Transcripts For CSPAN2 Health Insurance Outlook Part 2 20170408

In congress, some states are looking to expand medicaid, some additional states, many are talking to cms about what might be possible in the way of theyre talking about waivers, what can be done. And so to today were going to k about, our goal for this panel is to both talk about where we are going into this next year, so writer we are, what the aca did, where we are with medicaid, whats under discussion, and were going to talk about the considerations and possible implications moving forward. So we are lucky to have with us today three exceptional panelists. Youll notice there is one empty seat, and that belongs to trish riley. Unfortunately, because of the crazywet we had in d. C weather we had in d. C. , trish is not going to be able to get boo town, so she will not be with us. But fear not, our three other panelists watch whats happening in the states very closely and will be able to give us a full picture of whats happening. First to my left we have diane rowland, executive Vice President of the Kaiser Family foundation, also the inaugural chair of mac pac which advises congress on policy. To her left is Josh Archambault who spent time with the heritage foundation, and hes up in massachusetts where he also worked for former governor mitt romney. And at the end of the panel we have judith solomon, Vice President for Health Policy at the centerren on budget and policy priorities. I wont go into further detail, you have their full bios in your packet. And what id like to start off doing is id like to ask diane if you would please help everyone in the room to understand whats our starting point here . What happened with, that was created by the aca, and just where are we . What is our starting point . Well, weve spent much of the last few years talking about medicaid in a very narrow way. Weve been talking primarily because of the Affordable Care act about medicaids role as an Expansion Program to cover additional adults who are very low income but who didnt previously qualify for the program. And i think to remind you, that goes back really to the history of medicaid, enacted in 1965 as the program that was intended to provide coverage at that time to the welfare population, since expanded tremendously. But in that era, the aged, blind and disabled, children and adults with dependent children. Initially, just single adults with feint children. And as weve with dependent children. And as weve seen over time, weve expanded the role of medicaid to be role of insurer for many children, help with Longterm Services and supports for the elderly and disabled as well as children with special health needs. But states were unable to obtain the federal matching funds if they wanted to afford coverage to adults without dependent children because they were not one of the categories of medicaid. And what the Affordable Care act did was to say eligibility should no longer be based on whether or not you fit a category, but instead should be based on whether or not you are truly low income and defined that as 138 of the federal Poverty Level or about 23,000 for a family of three. So the big change in the Affordable Care act was to really reframe medicaid as a program for low income individuals that would provide Health Insurance and health care. And they intended to build on the mandate that was already in place in the medicaid statute of covering all children up to 100 of poverty and for younger children 138 by extending that to adults which would have raised eligibility for the parents of many of the children who were well below the abovety level in terms of their state coverage and also to try and provide for a National Standard of how many low income people one would be covered. Obviously, when the Supreme Court weighed in, it weighed in so to say for adult coverage that should be a state option rather than a requirement even though initially the federal funding was 100 . So i think much of the discussions of which states are going to expand, which states did expand, what was the impact, who did it really cover, what kind of individuals were covered by this expansion x we know that in the 32 states that expanded, some 11 million individuals became newly eligible for coverage. But when we look at where the debate is going today, its not just stopping at what should we do about the expansion population, but instead in the gop house bill that we just saw brought to the committees and then possibly someday to the floor, its now taking on the entire Medicaid Program. And i want to remind everyone here that medicaid is a far Bigger Program than the expansion. It is our largest Health Insurance program that takes care of some 74 million americans including many of the 20 who are Medicare Beneficiaries who need medicaid to help supplement medicare as well as to provide for Longterm Services and supports. It takes care of many of the Mental Health and other challenges. Its been one of the front line programs today on the opioid addiction program. And it has been structured over time to provide states with the ability to draw down federal matching funds to cover the population that they are covering as long as they abide by some basic federal rules about who they can cover, what they can cover. But a lot of builtin Optional Services and optional coverage. So the proposals to change that openended federal financing to some sort of a per capita cap has been introduced over time. The federal government seems periodically to like to say well give states more flexibility in return for being able to limit the