. I am sorry. Next slide, please. Oh, it is backwards. Sorry. Ok. Now we are all right. This slide shows the impact of medicaid on the aca impact on medicaid caseloads. You can see where the Medicaid Expansion happened in 2014. Between 2014 and november 2016, caseloads have grown from 330,000 to 630,000. The two groups that cindy talked orut, new eligible parents parent caretakers and new eligible adults, they represent about 230,900 of the total population. What is interesting here is that not only did those two caseloads butease, the new eligible, we saw a pretty substantial increase in the traditional caseloads of aged, blind, disabled, moms, and kids. Why did that happen . Primarily because of the woodwork affect. People becoming aware of the medicaid and saying i am eligible for medicaid and so are market or my disabled parent or spouse. It is the message that got out there that have these people apply. They are eligible as a result of the traditional program. Any cuts that occur in the state, and i will say cuts, are going to have to come not only for the new eligibles, but are going to have to come from the traditional population. Next slide. The next slide. Ok. I am going to keep rolling. Right there. Stop. Ok, so this is our patient population. You can see before and after the expansion for children in our practice, in 2013, we had 41 uninsured children. Today, 17 . For medicaid, our childrens enrollment went from 50 to 73 . 70 adults, it declined from 22 . 78 to next slide. This is what i mean about breaking hearts. Josh mentioned the ablebodied, people that just got on medicaid because they could. Well, this is one of those socalled ablebodied individuals. People with competentr medical conditions as well as Behavioral Health problems. She has type dude diabetes and two diabetes. They keep me a little bit well and send me on my way. She is a beneficiary of the Medicaid Expansion. She worked as a Bank Loan Officer but becametoo ill to work and lost her insurance. She is spending time with her grandsons. I go to soccer games, church. I am not bedridden. I do not ever want to be in this life without insurance. What is going to happen . She is not a unique individual in this situation. People who are in our program in our Health Centers who are expansion eligible, a lot of them are disabled, but they do not qualify for ssi. 35 of them have a Mental Health this order. Many of them have chronic conditions. You cannot tell me these are all healthy ablebodied people that are going to go right to work when there is a job opportunity because they struggle already and they do work. Again, im wearing my heart on my sleeve, but that is extremely important to understand about this population. These are the people that are going to be affected. Last slide. The last thing i want to do is kind of give you an idea what medicaid administrators and governors are going to have to do, particularly in the state of nevada. Been some other number stone around in the last few days about the loss of federal revenue to nevada. 2, it estimates nevada will lose 1. 4 billion in medicaid funding. That would be a 43 reduction. Granted, the cpi will be there. And there will be an increase in spending, but a 43 reduction in federal funding is going to result in people losing coverage. The other complicating factors in nevada is we have a relatively high mass rate. The loss of those federal funds will be equally significant. We have a high expansion population. High chronica Disease Burden in a lot of these folks in the expansion of revelation. A lot of Mental Health disorders, edition, hiv infections. We have rural and frontier counties which will be adversely affected by this. We have a rapidly aging population in nevada, which will be ultimately dependent on Homebased Services or nursing home care. We have a low tax base. What our governor is going to thatto do, i have 4 dials medicaid directors usually adjust. I will talk a little bit very quickly about some of these because these are the decisions that governors and medicaid directors are going to have to make. Eligibility, services, utilization, payments, and it is a little control button on the bottom called managedcare if you cannot see it. Eligibility, you can do things like put work requirements, asset limit increases, income limit increases. You can do things like more frequent eligibility determinations. All of those things have the result of knocking people off the program. That is fine. But the real big gun on eligibility is you have to take whole populations out of the program at once. That is the only way to get the costs out of the system. You have to get rid of the extension population and some of the people involved in the traditional program. That is where cuts are going to come, or reductions i should say. You can look at eliminating Optional Services. But those have collateral cost impact on the rest of the program, and it is not necessarily wise to cut those services. You can look at utilization management. Those really have marginal impact, but you cannot beat willynilly about it because states are required to maintain a reasonable medical necessity criteria with a look at utilization management so you cannot just do that. You can look at cutting payments, but cms is looking at whether or not cutting payments has an impact on access. You cannot just willynilly cut payments. This is a little control button on the bottom. It does not do a lot, but people like to press and a lot. It is called managedcare. I can say that from my experience in 15 