vimarsana.com

Includes medicaid administrators at the state and federal levels. This is about 90 minutes. Hello, everybody, and welcome to todays briefing on understanding whats next for medicaid. Im sarah dash and the president of the alliance or Health Policy. Its a pleasure to be with you here today. For those of you who are not familiar with the alliance, we are a Nonpartisan Organization dedicated to advancing learning and dialogue on Critical Health policy issues. I want to say hello as well to those in the audience are watching us live on cspan this afternoon. And to those are joining us on twitter using the hashtag whats next for medicaid. For moderate today spent with me is melinda abrams, Vice President for Delivery System reforms at the Commonwealth Fund and we think the fund for the partnership in organizing todays briefing. Since medicaid was created alongside the Medicare Program in 1965, it is grown into one of the most farreaching Health Programs in our country, both in terms of the number of people it serves as well as their health and life circumstances and the cost of the program. Its run by the 50 states and territories within federal guidelines and financed by both the states and the federal government. While medicaid policy has National Implications come it of course also as major implications for states and their citizens as well. As we know major changes to the Medicaid Program has been at the forefront of recent Health Policy discussions, included within legislative proposals in both the house and the senate. And so today were going to talk about what those proposals are, how they would work, and what it would mean in practice based on our best evidence and projections. I just want to make a special note because while its real easy for medicaid policy to get very wonky very fast, and as the old kind of thing goes if using one Medicaid Program using one Medicaid Program, this is obviously, has been an issue international conversation. It does hit home for many peoples i think it speaks to the need for continued respectful dialogue on the different perspectives that are brought to the Medicaid Program and thats with the alliance for Health Policy is all about and thats what the speaking is all about. We are pleased to have a terrific panel here today to help us with this discussion. Let me guide introduced our panel and then and then ill turn over to Melinda Cindy mann is joining us today a partner at phelps and phillips. She has been a deputy administrator of the center for medicare and Medicaid Services she directed the center for medicaid for services at cms as well. Next to my left is trying to, senior at the foundation for government accountability, and prior to joining that foundation he served as director of the center for Health Care Solutions and Program Manager for the middle Cities Initiative at pine institute. He also served as legislative director for scott brown in the Massachusetts State Senate and as senior legislative aide for then governor mitt romney. I already introduce melinda, so next to melinda is chuck duarte, ceo at the Community Health alliance in reno nevada. Before joining them he worked at university of Nevada School of medicine and served as the nevada medicaid administrator. Finally doctor Richard Frank is professor of Health Economics in the department of Health Care Policy at Harvard Medical School and previously served as Deputy Assistant secretary for planning and evaluation at department of health and Human Services as well as special advisor in office of the secretary. So welcome to our panel. Melinda has a few quick opening remarks and then will turn it over to cindy. Can you hear me . Hello . Great. Thank you. Good afternoon, everyone, and welcome and many thanks to the alliance for Health Policy and to the panelists for joining us. Ive been asked to briefly frame of the conversation. As sarah mentioned medicaid has taken center stage as we have a number of proposals to repeal and replace the Affordable Care act have been introduced. And these proposals dont just change the expansion, the recent expansion of the Medicaid Program, but action also address the underlying traditional Medicaid Program. So its a timely to say whats next for medicaid. Before we discuss the implications and hear a range of data and perspectives, its good to be reminded of some of the basics. So next slide. Thank you. The ones that are being projected by the way are not actually as good as the ones in your folder, so if you want to pull out your folder and you can see some of the numbers. Just to be reminded, its a federal and state program. There are federal standards, but states have an enormous amount of, an extensive amount of discretion on the design and administration of the program. Currently covers more than 74 Million People, and that can be roughly, there are roughly four groups, infants and children, people of all ages with disabilities, lowincome seniors, elderly, and other adults. Children represent the largest group, but the elderly and the 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, but its important to stress that medicaid covers nearly half of all births. 40 of all children. Theres a comprehensive benefit for children known as eps which is to comport for children with disabilities. Medicaid covers longterm care including both nursing home care and Community Based Longterm Services and supports. Currently more than half of the longterm care covered by medicaid is in home and Community Based. It is in the home and the community which is enabling seniors and people with disabilities to continue to live independently. The fund has a number of years, the Commonwealth Fund, has supported research to examine the implications and effect of medicaid on people. And so thats whats in this next slide, some data from my colleagues and also from our national survey, our biannual survey. And essentially what it shows is people with medicaid are less likely than those with private insurance or the uninsured to skip Necessary Services or medications due to costs. Other analyses look at how medicaid beneficiaries, their satisfaction with their care and that they rate the care actually fairly highly. But its not just Commonwealth Fund the date of birth and was recently want to draw your attention, there was recently aa paper in the needing them the new england journal of medicine that did a look back, an 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 Early Detection of disease, are likely to be adhering to the medication regimen, had better management of their chronic condition, and really important and maybe not, 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 implication for the people and the state economies but also the providers. This is a study that the Commonwealth Fund did with the Kaiser Family foundation, and shows that among these primary care providers, while they were seeing more patients with insurance, most doctors reported no decline in their ability to provide quality care since the Medicaid Expansion. So at the Commonwealth Fund our goal is to support rigorous analyses, to understand the implications of the various Health Policy proposals. And really we strive to look at the applications at multiple levels, whether its on state economies, on providers, on people or subsets of people. So this next slide look at a recent analysis done by al dobson and his colleagues looking at the medicaid provisions in the house bill, the American Health care act come on hospital finances. And what we see is that for all hospitals, to those in expansion states, can anticipate over the next ten years and increase in uncompensated care so thats a treatment or a service for which there is no insurer in the patients are unable to pay. Anticipate an increase of about 78 over the next ten years. Just to put a number on that come its about 114 billion. So big increase but also a lot of money. In the nonexpansion states, expect about a 10 increase in uncompensated care. Again over the next ten years. May sound smaller but still 17. 