federal governments commitment to this program. And that was part of the other debate that was going on around the gop house proposal. So we have two issues here; really what happens to the expansion and the expansion population and then what happens to the broader Medicaid Program and its role as our Health Safety net. So lets take that one at a time, those two pieces. One is the broader conversation of do we move to a per capita cap, or to we move to a block grant. What do we do in the long term, if anything. But first, lets talk about the more immediate question. Without that broader conversation, we are here and now looking at some states thinking about waivers, some states deciding now whether or not they are going to join the expansion. And so id like to ask all of our panelists where are we now and what are we likely to see happen . Why dont we start with josh on that one, and then others can weigh in. Sure. So thank you so much for having me this morning. So, first, i would say with a new administration its, from a state perspective, its a whole new world when it comes to what they can ask for flexibility for. So we have been involved in a number of conversations and heard from a number of governors and medicaid offices that they are thinking very differently than they have in the past about what theyre going to ask for for flexibility from the federal government. So thats certainly, we can unpack that a little bit as we go. But there is a big discussion about plan designs and what kind of how you set up these programs outside of the financing. The second question on medicaid expansion, you know, we have seen already a up couple states a couple states look at expanding, kansas being the most recent one. That is a multiyear campaign by hospitals and insurers in the state to fund candidates who are more sympathetic to that. So that was, should not be viewed in isolation. What i think ultimately it comes down to is if the house bill moves. If the house bill moves as currently structured and the senate makes tweaks but it largely stays the same, i actually dont well, first of all, the first managers amendment restricted new states from expanding. So that would kind of end that conversation if it became law. But then we move to that bigger question about financing. So the expansion debate, i think, is active in a couple states at the moment, not as active in others because theyre still waiting to see will this house bill move as currently conceived or how much will that change. Sure. Also, thanks for having me. I want to step back a little bit on waiver withs because i think, you know [inaudible] into that conversation about really thinking about what they are and what theyre supposed to do in the Medicaid Program. And if we think about medicaid, it has numerous options that dont require a waiver. It is a very flexible program. And waivers are really on top of that, to give some additional things states can do. But what they really are is saying, you know, we have a medicaid statute that was passed by congress and amended over the years, and in some cases if a state wants to try something and wants to try something that is going to pursue the objectives of the statute which is essentially to provide health care to low income and Vulnerable People in this country, then well let you try that, and well let you try it for a limited period of time, and well look at it, and well test it. And so if we start there, then i think its a good framework for thinking about some of the things that are coming up, as josh said. A lot of new things are coming up, things that have never been allowed and things that have never been tried. And among those things are work requirements, and we can get into sort of the details of why we believe very strongly that these are a bad idea for medicaid, and the rejection of them in the past has been right. Theres really no evidence base. But even things like, you know, premiums where the medicaid statute says we have low income people were covering here, they cant afford to pay premiums, so you shouldnt charge them premiums. So giving a waiver when we know and weve tried this in other situations and weve actually seen that waivers keep people from participating in the program. So if you go back to really the beginning and when the aca was passed, as diane described why we had the expansion, it was to have a continuum of Health Options for, you know, low income people, particularly working people in jobs that didnt provide health care. And to say now were going to do something that we know will decrease participation, i think, is not really consistent with the purposes of the waivers. And i think its just really always important to think about these as demonstration projects and that they are supposed to pursue the objectives of the program. You know, i think its really interesting that sometimes waivers proceed legislation, and that certainly is the case with the Affordable Care act expansion. Because prior to that, 11 states had come in for waivers saying cant we please cover some of these adults without dependent children . Many of them have a lot of disabilities, but they dont yet meet the disability threshold for coverage. And so it was really a series of demonstrations that led to the argument that maybe extending coverage through the legislation would be possible. And i think that is generally one of the purposes of the waivers both to see if states can test new meds, but to methods, but to see if those new methods ought to be made available through legislative change or at least through broader adoption by the states. And