years of running medicaid. It is great. I call it the pontiusi call it e program. Again, if i am talking to a patient who is going to lose coverage, i am going to tell them i am going to borrow a line. Do not worry it is not because of cuts. It is because of reductions in spending growth that you lost your coverage so it is not a problem anymore. I am sorry to wear my heart on my sleeve and not be totally datadriven. Like a couple of lessons here. Language matters. Consequences, whatever they may be, are going to happen one way or another. We will keep talking about that. First, we have one last presenter, and we will get into a discussion in q a. Thanks. Thanks. I am happy to be here. I really wish i had chucks social skills. [laughter] but i will keep going. First slide. First next slide. Addressing many types of Public Health emergencies that we have been facing over the last few years. Opioids, zika, flew, you can throw in diabetes if you would like. I will really focus on opioids as a tracer condition for this broad set of Public Health threats and how medicaid works to give us tools to deal with it. Access toby expanding preventive interventions and treatments, medicaid is an important part of the arsenal that most governors are using to fight the Opioid Epidemic both anderms of addiction itself in terms of the mortality consequent is of addiction. Third, the proposals to repeal the Medicaid Expansion and shift the per capita cap will be disruptive to state efforts to remain in the Opioid Epidemic. I will show you a little bit of an illustration of the kinds of pressures that are put on states under these types of arrangements. Proposed,money being and there is a lot of recognition in various parts of congress that certain kinds of Public Health emergencies are being threatened, opioids in particular. None of the proposals that i have seen will come you providing the kinds of money you need to deal with that problem. You can imagine that going down d. E road, fo for a we have seen an uptick in methamphetamines that no one has started to talk about yet. Next slide, please. Let me start out with some fun facts about opioid use this. In 2015, we that had over 53,000 people die from overdoses in this country. About 61 of those or little over 33,000 were due to opioid use disorders. Grew atdose death rates 15 between 2014 and 2015 nationally. In fact, this is not a new problem. The Opioid Epidemic has been going on since 1979. It has grown pretty steadily at 9 a year since 1979 with respect to mortality. Opioid epidemic and opioid use disorders concentrated on lowincome populations, you see the Medicaid Expansion population being responsible for treating these folks. In states like maryland that expanded medicaid, two thirds of the people that died due to an opioid overdose were enrolled in medicaid. Aboutt turns out that half of the people with an opioid use disorder also of use or use other types of drugs. Methamphetamines, alcohol, cocaine among others. A large number of them suffer from chronic diseases. Some of some of them directly related to the opioid use. Some of them not. Other illnesses such as diabetes and asthma that also tend to accompany opioid use this orders. What that means is the average amount of spending for a person enrolled in medicaid who has one of these disorders is somewhere around 11,000 to 12,000 nationally. To put that into perspective, treating summary with medication assisted treatment for a year costs 5,500. That means half of their costs are not directly related to their treating that disorder, but are related to all sorts of other problems that they have. Next slide, these. Next slide, please. This is to elicit the impact of the expansion population has had on prevention efforts. Meloxicam drug called which reduces opioid overdoses. What you see in front of you is a comparison of the growth in the use of it in the Medicaid Program and expansion states relative to nonexpansion states. The steeply increasing one is the expansion states. The modestly increasing with is the nonexpansion states. Exactlyhave seen is coincident with these increases is data showing that between 2013 and 2014, there was a doubling of the use of naloxone. Medicaid is contributing to getting more of the Opioid Overdose Reversal Drug in the right hands at the right time in order to save lives. Really, this graph is a reflection of the number of reversals that have occurred as a result of making the drug more available. Next slide, please. Now, we are going to do something arithmetic. The arithmetic here is not meant to be a precise estimate of the future, but rather to illustrate the kinds of pressures. 42 million on Substance Abuse Disorder Treatment in the nonexpansion part offuture, bu. Ok . Rate of utilization of Health Services has been at about 5. 