3 billion. We also have an above analyses like rural hospitals can look at a bistate look at just the safety net hospitals. Theres a lot of analysis there. For you to turn to. Another analysis that we released yesterday is looking at the implications of the Better Care Reconciliation Act, the senate bill, on state economies and particularly on jobs. And as it says on the slide, if you were to become law we anticipate about 1. 46 million jobs would be lost, affecting gross state products as well as the business output. So really again, and also not just looking at this at the National Level but at the state level. And so here is my little plug for some new fact sheets that we pull together and that in the back for kentucky and nevada and california are examples we have available but actually theres one for all 50 states. I only covered to pieces, which was at the hospital component and the jobs component, because two of our speakers, cindy mann and Richard Frank, will look at the implications for federal dollars to the state. That will be cindy and thin rigid will look at a subset of the population, people with opioid addiction. And so with that i just will say, echo saros 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. So were going to have, were going to go right down the line, cindy, josh, chuck and richard. Then we will have time for some q a and discussion, and again for those of you just joining us you can use the hashtag whats next for medicaid, if youre using twitter. And go ahead, cindy. Thank you. Its great to be here with everybody. Im going to open it up with a little bit of an overview, short overview of the key changes in the senate bill with respect the Medicaid Program, and then really focus my remarks today on the percapita cap provision and its implications for states and the program and the people that the Medicaid Program serves. And 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 at both the house bill and the senate bill, and i will draw on both of those analysis as i go through my presentation this morning. So if you want to go to the next slide. Heres an overview of, theres a variety of different provisions into Better Care Reconciliation Act that affects medicaid but here are some of the key changes. Like the house passed version of the bill, nobody quite knows if youre supposed to pronounce the initials or just say them out loud, but the cra i will say converts medicaid essentially to a funding program, for a fundamental change as sarah identified in the basic structure of the Medicaid Program and really goes beyond any changes that the aca had with respect to the Medicaid Program. So it would convert starting in 2020 medicaid instead of program with the financing is doing a shared by the federal government, the federal government share would be limited by percapita cap that builds up to aggregate cap that i will explain. I would go into effect in 2020. The bill also offers states instead during a percapita cap and block grant option but for a limited population to the percapita cap generally applies to virtually all spending and all people in the program. Theres some carveouts for the cap but longterm care, acute care. I think the key point is its not just expansion population to people think we talk about repeal or replaced. Must be but expansion, the financing changes are really pretty much walltowall and 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 did make available for states to expand coverage to lowincome adults. Usc i in the slide it phases tht began in 2021, and has a threeyear dropdown of the match rate in 2020 under the aca. It would be at 90 . It goes to 85, 80, said 5 . Then it goes down to states regular match rate. So big change in terms of the federal financing. Theres also some provisions in the bill that would provide some extra funding for the states that did not take up the option to do an expansion, some funds come 2 billion dollars of funds to the states to be shared among the 19th states. Also changes the expansion states continue experience i will expense cuts their skill to go into effect disproportionate Share Hospital payment, its a special of the Medicaid Program which provides funding on a match basis to help provide financing to hospitals that serve disproportionate share of medicaid are uninsured individuals are aca tech edition spending on if there would have more coverage and there would be less uncompensated care and what the senate bill would do is restore those cuts and not but this gets into effect. They go in effect in december for the nonexpansion states but that expansion states they would go into effect. Even after the enhanced match goes with it so those are some of the major things. I need to get going on this so if you would go to the next slide. It just briefly shows you what the reductions are in, if you go to the next slide, please. No . Next slide. No, back, back slide. Follow your booklet. It just shows year by your reductions that cbo has identified in the be cra. Overall and youre probably fully with cbo scores, cbo says that the bill would reduce a loss of 772 billion over ten years for the Medicaid Program and, of course, very importantly, by 2026 cbo projects that 15 Million People covered by medicaid would lose that 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. Im not going to spend a lot of time explaining this. Its a wonderful diagram and hopefully it will teach you but we can have time during q a. But the bottom line is that they percapita cap, meaning the amount of dollars each state gets is based on their historic spending, and then that a stroe spin is trended forward by a trained rate. In both of those factors are really critical in terms of understanding the impact to state Medicaid Program. What was that spending in the early years . Estate is locked into that spending overtime in perpetuity, except for the adjustment. What you see in this diagram is that theres different trend rates that the bill pics medical cpi and medical cpi plus one to bring the caps forward yearbyyear until the year 2025, all groups go down to the cpi which is a much lower trend rate. That all builds up to an aggregate cap. You have your caps for the individual groups of people. You can multiply the cap times the number of people you covered in each of those groups and that builds up to an aggregate cap, and thats what the state is going to be guided by in terms of its spending. So if a state spending goes over the cap, and a start 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 other dollars actually 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 the federal government. If you go to the next slide. If you could go to the next slide, please. This just looks at how this trend rates compare. I wont go into detail on this but let me just say the trend rates are designed intentionally to say the federal government dollars. So they are pegged at a rate that is intentionally below what states are expected to spin over the next ten years. And thats one of the main ways in which the bill achieves, some of the savings in the 772 billion score. It you could go to the next slide, please. This when you might want to look at, at your booklet. Got a little lost in the translation. Sorry, dropped my glasses. This shows the yearbyyear, and we had to visit data by state impact of the cap on, this is just the caps, not the effect of the expansion. So as part of the 772 billion. What you see here is the federal loss of dollars what else want to point out which is often forgotten that will be a state loss of dollars. If a state says im just going to spend to the cap, im only going to spend that which qualifies for federal match, which is what most states do not under federal law, they can spend all their money on health care if they want to buy the general essay i will spend what i can spend that qualifies for a match. If they only spend what qualifies for a match under a captive environment, their state spending will also increase. So the total impact of the Medicaid Program is bigger than the impact of the federal cost. Its also a reduction in state dollars. State doesnt have to reduce its dollars. They can simply spend state dollars without getting a match. But on the assumption here that a state wont keep below the cap to avoid a clawback and to avoid spending 100 federal dollars, you see the total cuts. The other thing i would point out in this graph is because of the cpi trained rate pops an innocent bill in 2025 you see a very, a deep, significant jump in the cuts between 2025 and 2026. Because of the change in that trend rate and so the gives you a sense cbo has looked at this, a sense of how the cuts will grow over time. They will become, they do become deeper every year but they will become even deeper after that 2026 timeframe. Let me try to make one more point here if you would go to the next slide, please. One of the things that we have modeled is the lack of certainty of what life will be life will be like, right . The one thing we know is that Health Care Costs are difficult to predict. But the other thing is that these trend rates are difficult to predict. When weve done these analyses we have taken cbos projections of the trend rate. Cbo says i think medical cpi will be 3. 