the Family Planning waivers are, i think, a really good example of that, where states were allowed to provide Family Planning services to adults that werent otherwise eligible for the program, and that was shown to prevent pregnancies that were not desired at the time and also that was in the statute. So thats the kind of approach of and, you know, that requires rigorous evaluation. Perhaps i could offer a slightly different perspective here on waivers. In our experience regardless of the political stripes of a state, you can find a blue state medicaid director that will gripe, at least privately, about the whole waiver process for a variety of reasons. And it is important to realize that there are a couple of different ways states can get flexibility whether its a state plan amendment which is usually a shorter process and kind of rules around that or the 1115 waiver process which usually is the bigger medicaid waivers. But what is not told about the flexibility is usually it takes well the average is well over a year for approval for those sorts of waivers. So if im a medicaid directer and im at the state level and i have to balance my budget every year unlike congress, i know [laughter] but at the state level, i have to balance my budget, and it takes me a year to get a yes or a no on whether i can do something dramatically different . Thats not flexibility. From their standpoint. The other thing is i have to go to d. C. To is ask if i can do something, yes or no. When im funding at least partially funding the program. But not fully. Well it fends on the state. But, again, this is a statefederal partnership. So im just i want to reflect that theres a lot of frustration at the state level with how this process has played out over the years and the fact that they simply have to come. And you have states and why probably more republican governors are interested in the block grant conversation, for instance, is to say, look, let me wash my hands of this process. Let me determine how i want to do it. If it means i have to put more state dollars on the table, ill consider it because at least i can cover the populations that i want to cover. So i know theres a big federalism discussion here thats happening, and were bouncing around a funding piece of this because that largely drives this conversation, but i do want it to be heard that a lot of people at the state level dont think its actually that flexible of a process. Even though they can ask for a lot, it just takes a long time. Well, the waiver process is different from the process for asking for for not even having to ask, for indicating which options you want to adopt in the Medicaid Program. And theres multiple options in terms of the benefits that are provided, like what kinds of how you want to design your Delivery Systems. When were talking about these waivers that take time and have to be requested, its because youre asking to change the law, essentially. Youre asking for permission to do something that is different than what the law allows. And it would be pretty untoward if we were going to say that, you know, states could just to that and not have to come to washington or write to washington and just do it. We want to protect the people that are the intended beneficiaries of these programs. And these are really important protections around premiums, cost sharing, continuous coverage, all of that. Whos covered, how long theyre covered. And i dont think anyone should apologize for the fact that permission needs to be requested. So lets talk, lets take a half step back now and talk about flexibility and how much flexibility already exists, what can states do currently. Well, lets start there. How flexible is the program to begin with as a baseline . Well, one of the most flexible areas of the program is really what can be done for home and communitybased is services and for a lot of the services to the elderly and the disabled. There you can get special sometimes its a waiver to be to able to cover children with special needs for whom private insurance is not sufficient to help cover those children. A lot of states have liked to use waivers in that case because they can limit the population, they can have slots for home and communitybased services and not have to open it statewide. So thats, i think, an area thats very important. The really only requirements for the you would orally and the dis the elderly and the disabled are more nursing home care and states have broadly used their authority for Optional Services and waivers to expand what they can do around keeping people in the community and rebalancing Longterm Services. Give us an idea of how widely waivers are currently used. If im not mistaken, every state has them. Every state has multiple waivers. Clearly for the home and communitybased, multiple waivers targeted at different populations. And the reason theres waivers is because, basically, as diane staid, nursing home said, nursing home care is a required service in medicaid. Providing services in the home which is more advantageous, more desired by people and now is more than half of Longterm Services and support is basically optional. And what the waivers do is allow states to design packages of services that are specifically targeted to the population. So they may have, you know, waivers for people with intellectual disabilities, seniors, children with special needs, different packages of services, some of the things that are not normally covered by medicaid such as respite care. Theres a lot of flexibility there. Theres a lot of flexibility in how you provide services, whether