7 a year for the last 10 years. Out theu start to move spending along that trajectory, you see that by 2026, you would expect the main part of the Medicaid Program, the nonexpansion part of the Medicaid Program, to spend about 445 million a year on Substance Abuse Disorder Treatment. Ok . That by the cpim, which is the more generous of the indexes being proposed in the two health care reforms, you see you come up with about 368 million in spending. The difference there is 77 million and clearly not the whole difference is on the table, but recall that West Virginia has a very high managing rate, 71 . About 55 million of that would be a different in the federal spending. I think this is not meant to do anything but illustrate the kinds of pressures that states will be under. Last slide, please. Let me turn to the expansion population. Aboutirginia treated 50,000 about 50,000 people in the expansion population. About 112 million. . Ok . If that goes away, and i am not indexing to the future, those dollars will no longer be available since we are still paying about 100 . What does that mean . That means that those people, those 50,000 people, are going to have to look elsewhere for treatment. The state is going to have to take it on. Just to put that into me take thatlet 45 billion that has been proposed in the senate to deal with Substance Abuse disorder problems. I am going to allocate it the ay that the 21st century West Virginia gets 62 1 million a year. Right off the bat we are taking out 112 million. First day. That is going to continue to grow. The 61 million is every year and does not grow. Grow. We are going to get to the discussion portion. You guys have a couple of options for asking questions. As usual, your green cards if you want to write a question down, someone will come and pick it up for you. There,re two mics right that you can come and ask a question. Or you can send it in on twitter at whatsnextformedicaid. Let me kind of trying to pull it back. It seems like what is coming across from a lot of the comments are a couple of issues that weng to talkin are talking about here. Healthy, they may have chronic conditions, but they do not qualify based on the basis of a disability. One question is what is the best way to offerone question is what way to offer coverage . From the panels perspective, what do is the fundamental what is the financial issue that needs to be solved . Josh, you mentioned slowing the growth rate in spending, which is something we are talking about not only here in the Medicaid Program. Debate brewingle over the independent payment Advisory Board that would also reduce the growth rate or have a cap on the growth rate in medicare spending. One thing that is outside the scope of this briefing but is nonetheless also part of the care act is part of the cadillac tax, this cap on employersponsored coverage. Are we being a little schizophrenic and how we are approaching this question . A lot of pontificating from my end. The question from the panel took it off is, what do you think is the problem we are trying to solve it . Here . I would step back for one second and say we need to decide whether medicaid is a Health Insurance program or a Welfare Program. Depending on your answer to that question, you will change the structure of it. The other thing is, is the goal for people, since it is largely an incomebased program, is the goal for people to be on it for a long time . I would answer no. Anything that we can do to help people to get off because it means, by definition, they are poor, we want to do. I think there is a lot to that that you can peel back. Why cant they afford insurance . We get into all these other questions about scope of practice and regulations, which i do nothing we will focus on today, but that is part of this answer. But ultimately, what we need to ask ourselves is having somebody on a program for 20 or 25 years, that means by definition they remain poor and probably not working as much as they want or working at all. In ohio, the Medicaid Expansion population, 60 of them are not working. That should be deeply concerning to you no matter what your view of medicaid. We want to make sure that individuals do not get stuck that are able to work. I think that is a bipartisan goal. Perhaps not anymore in this country. But i think that is what we need to start to ask ourselves. I know other panelists was a you cannot get everybody to work. I get that. For those violations that we can, we should be focused on that across programs. If you are on food stamps or medicaid, you need to understand that our goal should be to coordinate and get people off of it as soon as possible on to affordable private insurance, which is a whole other conversation. Richard. Sorry, cindy. Richard, why dont you go next . I am going to speak as an economist here. Money is the problem. Deepepeople are poor. I want to get to this issue of cut versus growth. Looking around the audience, there are three people in the audience who remember ronald reagan. [laughter] thingald reagan had a called the misery index, which had to do with inflation. In fact, if you look at cbo and everything, none of the projected index rates in medicaid are keeping up with cbos projected increase in health care inflation. Theind of say that, ok, dollars are going to grow, but we are going to pretend there is no inflation seems like really deflating. I think the problem is money. The problem is money in two places. One, people are poor. Even when they work, they do not have enough money to buy Health Insurance. Two, budgets are tight. People, to pay for poor you need budget dollars, and they need to keep up with real resources. Check, you want to go next . I would love to go next. Thank you. Again, i am not as smart as richer, but we are talking about money. Richard, but we are talking about money. Calling medicaid a Welfare Program is an interesting concept because welfare goes back to the 1990s, where people were Getting National assistance. Medicaid assistance. Medicaid does not provide cash assistance. These are poor people to start with. They are struggling day today if they are working or not working to make sure they can put a roof over their head and food on the table. We serve about we have a food pantry. We get about 