7. I think cpi will be 2. 4 over the next period of time. Its a good a projection as anyone might make so ive no quibbles with a projection but what we are showing is the last period of time, and its not unique to this time we look at, its these trend rates go up and down. They are bottle. It matters a lot which trend rates Congress Pics but which ever trend rate Congress Pics we need to understand it is not set in stone. It is a trend rate that will fluctuate. One of the things we did is we look at, what if the trend rate isnt exactly what cbo projects . What if the trend rate instead of being 3. 7, is just a little lower, 3. 2 . What you see on this is that the total cost just again due to the caps would change between 20202026 from about 267 billion, it would jump to almost 400 billion just because that trend rate changed and didnt turn out to be exactly what cbo thought it would be. Such is to close i think thats one of the most important points we want to make about the fundamental change in financing of the cap is that yes, it produces significant reductions in federal dollars to states for the Medicaid Program but it also introduces a great deal of uncertainty. All of that risk of uncertainty of the trend rates or a factual Health Care Costs are going to be borne by the states, by the Medicaid Program and by the beneficiaries. There. All right, thank you. All right, trickier. Thank you so much for the alliance for Health Policy and the Commonwealth Fund for inviting me. Just for those who are not the mode, sga is a think tank that works roughly and 35 states to also work here at the federal level and health and welfare reform. I want to start with a fall. Raise your hand if you think based on the Media Coverage, at the end of the tenure cbo budget window we will be spending less money on medicaid. Raise your hand. Raise your hand if you think were spending more money at the end of the tenure budget window. A couple people, okay. Im just saying absolute dollar amount if you compare what we are spinning today versus the future. So i think what we found around the country is a Media Coverage is us using this language around cuts, massive, severe cuts. But whats interesting is that for years without agreement on the right and left and Health Policy role that 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. Now, theres lots to unpack some 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 Medicaid Expansion hits the ablebodied adult who are part of expansion population against the traditional medicaid population. Let me explain that. The federal government put extra money towards Medicaid Expansion population, try to get states to expand. The challenge with that is that if im a state budget writer and active bows would budget every year, which by the way they do come unlike you in washington, they have to come if you have to find one dollar at saving come to determine whether going to try to take that one dollar at savings. They has a few different options. Ill tell you first and foremost that when it comes to medicaid it comes out of their traditional medicaid population, the elderly, kids, the disabled because they lose less federal dollars if they do so. If it doesnt come out there, then it comes out of education spending, safety, infrastructure here we cant spend the same dollar twice. Secondly, as far as the status quo is concerned, we cant assume federally we can sustain the spinning that we have. If you look at gao, cbo, looking at the supports historically, when you look at ssi, medicare and medicaid, they are going to eat the federal budget a live over the next 50 years. For us to just assume we can do anything for reform, i think is naive. Its also going to hurt people more in the long run. The deeper concern that we have is i dont think the Medicaid Program in general has lived up to the promises that we may to the truly needy before making new promises to the expansion population. I also would say that the current openended structure actually did some pretty terrible state behavior the new york budget director for long time at the somewhat statement saying if it moves, and medicaid can pay for it, then, put it in medicaid so we can pay for it. Things like school services. If not, appreciate it if we cant pay it off. At the heart of what that is used to say were 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 im sure many of you are aware there have been some questionable, whether its organ studies or others look at questionable outcomes on medicaid. If we have a program that estimated to deliver about 2040 sense of value for anybody, why would we just defend the status quo . Why wouldnt we be open to trying something new . I do think that 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 in blue, purple and red states alike is additional flexibility. They want and desperately need additional flexibility on medicaid. So what does that mean . On a per capita proposal, this use to bed bipartisan, President Trump clinton had a proposal. There had been democrats in the past that lived in boston, reduce the rate of increase in medicaid, so i want to make sure that we are having an informed, intelligent discussion about what the actual changes are Going Forward. Whats interesting to note is two things, one, for those that were supportive of the aca, there were 700 billion in reduction in payment in medicare. I dont recall seeing rhetoric around that time. I went to the website to look and what i found karen davis testifying about this was positive, in fact, she said more is needed to have a Sustainable Program and she layed out a number of different proposals to do so but i think its just interesting that we have people that want to have it both ways. If we recall, in welfare reform, in the 1990s, the sky was falling during that reform as well and what was missing from that discussion similar to what is missing two is is two components. In health care theres a tax credit and robust debate to be had about how generous it is and who is it offered to but in the medicaid space when a state decides to move away, theres a tax credit available and nonexpansion states for people who are not qualified for medicare, that should be part of a conversation that we are having about holistically looking at decisions that people are going to be made. Im not trying to poke at cbo too much, however, i will make a couple of coverage of losses, what we need to understand about the public and i get why the public doesnt follow it, they modeled off of 2016 numbers, assumptions of how many people were going to sign up, they didnt model off of updated numbers in 2017. 