you use managed care, different forms of managed care. Were now seeing things like Accountable Care organizations similar to what medicares doing. So all of those things and a tremendous amount of innovation that has taken place over the last years, and a lot of that has been, you know, facilitated by states being able to get some upfront frame dollars to federal dollars to allow them to improve their Delivery System, set up better means of coordinating across providers, integration of behavioral and Mental Health services, all of that, improving delivery for people with Substance Abuse disorders. Thats whats going on. And that is what would be at risk if the federal matching system is changed to a capped funding stream. Then wed be down to just paying for doctors and hospitals. So, josh, what is it that some republican governors are looking for to do with waivers moving forward now . Yeah. So i think this gets at a bigger issue about medicaid. Is it Health Insurance or is it a Welfare Program . And depending on how you answer that question is how you think about how you design it. So you have a lot of republican governors in particular although you have some democrats, the governor in West Virginia comes to mind where they look at it a little bit more like a welfare entitlement9 program. So if youre going to follow that logic, then things like work requirements, time limits become things you want to look at for certain populations on medicaid. So i think theres actually a decent amount of research on other Welfare Programs showing for certain populations its tremendously, influential. Weve done some Great Research on that. But if you view it more like Health Insurance, then youre going to want it to look a little bit more like Health Insurance. So this discussion about plan design, deductibles, premiums, copays that when you show up to the emergency room and its not an emergency, you have some financial skin in the game, and then when it comes to the actual benefits that are mandated, there are a lot of states just to give one micro example nonemergency medical transport, tremendously expensive. Nonemergency medical transport. So do states have flexibility in how they set that up . Could they work with uber or lyft . Could they say for certain things, you know what . You live near the bus route, youve got to take the bus or the subway. But this is not a lot of flexibility in how States Imagine around those. The authority is quite wide, but for the Obama Administration and really the bigger problem, and im not trying to knock the Obama Administration, whats the interpretation at cms at that moment for what you can do. And thats, i think, the bigger criticism. I think republican governors are thinking wider, broader than they have in the past. Theyre seeing a political window to ask for things. I know the cms folks there now have been welcoming that. Theyve sent out letters, come to us with your ideas. And well have to wait and see how flexible they are or whether they wend end up putting a lot of situations. Waivers are temporary, and perhaps some see that as a good thing, but perhaps others see it as bad thing because political winds change in d. C. And so, oh, i object to that for ideological reasons, take it off. You dont get it anymore in your next waiver request. If its proven to work, i think wed want it to continue. I think those are the sorts of conversations were hearing in state capitols. Kentucky already has a waiver in, involves work requirements for their expansion population. Arizona is about to put one in, has time limits and work requirements. Maine and kansas are working on waiver requests, theyre going to come in with a bunch of different, new things. So i think very shortly were going to see those details flushed out in actual waiver requests. But those are all that very narrow part of the medicaid [inaudible] thats about adults, not about children, and its not about the aged, blind and disabled who really are where the bulk of the dollars in medicaid are spent. Where i think most of the innovation needs to be, how to better deliver services to those highneed populations rather than trying to focus on looking at just this narrow slice and saying this is what the whole program is about. And certainly, the issues that we were raising around home and communitybased services and all of those kinds of innovations are ones that we want, and we see that im going to channel trish, whos not here. We see a lot of innovation going on in the payment and delivery and organization of care, and i think everyones always poised that the states are backward because they dont have enough doctors seeing patients. Yet weve seen them move tremendously into managed care, into better quality measures now around some of that managed Care Services and to trying to do better coordination across the board. So i think thats where the promising future of medicaid is. And, you know, we can, you know, we can look at who could work and isnt working. When we tried to look at the expansion population, the majority of them were working, they were just working in such low wage jobs that they didnt have Health Insurance, or they were ill and couldnt work. And i think we really need to look more at, you know, how broadly if work requirements are put into effect, how broadly would they actually apply to that Huge Population that now depends on medicaid. And how much money would we spend administering that . Because even if we sort of leave aside our, you know, ideological difference here, i think we should be able to agree that spending huge amounts of money, the kentucky