2000 people a month that come in and do not have food in their refrigerator. A lot of these are expansion population folks. We give them food until they can get to the food bank. You are talking about the economy of a household where medicaid does not contribute to the economy of that household, but it provides protection, a safety net for that household so it does not collapse. If you look at the root word of economics, it is oicos, and i think it means home. The whole route of economics root of economics has to do with the sanctity and protection of the home. In the 1700sdized by the english and became something totally different. There is no dollars associated with medicaid. Again, i do not consider it a Welfare Program at all. I have been involved with it for 15 years. As we pass it down to cindy i wanted to, add that i dont think it is just about being poor. It is also about being sick. The program is there for people who are really sick, who may be because of their illness, they illness, they have disabilities, and it is hard for them to work. Noted in his earlier remarks, per person, per enrollee, medicaid costs growth have been well below the cost growth of commercial insurance and medicare. It is not a runaway cost in terms of it is just getting more and more expensive. Medicaid spending has increased because, as josh also said, it is covering a lot more people. Filling the gap that existed before the aca. K talked about, it has welcomed other people who were always eligible but did not know they were eligible and have applied. Hat problem are we solving . It is covering more people. They should get themselves out of poverty. I am all for solving poverty. I do not mean to be glib about that. Is a really important issue. It is not the Medicaid Programs role to solve poverty. I want to stress that medicaid is a very diverse program. We are talking a lot about these childless adults, but a third of the spending for medicaid is for longterm care. It is for Medicare Beneficiaries who do not get longterm Care Services through the Medicare Program, that extensive longterm Care Services. We have people, pregnant women. We have people who are totally and permanently disabled. Those are where the big costs are in the Medicaid Program. We really need to keep our eye on the ball of the diversity of the population and the services. Finally, if we want to focus on how to cover very poor people, lets look at the tax credits that are offered under the senate bill. It would be offered to people down to 0 of the poverty line. If the poverty line for a single individual is 1000 a month, 50 of the poverty line, 500 a month, not to spend on health care, to spend on food, rent, utilities, transportation, every single need, including health care. You can get a subsidy under the senate bill if you are at 50 the poverty or 0 the poverty or 100 of poverty. You will get a subsidy to help you up for the premium. That premium actually is pretty modest. There will be many very low income people who cannot afford a modest premium, but lets assume for a moment they can afford the modest premium. We looked at what the deductibles will be. We look at arizona in particular. We also looked at national data. We looked at actually what the premiums are in the marketplace in arizona in different counties. If you take the deductibles that that policy will end up requiring plus the premiums, but mostly the deductibles, the percent of income buying that coverage through the tax subsidy will consume between 76 and 90 of your total income if you are at 100 the poverty. No room for food, rent, anything else. Medicaid fundamentally is about providing affordable coverage , and the tax subsidies that are being proposed as an alternative just do not cut it. Thank you. Since we are on this topic, lets get into the question of privatesector alternatives to medicaid coverage. As part of the challenge here, it seems to me since its origin in 1965 as medical assistance wereeople who basically getting cash assistance and the program has grown and grown and grown, but is that in response to, frankly, failures to address the problem in other ways . To have a punching private insurance system that can be a portabl affordable for people oy income . I do not know if anybody wants to try to take that on. So the short answer is, yes. There is a lot of work to do. That is what i spend 50 of my job doing at the state level, trying to help states crack the code, but i want to return to one thing i said at the beginning. Anybody that criticizes the reform has to defend the status quo. Lets not pretend that we can keep doing what we are doing. We cannot. While i appreciate chuck and cindys passion about this, this is personal to me. I have to remember is on medicaid. You have three choices. You can try to come up with a reform now to make it sustainable Going Forward, you can defend the status quo that is going to hurt the traditional medicaid population, or you can kick the can down the road and have even deeper cuts in the future. Which one do you choose . That is what we are talking about here. There is lots of sniping in the media about it. I am not here to defend everything that is in the Republican Health care bill. Trust me. It needs a lot of work. However, when we talk about reform, if we want to give any sort of promises, we have to change it. Let me just make one last point here. For us to defend medicaid as a great coordination of care, chuc k knows this firsthand, when i talked to medicaid directors across the country, they are so