14 or 15 million lives number that we hear about, people losing medicaid coverage, its not losing, its changes. Theres a couple of things baked in there, they say that 5 million of those are people who lose coverage in states that they thought would expand medicaid. If youre not on medicaid, im not sure how you can lose it. They also make assumption on original mandate that 5 Million People will decide from next year to next year effectively free insurance program, that theyre just going to stop signing up. Theres reasonable questions to be raised about whether thats a safe assumption Going Forward. Thank you for the opportunity to share that. I look forward to q a. Thank you, josh, and i do want i know most of the people in this room are very similar with the Medicaid Program and thepolis but since we have talked about both the expansion population in medicaid and per capita cap, i just want to kind of raise a clarifying point thats all for those who might be watching on cspan that who was in the Medicaid Expansion population can cindy or josh give that overview of that . Sure. Happy to. So a lot of people i think thought before the aca that poor people got medicaid, old people go ahead medicare, and their medicaid grew up over the years, congress changed it over the years but there was always a missing group of people, so participants could get coverage, pregnant women can get coverage, children could get coverage, people with disabilities and elderly and if you didnt fit into those boxes, but you were still poor, you actually didnt qualify for medicaid and you to come and get a waiver and be complicated and so what the Affordable Care act said, people should be eligible for medicaid based on income and not based on family circumstances. So by filling in that gap, what it meant is the Expansion Group are participants above the income level that a state was covering before the aca, well below poverty on the average and socalled childless adults, socalled because in medicaid language a child is adult as somebody who is not living with a dependent child who is 18 or 19. Im a warrant but not childless. My kids are 19 and 20. Its adults that arent pregnant, arent disabled, arent elderly and and up to 130 to the poverty line. One more clarifying question, the 15 milliondollar number in cbo score, is that mostly related to that expansion population. So it related to other population that is are covered in medicaid . Cbo doesnt identify that precisely. We think its mostly related to the expansion population but there will be somism my cases because of the reductions in the in the federal funding that we went through through the cap and exactly how any given state might address those reductions, i think, are somewhat speculative but i think its mostly the expansion but its the combination. They dont pull it out. A point of note for context, roughly 75 of growth and spending in medicaid is due to medicaid administrator or former administrator, what i see as the tough decisions coming up for medicaid administrators and governors throughout the nation, so, again, my name is chuck duarte, if you wouldnt mind changing the slide. I run Community Health alliance. Its a Nonprofit Organization in northern nevada. Its a Community Health center. We have Six Health Centers in the county of waso. We provide integrated mental and Behavioral Health care. Next slide. We receiver about 30,000 unduplicative, 60 of patients indicate that they are of hispanic origin. 95 of patients are below mostly medicare or medicaid, uninsured. Next slide. What i would like to do is tell you about nevada and give you a snapshot. First thing that you have to learn how to do is say nevada, after me, nevada. Its not nevada. You go there and say nevada or nevada, waiters will refuse to receiver you and dealers will deal from the bottom of the deck, so do not do that. [laughter] so nevada is in the cross hairs and what people dont understand about the state is that you think about las vegas and nevada is really a frontier state, two population islands, las vegas and reno, reno is up in the north and las vegas in the south and theyre 500 miles apart and you can go across the other state and its 50 miles of 500 miles of nothing. 10 of the population and excuse me. And so they have benefited greatly from the Medicaid Expansion and if you look at the snapshot, 35 of nevada are low income, about twothirds indicate that theyre obese or overweight, onethird indicate that they have a Mental Health condition and 10 of diabetes. In terms of opioid deaths we are ahead of National Average 13. 8 for a hundred thousand and seventh in terms of rate of hiv diagnosis. Next slide. So this one slide tells the story, if you dont mind going back one, jared. Looks like its not going to work. So if you folks can go to your hand out, hopefully you have this in your handout but there is a slide that shows you the change in the uninsured rate in nevada between 2013 and 17, actually 15. One year after brian sandoval, our governor implemented the Medicaid Expansion in 2014 and the Silver State Health insurance exchange, we saw drop in uninsured rate from one year to 19 to 11 . Nevada boasted the highest uninsured behind texas at that point and changed dramatically with the implementation of Affordable Care act. I saw statistic for nonelderly hispanic adults, uninsured 34 to 19 . Thats the slide i was referring to, im sorry. Next slide, please. Its backwards, yeah, sorry. Okay, now we are all right. So this slide shows you the impact of medicaid on medicaid aca impact on medicaid case loads and this is from the state budget and so you can see where the Medicaid Expansion happened in 2014 and between 2014 and november of 2016, case loads grew and two groups that cindy talked about new eligible parents, parent caretaker and new eligible adults represent 230,900 and thats 900 of the total population but whats interesting here is that not only did those two case loads increase, the new eligibles but we saw pretty substantial increase in the case loads of age, blind, disabled and moms and kids and why did that happen . Primarily because of the wood work effect. Im eligible for medicaid and so are my kids or my disabled parent or sibling is now eligible or spouse. It was the message they got out there that had the people apply and they relatable as a result of the Traditional Program and so any cuts that occur in the state are going to have and i will say cuts, i will talk about that in a bit are going to have to come not only from new eligibles but traditional populations. Next slide. And then the next slide. Okay, im going to keep rolling. Right there. Stop. Okay. 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 at 17 . For medicaid our childrens enrollment went from 58 to 73 , for adults, it declined from 78 to 22 and Medicaid Enrollment went up 300 from 10 to 43 . Next slide. And this was what i mean about breaking hearts. Josh mentioned the abled body, people they just got on medicaid because they could. Well, this is one of those ablebody individuals and story published by nevada public radio about a lady who is a patient of ours and she is in our center for complex care which is a specialized Community Health care with people with complex medical conditions as well as behavioral problems. She has type two diabetes and copd and here is a quote, i would get really sick and end up in hospitals and emergency rooms, they would keep me, get a little bit well and send my on my way. Now shes a beneficiary of the Medicaid Expansion. She worked as Bank Loan Officer but became too ill to work and now had medicaid coverage and spending time with grandsons, going to socker games, i go to church, im not bedridden, i never want to be in this life without insurance, whats going to happen . Now she is not a unique individual in this situation. People who are in our program n our Health Centers who are expansion eligible, a lot of them are disabled but they dont qualify for ssi, 35 of them have a Mental Health disorder and Substance Abuse disorder, many of have chronic conditions and you cant tell me they are all healthy ablebody people that will go to work because they struggle already and they do work, and so, you know, im wearing my heart in my sleeve but thats important to understand about this population and these are the people that are going to be affected. Lastly. And the last thing i want to do is give you an idea what medicaid administrators and governor wills have to do particularly in the state of nevada, the urban institute put out a statistic and theres been other numbers thrown around just in the last two days about the loss of federal revenue to nevada and by 2022, nevada will lose 1. 