waivers a great example. So the, you know, for three months you dont have a work requirement, and then at three months you have to work i think its, you know, five hours a week or three hours a week. It keeps going up each month. And certain kinds of activities count and certain kinds dont. And thats going to have to be monitored. Thats going to have to be sort of interacting with people. Why didnt you work . Was it because of childcare . All of that, not really good use of funds. Same thing for a lot of these very complicated systems of accounts. You know, they say theyre hsas, but theyre not because the Government Funds them, and, you know, and then theres supposed to be incentives if you can roll over part of the money, but what we see very clearly in several states that have used these is that theyre not understood. So if you dont understand you have this account and you can use some of the money later for something else, its not an incentive to do anything. Because it really is hard to explain to people exactly how these things work. Theyre extremely complicated. Yeah, we have vendor contracts, big vendor contracts. Administering these accounts and, you know, paying out and making sure that people are not being charged more than the law requires, monitor oringing whether theyre making the monitoring whether theyre making the payments. So it really is narrowly focusing on a small part of the population for purposes that are not really consistent with what medicaids supposed to do and taking away from the ability to innovate and spend time on really improving the delivery of care and the quality and without outcomes. But i think josh is really pointing out, though, where we do have a big philosophical debate going on especially with the adult population. Whether this is a Welfare Program or whether its a health program. Obviously, many of us see medicaids roots as being based in welfare, but having evolved more and more to be the Health Care Program for the low income population. And ironically, the place where its still closer to welfare is for the aged, blind and disabled where theres mandatory coverage of the ssi population which does have work disincentives built into it. But i think that is the debate thats going on. What should we be doing. And i think i look at it as saying lets try to figure out in the continuum of how to give the American Population Affordable Health care and how does this program fit with the next layer up of tax credits or what were doing. So i think thats an important part of why i see it as a Health Care Debate rather than a welfare debate. But i do understand some of the concerns that have come up in the state legislatures around the country. This is not a, this is not an issue that josh has made up. Its an issue thats very real for many of the governors and the legislate colors. And i would just say legislators. And i would just say a couple points on work requirements. This is an 80 20 issue. 80 of the public supports it for ablebodied adults. Theres political wind behind this. And i think one of the questions for us to ask is, if states wanted to do this, what is actually the administrative lift . Many of these states already have experience in tanf and s. N. A. P. Following that compliance, so its not that big of a lift. But really the issue is do we want folks to move off of medicaid. Is that a goal . Is that a success . And i think youre going to get different answers in different states on that. For those that say no, one of the outcomes we want to track you know what the best way to get somebody back in the labor force is . Encourage them to work or volunteer or get an education. Thats one of the lessons we have learned over the years. Folks can work their way off that are able. I dont want everybody to think im saying kids should have a work requirement or Something Like that. [laughter] but in ohio, 60 report no income in the expansion population. Shouldnt we look a little closer . To we want them to do we want them to remain on medicaid . I dont think so. I think we ultimately want them on a tax credit or employerbased insurance. How do we point in that direction for the populations that should. But your point is right, this is one subset. Is so theres another discussion to be had. C. H. I. P. Reauthorization is coming up this year. Theres a lot of governors who would be interested in trying to move pregnant women or kids off the program. Its a little bit crazy to them that you have families on private insurance, but their kids are on medicaid. Why wouldnt you have them on the same plan . So those sorts of discussions of being able to move people off or kids in particular off even though theyre relatively cheap to cover, but at least you get a little bit more of a handle on your program. Longterm Care Services, Nursing Home Services this is probably the area where they want to lapping their head against the wall bang their a head against the wall. Ultimately, what is the fundamental problem . We dont have a robust private longterm or Care Insurance market. This has become the default. So you have all of these, this whole industry many of you in the room probably know this of lawyers and Financial Planners who basically help families take advantage of the system. Is that what we want ultimately . Its costing us a fortune. So should we be thinking differently about this . What do we need to change about medicaid so we actually do have a robust Insurance Program for people who end up needing this endoflife care which is is so important and so expensive . But we have to crack that nut, and we havent gotten