frustrated with people going to on medicaid because we know that is not the best way to get your care. Everyone agrees on that, yet it is a persistent problem. We are delivering the best quality care. It is sadly not true. There is a lot of ways to fix it. Since 2000, i do not think any state would have exceeded their per capita cap. In the housete bill and in your packet is an analysis we did on the house built. The growth rate for the elderly and disabled is much more than what our projected growth rates are for those populations, so we justly to understand, yes there is lots of moving parts here, but lets at least understand the dynamic Going Forward the impact and whether we actually think the status quo is something we can sustain. I would argue, absolutely not. I want to give her an opportunity to ask for question. Thanks very much. Katelyn connolly with the National Employment law project. I want to ask a little bit more about longterm care and services and support, but first, i want to say that beyond your three suggestions, there are 4, revenue, adjusted revenue, and not giving tax cuts to the wealthiest. Going into Longterm Service and support, which we know medicaid is a primary funder of and plays a huge role, as we are looking at an aging population, demographics that we have never seen before, this legislation will harm our Current System and our future one in even greater caps. Y both per capita it will not adjust for higher costs of the oldest old population, those 85 and up. Also, the job losses, particularly in addition to the. 5 million projected the specifics of those in the home care workforce, we are looking at leading age in Community Catalyst and Community Catalyst released a report saying jobs can be lost because of the cuts. That is just at the time where we need to have more home care workers to meet that demand. I wonder if you can address that. Weo, the job losses by 2026, are able to account for the even greater losses when medicaid is cut by 35 . Taking on the last piece first, the analysis just went to 2026. It is done at George Washington university. You can look at it on our website. Their project out 10 years to it project out 10 years to 2026. I will go back to my previous life as a medical administrator. One of the things i am most proud of in nevada is we flipped the expenditures between nursing facility care and homebased Commodity Services over a decade. It took a decade. That was by establishing programs like personalcare attendant services and making sure they were funded adequately so we can not only in urban centers but in Rural Communities be able to take care of people at home. I am very proud of that as well as expanding home and Community Based care. Your point is spot on. I do not disagree with josh that we cannot continue to see increases in health care percentage of our gdp, but we have to find a way to make it more affordable. With an aging published in nevada, we have the second highest growth rate projected for 85 plus individual. They are going to be ending up in acbs services or in longterm health care facilities, and we have to find a way to make that affordable. It is revenue. How much does it cost . I worked for Blue Cross Blue Shield in the 1980s, and i started a longterm Care Insurance product. It cost me when i was 30 years old in premiums five dollars a month for a cbs coverage through blue cross hcbs coverage through Blue Cross Blue Shield. If we charge people five dollars a month as a part of their Medicare Program taxes or other taxes, we could be able to afford, in the long run, payment for hcbs services. You offer everybody, but we would have a modicum of services that could be income adjusted and would provide for longterm Care Services. Revenue would be a solution to that problem looking at our growing elderly population. Thank you. We actually have been talking so much. We only have 12 minutes left in his briefing. I want to make a note over here that this is obviously a huge issue. There are some reports coming out around town on that issue. Certainly something that we plan to look at in the future separate from this discussion. But i want to get to one of the questions on the cards. We have been talking a lot about adults and older americans. I believe melinda mentioned these statistics on how many children are covered. This is a question for cindy since you were in the chip program as well. What intersections between chip and medicaid and some of the changes that are proposed, and chi beul have worked implicated in all of this . I appreciate the question, however sent it in, because it is often overlooked that medicaid is such a significant player in the lives of children across the country. About 40 of children around the country get their coverage through health care through the Medicaid Program. The chip program as is often said stands on the shoulders of the Medicaid Program. Little over 8 million children covered through the chip program. About 37 million children covered through the Medicaid Program. Both covers some healthy children. Lionsicaid covers the share of the kids who have Greater Health care needs. Chip has been enormously successful, has a lot of bipartisan support. It has really helped with continuity of coverage, helped make sure that the uninsured rate has plummeted for children over the last 10 years. It is now below 5 thanks largely to medicaid and chip, but it functions a lot because medicaid sits beneath it. It is covering so many more of those children. It is covering the children with a Higher