4 billion in federal medicaid funding, that would be a 43 reduction. Now, granted, the cbi is going to be there and theres going to be increase in spending but 43 reduction in federal fund asking going to result in people losing coverage and so the other complicating factors is we have a match rate and loss of federal funds is going to be equally significant and we have a high expansion population. We also have a high chronic Disease Burden in a lot of the poll incomes the expansion population, a lot of Mental Health disorders, addiction, hiv infection. We have rural and frontier counties which are going to be adverse affected by this. We have a rapidly aging population in nevada which are going to be ultimately dependent on Homebase Services or nursing care and we have allow tax base. What are governors going to have to do . I have four dials there that medicare directors usually adjust and i will talk very quickly about some of these because have the decisions that governors and medicaid directors will have to make. Theres a little control button on the bottom called manage care if you cant see it. So eligibility, you can do things like put work requirements on, asset limit increases, income limit increases, you can do things like doing more frequent eligibility determinations, all of those things have the net results of knocking people off the program. Thats fine. But the real big gun on eligibility is you have to take whole populations out of the program all at once and you have to get rid of expansion population an you to get rid of some of the people involved in the Traditional Program and thats where the cuts are going to come or reductions, i should say, reductions in spending growth. For services, you can look eliminating Optional Services, Prescription Medications but those have collateral cost impacts on the rest of the program and its not necessarily wise toe cut those services, you can look at utilization management and you within the be willy nilly about it. So you cant just do that. You can look at cutting payments, but of course, cms is looking at whether or not cutting payments has impact on access and so you cant just willy nilly cut payments and theres a control button on the bottom, its called manage care. I can say that from my experience at 15 years of running medicaid, its great, i call it the punch pilot program. Governors can say i wash my hands and give it to management care programs and be done with it, thats why they do it, it doesnt save money, people. Finally, i would like to say that, you know, again f im talking to a patient that is going to lose coverage, dont worry, its not because of cuts, its because of reductions in spending growth that you lost to your coverage so its not a problem anymore, so, again, im sorry to wear my heart in the sleeve and not be datadriven but i had to do it, bye. Well, it sounds like a couple lessons here, language matters but consequences, whatever they may be are going to happen one way or another so we will keep talking about that, first, we have one last presenter Richard Frank and we will get into discussion of q a, thanks. Thanks, im happy to be here and i really wish i had chucks social skills. [laughter] but i will keep going. Im going to first slide. Yeah. Next slide. Yeah. That one. So i want you to walk away with four take aways, first of all, im going to really focus on medicaid and its role as a tool in addressing many types of Public Health emergency that is weve been facing over the last few years, opioid, zika, flu, you could throw in diabetes and how medicaid works to give us tool to deal with it. Second is by expanding access to preventive interventions and treatments medicaid is an important part of arsenal that most governors are use to go fight the opioid academic both in terms of addiction itself but also in terms of mortality consequences of the addiction. Third, the proposals to repeal the Medicaid Expansion and then to shift a per capita cap will be destruct i have to state efforts to rein in Opioid Epidemic. I will show you a little bit of illustrations of what pressure is put on states and then last, the moneys that are being proposed and theres a lot of recognition in various parts of congress that certain kinds of Public Health emergencies are being threatened and, in fact, the opioids in particular that none of the proposals that i have seen will come near providing the kinds of money you need to deal with that problem and you can imagine that going down the road, for example, we recently seen as uptake in methamphetamines. Next slide, please. So let me start off with some fun facts about opioiduse disorders. The first is in 2015 we had over 53,000 people die from overdoses in this country and about 61 of those or a little over 33,000 were due to opioiduse disorders. The overdose death rates grew 15 nationally but in fact, this is not a new problem. The Opioid Epidemic has been going on since 1979. It has grown steadily at 9 a year since 1979 with respect to mortality. And because the Opioid Epidemic and opioid use disorders are concentrated in lowincome populations, you see the med cakesexpansion population being responsible for treating these folks and in the case of maryland that expanded medicaid, roughly twothirds of the people that died to opioid overdeuce were enrolled in medicaid. A large number of them suffer from chronic diseases, some of them directly relate today opioid use and some of them not so hiv, hepatitis c are two that are but there are things, there are other illnesses such as diabetes and asthma that tend to accompany opioid use disorders, what that means that the average amount of spending for a person enrolled in medicaid who has one of these disorders is somewhere around 11 to 12,000 nationally. Treating somebody with medicationassisted treatment for a year costs 5500. Half of their costs are not directly related to their treating that disorder but are related to also some other problems that they have. Next slide, please. This is to demonstrate the impact of the population that it has had on prevention efforts. Theres a drug called melaxo which reverses opioid overdoses, what you see in front of you is the comparison in growth naloxone, the increasing one is expansion states, modestly increasing one is nonexpansion states, and what we have seen is exactly coincident that in 2013 and, save, 2013, there was a down lg of the doubling of naloxone. Medicaid is contributing to get more of the opioid reversal overdoes reversal drug into the right hands at the right time in order to sort of save lives so really this draft 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 the arithmetic, illustrate the kinds of pressures that states are going to be under as they sort of fight this epidemic. This is the case of West Virginia. In 2016, West Virginia spent 242 million on Substance Abuse Disorder Treatment in the nonexpansion part of medicaid, okay. The growth rate of utilization has been 5. 7 a year for the last ten years. And so if you start to move out the spending along that trajectory, you see that by 20 2026 youd expect the main part of the Medicaid Program, spent about 445 million a year on Substance Abuse Disorder Treatment, okay. If we grow that by the cpim, which is the more generous of the indexes being proposed in the Health Reform proposal, you see that you come up with about 368 million of spending. Now the difference 77 million and clearly not the whole difference is on the table but recall that West Virginia has highmatching rate, 71 , over about 55 million of that would be difference between federal spending. Last slide, please. Now, let me turn to the expansion population, West Virginia treated about 50,000 people in the expansion population for Substance Abuse disorder in 16, okay, and the spending that corresponded to those 50,000 people was 112 million, okay, now, if that goes away and im not indexing to the future, those dollars will no longer be available since roughly we are paying 100 , what does that mean . That means that those 50,000 people are going to have to look elsewhere for treatment and the state is probably going to have to take it on. Now, just to put that into perspective. Let me take that 45 billion thats been proposed in the senate to deal with Substance Abuse disorder problems and im going to allocate it the way that the 21st century dollars are allocated. West virginia would get 61 million a year, so right off the bat, youre talking about 112 million first day and thats going to continue