there yet, and i dont hear a ton of conversation about it. And the acas attempt was shut down right away because it was illconceived. What else can we try . What are other alternatives . So we clearly have eased into the discussion of what is the purpose of medicaid. So were looking longer term now. So, josh, you raised the question of Longterm Services and supports, and thats id love to hear from one of you what some of the facts are about numbers and costs for people with ltss. And clearly, the Affordable Care act did pass the class act which was supposed to be a selfsustaining program and that was eventually killed, you know, after passage because it was determined that it would not be selfsustaining. So lets talk just a little bit about some of the other purposes, whether were talking about it being insurance or, you know, a Welfare Program. We have groups like the longterm care or group. Care group. Is it a high risk pool . Is it a safety net . What about Population Health . Certainly, the longterm care debate has gone on for as long as ive been which is a long time trying to do health care policy. And weve had commission after commission try and figure out what an alternative is. Weve had demonstrations and investment in trying to develop the private longterm care market which has never really developed. Weve tried partnerships between medicaid and private longterm Care Insurance. And i think part of the problem is just that its, the its a very hard market to create a risk pool in. And people nor Public Opinion polling think that medicares going to cover those services when they need them. So theyre not exactly investing in those kinds of plans, though there has been some growth in them over time, but theyre mostly related to nursing home care, not to care in the community which is the preferred care. And then we have in medicaid that you have to spend down to get on to the program, and we do have issues over time of trying to tighten on the asset rules. But basically, as a country we are, were failing in having a comprehensive Public Private partnership that provides for Longterm Service and supports. And so i think we keep ending up with medicaid as the default. But for those who need those services, its a very important default. But i personally am concerned that as we see and weve been talking about the baby boomers aging forever, and now they really are. [laughter] and its time to really try and say how do we provide that continuum of care so that the alzheimers population and those with really severe needs who could be, i think, many could be maintained in the community, but people in the Community Need some support to do that. And were a very Different Society now with so many people working that theres no one at home to take care of some of the frail elders. So its a policy dilemma still to be solved, in my mind. A couple reasons. First, that that baby boomer aging, if you think about how you would structure a capped funding system whether a block grant or per capita cap, youre going to do it based on spending now. And spending now a population of seniors that tend on the younger side. So theyre not and if you set your cap based on that younger old, you know, 10 years from now, 15 years from now when you have a lot more 85 and 90yearolds, its going to fall short for that. I think the trend to providing the second part is the trend to providing more care in the community. Ands this is not just for seniors. This is also very important, we the role for people with disabilities. Including, you know, physical disabilities, but also intellectual disabilities where a lot of the home and communitybased services are provided. Because states dont have to provide these services, theyre optional, and its only the Nursing Home Services that are optional. If you move to a capped funding system, you could seedy minishment see diminishment of the home and communitybased services. And leading it to fam leaving it to families to have to figure out what to do. And the other thing that i think is worth mentioning. Its not its a little bit unrelated, but ive been struck by the fact that, you know, we talk about that there is a coming together of these populationings, that the adult populations, that the adults, and that there are a large share of caregivers of the people in home and communitybased services that are actually covered by medicaid. And whether its the family that has to stay at home to take care of their loved ones or workers in home care that dont have an offer of health care. So i think all of these threads if you sort of begin to look at it, it is woven together. And, you know, i think in that New York Times article that was so great on medicaid sort of coming of age. They talk about it being part of the fabric. And i think thats where, for me, it really is. When you put all the pieces together and see the multiple roles that it plays and how if you pull at one of those threads, youre going to have some unforeseen consequences. But if i could just speak from the state budget perspective, this is pac manning state budgets whether you expand it or not. So the issue about how much money you have and how much youre spending is now hitting education, is now hitting roads, is now hitting public safety. Because you go to a state like massachusetts where i live, its over 40 of our state budget. Thats a opportunity of money. And so a ton of money. So the question then becomes are you getting value for every dollar youre spending. Weve been talking about longterm care and services. Really important. Thats why so many people maybe at the state level