Health care needs. So you really need both to complement each other in order to maintain the coverage in the Health Outcomes we have seen for kids over the last few years. Let me kind of follow that. We have a question about pregnant women and the grant option in the legislation. Can you talk about, what is the option for states to do a block grant instead of per capita caps . I believe that is mostly pertaining to pregnant women and not disabled adults. Can you explain what the proposal actually is, and what would that mean . What incentives with that put in place for states . What it put in place incentives to do a better job with maternity outcomes or not . If not, why . Sure. In terms of incentives to do a better job on maternity outcomes, let me just pick up quickly the point of the status quo. I do not think there is a program, a Medicaid Program in the country that is just running on autopilot. There is no status quo in the Medicaid Programs. They are quickly dynamic. What has been going on really since the end of the Great Recession is a very focused costs on trying to lower cost or care improvement through better integration of carechangn the Medicaid Program. I am forgetting. The block grant. The block grant proposal the senate is more narrowly drawn. It is also more detailed than in the house proposal. It would largely be for pregnant women and is very low income families that did not fall into the expansion population. Capitad not unlike a per cap, it would not very. The amount of money that would be based on historic spending, but it would not vary over the years based on the number of people that enroll. That is a big financing difference. The other thing is in the senate bill. The growth in the block grant would be at the cpi, the lower trend rate for the entire period of time. It would not vary based on enrollment, and it would not grow as much as the per capita caps would. Why would a state want to do that . It does give the state more flex ability. Benefits to pregnantlower women require federal requirements in terms of what services are covered for the amount and scope of those services, but it also has this feature that is kind of hidden. But it allows states to draw down those federal block grant dollars and spend a lot less of their stay dollars so it may have an attraction to state for states forn that reason. I know people in this room probably know this, but maybe not all the viewers. Cindy describe what is in the senate bill. That is likely to go to the committee. The final version that comes out of this may look different from what we are describing. As people are reading the media, they say this is in the house bill. Bill. S in the senate a lot of americans assume what is being debated will be the final version, and there is no guarantee of that. I wanted to mention this is a moving target as many of you are aware of. Thank you. That is a great point. We have time for one more question at the mic if you can keep it brief, and we will ask a couple reppo questions. Thank you. I am one of the clinicians that chuck mentioned treated patients. Bringing up ronald reagan, my first position here in washington was in the reagan white house. Not only did he have the misery index, but one thing he was noted in saying he was asking a rhetorical question, are you better off now than you were four years ago . That is a great way to perceive what is going on with medicaid in our entire health care system. Particularly with the changes that happened with the aca, what it means for people on medicaid. Churncan be a lot of between people going into medicaid, and it sure, private insurance, employeebased insurance, that kind of thing. I am wondering if you can talk a little bit about how the challenges of a Medicaid Program dealing with those people going in and out of different insurance eligibility coverages and how the current situation, i will not call it the status quo, makes their lives better, simpler for Insurance Coverage and continuation of coverage. Thank you. A number of ways in which the Affordable Care act and also states decisions on how they are able reading the horrible care act, whether they are an expansion state were not, but that has reduced churning. There is still a lot of in and out, but a lot of the lifications means thecations are in place. The benefits of that really goes to some of the issues we were talking about in terms of what states are working on, which is if you are really trying to get at the high cost case individuals, if you are really trying to change the trajectory of their health, you need to have their lives covered. You need to be connected to them for a continuous pe oiod of time. There is good for the goals of helping to improve the management of care and bring down that curve. That cost curve. A really quick note on that. I think some of this sounds like from josh, what you were saying earlier, getting people off of the Medicaid Program as soon as possible. It depends on how you view the Medicaid Program. Should it be a temporary sort of assistance or longerterm Health Insurance program . We have a few minutes left. We certainly have not solved all of the problems today, but we have a robust discussion. I guess i just want to close by asking the panelists in 30 seconds or less, if you could wave your magic wand and make one change or state one principal about this program, what would it be . That is about all we will have time for. We will wrap it up. I will start with richard. If you do not mind, i will take my time. I want to issue