to grow and then the 61 million doesnt grow. Thats all i have to say. All right. Thank you, everybody, for your very thoughtful presentations, thank you all. Its a little cold in here, but we are going to get to the discussion portion and so do you guys have a couple of options for asking questions as usual, green cards if you want to write a question down, someone will come and pick it up for you and two mics that you can come and ask a question or you can send it in on twitter at whats next for medicaid. Let me kind of let me try to pull us back and frame this, it seems whats coming from comments theres a couple of issues that we are talking about here. One is what is the right way to offer coverage to lowincome people who have, you know, they may be healthy and chronic conditions and they dont qualify based on the basis of a disability or a functional limitation, one question is whats the best way to offer coverage and then the other is, you know, whats the best way to offer Longterm Services and support and finance all of that. What i am cowr use curious about from the panels perspective, what do you see as whats the fundamental issue here that needs to be solved or issues that need to be solved when it comes to looking at the Medicaid Program. Josh, you mentioned, of course, slowing the growth rate and spending which is something that we are talking about not only here in the Medicaid Program, theres a little debate brewing over independent payment Advisory Board that would also cut, reduce growth rate in medicare spending and one thing thats outside the scope of this briefing but is nonetheless, you know, also part of part of the Affordable Care act is the legislative puzzle that cadillac tax, tax on employer coverage. So a lot of kind complicated from my end. What do you think is the problem that we are trying to solve here . Well, i would just step back for one second and say, we need to decide whether medicaid is a Health Insurance program or a Welfare Program and fending 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 theyre poor, we want to do. So i think that theres a lot to that that you can peel. Why cant they afford insurance . We get back to regulations which i dont think we are going to focus on today but do i think that thats part of the answer but ultimately i think what we need to ask ourselves is, having somebody on the program for 20, 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 dont get stuck that are able to work. I think thats a bipartisan goal. Perhaps not anymore in this country but i think thats what we need to start to ask ourselves and other panelists are going to say, you cant get everybody to work, i get that. For the population that we can, we certainly should be focused on that across program. If youre on snap, food stamps, on taniff, you need to understand that our goal to coordinate and get people off as soon as possible onto affordable private insurance which is a whole other conversation. Richard [laughter] sorry, cindy. Im going to speak as an economist here. So money is the problem, people are poor. I want to get to this issue of cut versus growth. Looking around audience theres like three people in the audience who remember Ronald Reagan. [laughter] but Ronald Reagan had a thing called the misery index which was had to do with inflation and in fact, if you look at cbo and if you look at anything, none of the projected index rates in medicaid are keeping up with cbos projected increase in Health Care Inflation and to kind of say that, okay, the absolute dollars are going to grow but we are going to pretend theres no inflation seems like really misleading and so i think the problem is money. The problem is money in two places, one, people are poor and even when they work, they dont have enough money to buy Health Insurance and two, budgets are tights and in order to pay for poor people, you need budget dollars and they need to keep up with real resources. Chuck, you wanting to next . I would love to go next. Okay. Thank you. Again, im not as smart as richard but we are talking about money. Calling medicaid, excuse me, im losing my voice, calling medicare and medicare Welfare Programs because welfare has connotation that goes back to the 90s where people were getting cash assistance, medicaid doesnt provide cash assistance, it provides a service, it pays for a service, there are no dollars given to a medicaid beneficiary as a result of them being on, it protects them from financial bankruptcy and these are poor people to start with, okay, and so theyre struggling daytoday if theyre working or even not working to make sure that they can put a roof over their head and food on the table, we receiver about serve about we have a food pantry, 2,000 people a month who dont have food in the refrigerator and a lot of these are expansion population folks and we give them food until they can get to food bank or snap and so youre talking about the economy of a household where medicaid does not contribute to the economy of that household, but it provides protection, safety net for that household so it doesnt collapse, i think if you look at the root word and richard would know, the root word of economics, it means home. Whole root of economics has to do with the santity. There is no dollars associated with medicaid. So, again, i dont consider a Welfare Program at all and ive been involved with it for 15 years. So as we pass it down to cindy, i just wanted to add that i dont think its just about being poor, i think its also about being sick, the program is also there for people who are really sick who maybe because of illness they have disabilities make it harder for them to afford and make it harder of time. It is filled in that gap that existed before the aca and as chuck alsup talked about it is welcomed of the people into the program who are always eligible but didnt know they were eligible and have applied. So what problem are we solving . Its coming more people. Seems to be why the growth and medicaid dollars are there. Is that a thing unto itself . Well, josh has proposed people should be on medicaid, they should go to private Insurance Company they should get themselves out of poverty. Im all for solving poverty, and we, i dont mean to be glib about that. It is an important issue. Its not the Medicaid Programs role to solve poverty, and, but also as melinda said i want to stress medicaid is a very diverse program. We are talking a lot about these now childless adults, but onethird of thi of the study fr medicaid is for longterm care, is her Medicare Beneficiaries who dont get longterm Care Services through their Medicaid Program them extensive longterm Care Services. We have people, pregnant women. We have people who are totally and permanently disabled. Thats what they cost are in the Medicaid Program. We really need to keep our eye on the ball of the diversity of the population and the services. And finally just if we want to focus on how to cover very poor people, all right, 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. So the poverty line for single individuals come 1000 a month, the 2 of the poverty line 500 a month did not display in health care. To spend on food, to spend on rent, just undone utilities spend on utilities, transportation, to spend on every single need including health care. You can get a subsidy under the senate bill if you are at 50 of poverty, or 0 , or 100 of poverty, and you will get a subsidy to you afford the premium. That premium actually is pretty modest. There will be very low income people who cant even afford a modest premium, but lets assume for a moment they can afford that modest premium. We looked at what they deductibles will be. We looked at arizona in particular and we also looked at national data, and look at actually what the premiums are in the marketplace come in arizona in different counties. If you take the deductibles that that policy will end up requiring, plus the premiums, but it is mostly the deductibles, and as a percent of income buying that coverage to the tax subsidy will consume between 769090 of their total income if you are at 100 of poverty. No room for food, no room for rent, no room for anything else. Medicaid fundamental is about providing