at least were scratching their head when the aca came out and saying, so wait a second. Were struggling to afford longterm care and services, we have waiting lists in our states for home and communitybased services, and now were going to prioritize more federal dollars towards the ablebodied adults without dependents, some of them who have employerbased insurance. Why . So thats part of the opposition in some of these states that havent expanded. The media almost never tells that story. But if you talk to some state legislators, thats their awareness. And so for them, even though they only have to pay 10 of the expansion population, thats a ton of money when you have to balance your budget. And theyre seeing and making these tradeoffs every day that are heartbreaking. I mean, skyler in arkansas, 13yearold little disabled girl on a wait list for home and communitybased services. Shes number 600. You know what she is now after expansion . 700, because theyve had to prioritize all this money for this ablebodied population. Im not saying we dont want to make sure folks get coverage, but how you do it and the value you get for every dollar youre spending should be the conversation. And just giving somebody a plastic card is not access, so we need to be a little more nuances in what is our goal. Is it getting people off the program . Is it getting them on . Is it getting them access or a plastic card . Theres no connection between expansion and waiting lists for home and communitybased services, and you know that, and i think you actually admitted it at a hearing. [laughter] [applause] seriously. Hold on i mean, states that have the biggest waiting lists are texas and florida that havent expanded. Because their Medicaid Program is eating up their budget. So im saying whether its prioritizing buying your wait list down or whether its more money for classrooms or any other public priority, there is a relationship but its designed their waiver withs to have a number of slots. Right. So they create the waiting lists. But theyre put in that position to have to do it, is my point. No, theyre not. Right. [laughter] they dont have to, they dont have to do the waivers or they have to take money from somewhere else to spend. Thats my point, correct . Fourteen states have no waiting list, ten have expanded. There really is no it was given four pinocchios in the Washington Post [laughter] so i think we should stop i think youre correct in that there are decisions that states make every day about what to cover, how much to pay providers, how much correct. To do other services. And the expansion states cut provider rates, thats one of the things they do, which raises access issues. Im just saying theyre connected. Thats my broader point. And for us to say theres no connection, you have not spoken to state writers who have to make maybe youre saying the federal government should be putting more money into the program. [laughter] maybe im saying the federal government thats a policy discussion. But ultimately, i think as a country we also need to decide as a country with 20 trillion in debt ultimately how do we prioritize these resources. Look, this isnt just me, okay . This isnt just me. Because you have Harvard Public School of Health Professors writing in top journals saying every health care dollar that is not delivering value for that individual is wasted and taken from some other public priority. So this isnt just me, oh, im going around to state capitols. We have to ask a value question. I dont understand why people would object to that. Its come to money. It was bound to come to money. So lets talk about the tradeoffs, because right now were in a place, right now, we didnt have a big bill. We may in the future. So were talking about waivers. Were talking about states, some states, some governors trying to do, to achieve what theyre saying is greater flexibility, and were talking about having a cms that appears to be ready to talk to these particular governors. And what is the tradeoff between flexibility and potentially, you know, josh, you had said that some of the states may be willing to take less federal money to gain the flexibility. So lets talk about that tradeoff. If were talking about money, i think then we should look at the, where the money is, right . And i think some of the things that are being done now have been [inaudible] and theyre being done by red states, blue states, purple states, all states. And that is focusing on the people with multiple kind of conditions and providing there are new options in the Affordable Care act to do that. And weve seen things like in missouri their Health Home Program save money and have better outcomes. You know, we dont disagree on looking for value for the dollar, but i think we do disagree on the fact that if we decide to change the structure of medicaid and cut the federal funds, thats i dont see how that helps the state budget issue. So i think around, you know, Better Services for people with Substance Abuse disorders, i think beginning to think more about social determinants, looking at justiceinvolved populations and a lot of things that can be done around thing Value Proposition around the Value Proposition. And not only saving money in the medicaid budget, but better coordinating other budgets. Theres a ton that can be done without arbitrary caps on the federal funds. I think the real place where there needs to be more work done, we have an Opioid Epidemic here. Medicaid a place on the front lines that can help provide support for some of the counseling and treatment services, and weve seen that thats