what i think is a correction, which is there is an impression that somehow the evidence out there from the oregon a spirit is there is no benefit to medicaid in terms of health. Somehow, everybody seems to skip over the fact that Mental Illnesses and diabetes are both sicknesses that cost this country a lot of money. Diabetes is probably the most expensive single illness in the country. Those are the places that the oregon experience had their biggest effect. Somehow, people keep speaking th that par. I understand it. I dont understand it. I think there is a lot of its fbility in medicaid o flexibility in medicaid. Some of the problems have been chronic underpayment in certain areas. Sense, wecause, in a have used prices to control supply. I think the advantage of managed care, apologies to chuck, is that it allows greater electability on that front flexibility on that front and allows a Delivery System in the Medicaid Program. I will accept that criticism. I think if i had a magic wand and i could wave it and fix medicaid and the rest of the health system, that is just one answer. You have to look at the most economical and efficient systems we have already operating in the u. S. , and that is medicare. I think Bernie Sanders said it. I will go right there. If i had a magic wand, we will need a Single Parents is that if we will be able to provide coverage for everybody. All right. Josh . I will take a slightly different attack. If i had a magic wand, i would hope our conversation about medicaid would stop assuming it can fix all of our problems and actually take a critical eye to say if we are really robust critical Public Policy makers, we will see if there is a better way to do it and do it that way instead if it is better, whether it is opioid treatment or others instead of assuming a managed care plastic card sold all of our problems. Where i would waive my one depends on the day or the week but i am focused on what is going on here in congress so i will talk about my wand relative to the present. No program is perfect, it is evolving, it is changing, it is growing, it is developing. What seems pretty clear to me having experience in the program for quite a number of years is that cutting off expansion funding that has supported the growth of people being able to get coverage for the first time and get care for the first time and regular care and arbitrarily capping the federal contributions and saying will not give you more is not improving Health Outcomes, guaranteeing the federal government some savings but it is not taking any of the issues in terms of health cost outcomes. To tackling the big issues, thank you so much, if i could fill with my magic once you will fill out your evaluation forms, thank you to our panelists, appreciate you being here. [applause] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [captions Copyright National cable satellite corp. 2014] if you missed any of this discussion, you can find it online at cspan. Org as this meeting is wrapping up some a the meeting is wrapping up between Vladimir Putin and donald trump. Cnbc saying that russia and the u. S. Have agreed to back a ceasefire in southwest syria on sunday, july 9. White housecs team, secretary tillerson is saying that President Trump opened his lengthy meeting with britain by discussing russian meddling in the 2016 election. Trump and kitten putin acknowledged several sets. A very robust and lengthy exchange, rt, russia today quoting president putin after saying there was a very long discussion with the u. S. President , many issues accrued including ukraine, syria, and other problems as well as bilateral issues. The russian leader said terrorism, Cyber Security also on the table. Coming up tonight on cspan. Harvard University Sociology professor and author William Julius wilson talks about Race Relations in america. Unlimited gap between whites and blacks following an economic downturn can be explained in part by race. Here is what you will see. In order to keep things in proper perspective when talking about the relative gains of more privileged blacks, it is important not to overlook the continuing interracial disparities. A report from the center for economic and policy Research Reveals that before the Great Recession, there was only a 1. 4 percentage point difference in the unemployment gap between recent black and White College areaate age 22 to 27 2013, shortly after the economic downturn, the gap had searched to a 7. 5 percentage point difference. Obviously a factor at play here because historically, the times during after before and downturns have impacted blacks more than whites. Racelliam Julius Wilson on relations in america. See all of that tonight at 8 00 eastern here on cspan. Q a. Nday on i am asking them to open their eyes to other people so that you can figure out your place in this infinite world. Gladstone, manager of dubya n. Y. C. s on the media. Media. The she looks at what constitutes reality today and how the criteria has changed over the years. I said at the set up our biological wiring at the beginning of the book and i wanted to show that we had evolved a culture that was designed to validate us and not to challenge us. Certainly not to contradict us. It gave us the illusion that our realities were watertight when really they were riddled with weak spots and places that would crunch in. Sunday night at 8 00 eastern on q a. Impact race, ethnicity, and religion have on Public Policy. Panelists focused on immigration other issues. It was held at the new york public library