affordable coverage for people, and the tax subsidies being proposed as an alternative just dont cut it. [inaudible] lets come since we are on this topic, get into the question of like private sector alternatives to medicaid coverage. Part of the challenge seems to me that starting from its origins in 1965, medical assistant for people who basically were receiving cash assistance, and the program has grown and grown and grown, but is that in response to frankly panders to address the problem in other ways . To have a functioning private insurance system that can be affordable for people of any income. I dont know if anyone wants to try to take that on. So the short answer is yes. Theres lots of work to do and thats probably where i spend 50 of my job at the state level is help states crack the code. But i want returned when the i said at the beginning. Anybody that criticizes the reform has to defend the status quo. So lets not pretend that we can keep doing what we are doing. We cant, and so while i appreciate chocks passion and cindys passion, this is deeply personal to me. I that family members on medicaid. You have three choices. You can try to come up with reform now to try 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 deeper cuts in the future. Which one do you choose . Thats what were talking about. While theres lots of sniping in the media about come and listen unlettered to defend everything that is in Republican Health care bill, trust me. It needs a lot of work. However, when we talk about reform, if we want to keep any sort of promises we have to change it. Let me make one last point here here rested and medicaid as a great coronation of care, chuck noses firsthand. When i talked to medicaid directors and others around the country, they are so frustrated with people going to the er on medicaid. Because we know thats not the best way to get your character everybody agrees yet it is a persistent problem. For us to say this is some great Silver Bullet where were delivering the best quality care, it is something that you and theres a lot of ways to fix it. When you talk about the percapita caps if you put that back since 2000, i dont think any state would have exceeded their percapita cap. And the growth rate in the house bill and in your packet is an analysis we did on the house bill, the growth rate for the elderly and the disabled is much more than what our projected growth rates are for those populations. So we just need to understand theres lots of moving parts but lets at least understand the dynamic Going Forward of the impact and whether we think the status quo is something we can sustain the i would argue absolutely not. [inaudible] want to give her an opportunity to ask her question. Thanks very much. Caitlin with the National Employment project. I want to just ask a little bit more about home care and Longterm Services in sport but for someone to say beyond your three suggestions, theres for which is revenue, adjusting revenue, and not giving tax breaks to the wealthiest. Going into Longterm Services and supports which we know medicaid is a primary funder of, and plays a huge role, as we are looking at an aging population, demographics that weve never seen before, this legislation will harm our Current System and our future one in even greater ways by both percapita caps will not adjust for higher costs of the oldest old population, those who are 85 and up. And also the job losses, particularly in addition to the 1. 5 million projected, the specifics of those in the home care workforce. We are look at leading age and community catalyst, between 300,00300,00070,000 homecare js could be lost because of these cuts and thats just for the time when we need even more Homecare Workers to meet that demand. I wonder if you could address of that . Also the 1. 5 million job losses by 2026, were you able to account for the even greater potential losses when medicaid by 2036 is cut by 35 . Taking on the last first, the analysis just went to its done by George Washington university, you can look at it on a website and it projects out ten years to 2026. Song going to go back to my previous life this is chuck come as a medicaid administrator one of the things i most brought up in the bad is that we flipped the expenditures between nursing facility care at home and Community Based service over decade. It took a decade. That was by establishing programs like personalcare attendant services and making sure they were funded adequately so that we could not only in urban centers but in Rural Communities be able to take care of people at home. So im very proud of that as well as granting home and Community Based care. Your point is spot on. I dont disagree with josh that we cant continue to see increases in the health care percentage of our gdp, but we have to find a way to make it more affordable and with an aging population in nevada, the secondhighest growth rate projected for 85 plus individuals. And they are going to be in the geffen services or in longterm care facilities. We have to find a way to make that more affordable, and your fourth suggestion is spot on. Its revenue. I mean, how much does it cost . I worked for Blue Cross Blue Shield in the 80s and i started in longterm Care Insurance product. It cost me when i was 30 years old in premiums, it cost me five dollars a month for coverage for Blue Cross Blue Shield and it he couldve continued paying those premiums. If we charge people five dollars a month as a part of either their Medicare Program taxes or other taxes, we could be able to afford in the long run payment for those services for individuals. Maybe not everybody but we have a modicum of services that could be income adjusted and would provide for adequate longterm Care Services. So revenue would be a solution to that problem looking at our growing elderly population. So thank you. We actually, weve been talking so much can we only have 12 minutes left in this briefing so want to just kind note over here that this issue of Longterm Services and support financing is a huge issue, and i think theres some reports coming out around town on that issue and certainly something that we find a look at in the future separate from this discussion. But i want to get to one of the questions on the cards. Weve been talking a lot about adults, and older americans. I believe melinda mention that statistics on how many children are covered. This is a question for cindy said she ran the chip program as well. What are the intersections between chip and medicaid and some of the changes that are proposed . And how would ship be implicated in all of this . I appreciate the question, whoever sent it in. Because its 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 to health care, through the Medicaid Program. The chip program, as is often said, stands on the shoulders of the Medicaid Program. A little over 8 million children covered through the chip program, about 37 million children covered through the Medicaid Program. Both cover some healthy children, medicaid covers the lionlions share of the kids hae Greater Health care needs. The chip has been enormously successful, has a lot of bipartisan support. Its really help with continuity of coverage, helped make sure that that uninsured rate has plummeted for children over the last ten years. Its now below 5 thanks largely to medicaid and chip, but it functions a lot because medicaid is beneath it. It covers only one of those children. Its coming to children with a Higher Health care needs. You really need both to complement each other in order to maintain the coverage and the Health Outcomes that weve seen for kids over the last few years. Let me kind of follow on that. We had a question about pregnant women and the block grant option in the legislation, so can you talk about what is the option for states to do a block grant instead of percapita caps . I believe that is mostly pertaining to pregnant women and nondisabled adults, but can you kind of explain what the proposal actually is . And then what would that mean, what incentives with the put in place for states . What it put in place incentives to do a better job with the maternity outcomes, for example, or not, and if not, why . Sure. In terms of incentives to do a better job on maternity outcomes let me just picked up quickly the point about the status quo. I dont think theres a program, a Medicaid Program in the country, that if she is running on autopilot. There is no status quo in the Medicaid Program. They are incredibly dynamic and whats been going on but since the end of the Great Recession is a very focused effort on trying to lower costs through care improvements come to better integration of care, through coordination of care, through looking at those high cost individuals, avoiding emergency room costs, avoiding preventable admissions. Lots and lots of energy going on around the site dont think any of this discussion around the bill should be in come and it is a criticism of the bill should be taken as a statement that ought to be no change or there is a in the Medicaid Program. In terms of now im forgetting the block grant. The block grant proposal innocent is more nearly drawn than the house proposal and also a lot more detailed than the house proposal to her would largely be for pregnant women and is very low income parents who didnt fall into the expansion population. And it would not unlike a percapita cap, it would not vary the amount of money that you got with the base on your historic spending but it wouldnt vary over the years base of the numbers of people that you enroll. So thats a big financing difference between a block grant and a percapita cap. The other thing is in the senate bill the growth in the block grant would be at that cpi, the lower trend right so that the entire period of time. So it wouldnt vary based on enrollment and it wouldnt, it wouldnt grow nearly even as much as the percapita caps would, at least until the outer years. It would both go at that way. Why would a state want to do that . It does give the states more flexibility, could lower benefits to pregnant women, reduce requirements in terms of federal requirements in terms of what services are covered for the note and the scope of the services but it also has this feature which is kind of hidden, but it allows states to draw down those federal block grant dollars was spending a lot less of their state dollars. So it might also have an attraction to states for that reason. I would just say one thing briefly about, i know folks in the show probably know not all viewers. Cindy described within the senate bill. This is likely to go to conference committee, and so the final version of what comes out of this may look different from what we are describing. As people are reading the media they are saying this is in the house bill, this is in the senate bill. A lot of americans assume what is currently debating what be the final version and theres no guarantee of that. I just wanted to mention that this is a moving target as many of you are aware of the. Hanky. That is a great point. Thank you. We have time for one more question at the mic if you could keep it brief and they will ask a couple final wrath of questions. Im one of the clinicians that chuck mention that have treated patients. Since you brought up Ronald Reagan, maybe think, my first position in washington was in the reagan white house, and not only did he have the misery index but one thing he was noted for saying come was asking the rhetorical question, are you better off now than you were four years ago . I think thats a great way to proceed whats going on with medicaid at our entire health care system, and particularly with the changes that happen with the ac, what it means for people on medicaid. One of the challenges medicaid has is there can be a lot of churn between people going into medicaid come into uninsured and to private insurance, Employee Base and turned kind of thing. Wondering if cindy or chuck or melinda can talk a little bit about the challenges of the 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 life better and makes it simpler for Insurance Coverage a continuation of coverage . Thank you. [inaudible] a number of ways in which the Affordable Care act and also just states decisions about how they are implementing the Affordable Care act and whether there and expansion state are not but, that is reduce churn in a Medicaid Program. Its not that its not containing to be an issue. There is still a lot of in and out, but a lot of the simplifications of the role of process and the renewal process has met that paperwork barriers that kept people from being covered continuously as long as they are eligible are in place. And the benefits of that really go to some of the issues were just talking about engines of what states are working on which is if youre really trying to get at those high cost case individuals come if youre really trying to change the trajectory of their health, then you need to have their lives covered burkini to be connected to them for a continuous period of time. So the churning is both good for people because they can access the care but it is also good for the goals of having to improve the management of care and to bring down that cost curve. So just a super quick note on that. I mean, i think some of the sounds like from josh can what you were saying about trying to get people off of the Medicaid Program as soon as possible, some of this depends on how you view the Medicaid Program, should it be like temper source of assistance or longerterm kind of Health Insurance program. We have a few minutes left, and we certainly have not solved all the problems today but we certainly have robust discussion. And i guess i just want to close by asking the panelists, 30 30 seconds or less, if you could wave your magic wand and make one change or state once principal about this program, what would it be asked that the buckeye all we will have time for and then well wrap it up. Start with richard. Well, if you dont mind i will take my time. I also want to issue what i think is a correction, which is theres an impression that some of the evidence suggests that from the oregon experiment, is that there is no benefit to medicaid in terms of health. Some of everybody seems to skip over the fact that Mental Illness and diabetes are both sicknesses that cost this country a lot of money. Diabetes probably the most expensive single illness in the country, and those are the places that the oregon experiment had the weakest effect for some people keep skipping that part. I dont understand it, but for me i guess i think there is a lot of flexibility in medicaid. I do think that some of the problems have been sort of chronic, sort of underpayment in certain areas. And thats because in a sense we have used price it to control supply. And i do think the advantage of managed care, apologies to chuck, is that, in fact, it allows greater flexibility on that front and allows sort of more of the mainstream Delivery System into the Medicaid Program. Ill take a slightly different tack. If i had to imagine one i would hope our conversation about medicaid would stop assuming it can assume it can fix all our problems and actually take a line to say if we are really robust, critical Public Policy makers, were going to see if theres a better way to do it and do it that way instead if its better, whether its opioid treatment or others instead of assuming a managedcare plastic card can solve all our problems. Well, where i waive my wind i suppose it depends on the day or the week but im focused on whats going on here in the congress so i will talk about my wand relative to the discussion at present. Medicaid is not perfect, no program is perfect. Its evolving, changing, growing, its developing but what seems pretty clear to me having experience in the program for quite a number of years is that coming off expansion funding that has supported the growth of people being able to get coverage. You can watch the rest of this on cspan. Org, now to a hearing on opioid abuse. Officials will testify about their efforts dealing with the problem, this is live coverage on cspan2. Its affecting every core of our nation. In 2015 there are 2000 deaths from drug overdoses in the us, 33,000 deaths involving opioid. 24 percent increase in the private previous year. The rate was seven times the death

© 2025 Vimarsana

vimarsana.com © 2020. All Rights Reserved.