been an important part. Governor kasich noted in ohio that that was an important part of what he was able to do with the expansion funding. So i think we really need to focus on some of the things that medicaid does that are uniquely different from what a standard private Health Insurance plan would do, and that really is around looking at much to have role the program plays in Behavioral Health. And in trying to see how we can better provide those services, because i think that has been one of the outstanding gaps in the entire way in which the Delivery System has worked for some of the poorest and most disabled individuals with Behavioral Health challenges. So how about they keep some of the money that the income cap now they have the motivation and i will tell you this is common sense is the many moods and a managedcare world view are enrolled enrolled the son of for another program. Value paid to manage Care Companies every month until the check eligibility for the first 12 months. Why . We are wasting money theres no way for estate and to be setup for this corrected the terrible so now we have this situation spending money out the door. Because then the states will get very serious about the sorts of efforts with almost 400 million they save and hundred 60 million in 10 months the doesnt help the financing problem but where to redirect the money so the states have the right incentives. Western twosome of repressions do we have a question in the audience . I have a client who is an assisted living provider. But your comment about temporary waiver since more than half of the spending for longterm care and is home base reposing that be made a program that featured or should it . The second question is moldavia mandated benefits . Talk about nursing home care but could the states choose how flexible are they . How flexible is the Waiver Authority . The discussion i was hearing was the car about so what what would end up on the back end of being carved out that makes a big difference also the growth rate of funding. So that with slightly influenced the structure. So my brief point about the timing is that most waivers are between three and five years. So there is to insides of the coin. But this isnt just a federal program. But if the state wants to do something for tenures then why does it take approval . If it has already been approved showing a positive outcome then it should be approved but it could apply to that population as well. With individuals who were on the wait list the leeway to give that up of they are institutionalized first. That is not make sense. We dont want that to happen. Change the rules. Sometimes it is not always cheaper. In minnesota families for taking care of their own family members for freed now you pay them. So there does need to be more discussion. Republicans in general need to spend more time thinking about a. So there needs to be some more effort what to make sure people are taking care of that the end of life. But it is a challenge. Sometimes it is us double as in the details under rock block grant that if the discussion only applied to children and adults purses the elderly and disabled but what services are counted and howdy you base that going forward. So i just want to point out some comments sound like uh great sound bite for example, you say the children of parents where they on medicaid . One perfect example is children under 26 that do not have a job for the grandchild of the person providing insurance they have no access if not for medicaid. That is one example. Another you point out nonemergency transport who is to say when it is not emergency visit after the fact an elderly person with a wheelchair today call the ambulance . Are they charged . That is another question and the third issue people staying home caring for people for free look at the economics nobody is doing that for free they have given up the job are forfeiting future medicaid or medicare for themselves is not for free those are issues of have much deeper layers. I am not trying to be the libor plus but my broader point if the states can explore Different Things with a grandparent that is a valid concern put our their cases that it could apply to move the child off . Share purchase a wide we have that discussion . Unjust raising the issue not trying to say a broad brush i am articulating lets allow for a state to have that discussion the nonmedical transport are there other options . Are you near public transport transix . But having that conversation with flexibility to say you have had 150 and 40 missed medical appointments that is a real example so what do we do about that . Had we allow the states to say we spend all this money youre not even showing up to the doctor. At the state level just those two examples all of that can be and is addressed the benefit for those who produce public transportation. Some cases they need to get dialysis is not emergency but if you dont provide that it will become an emergency. But for kids for the poor kids in particular it is critical with the Healthy Development as these children are now adults. They pay more taxes and there are some sound bites like drug testing because they think theyre attempting to look at the people because it is real people and to say yes you can working and you should. There has been some waivers granted around and nonemergency transportation and also have the evaluation of what the impact has spent tuesday better informed. And there is the better way to do with. And not just tried to make decisions without some of the facts. I do believe that facts sometimes matter laugh laugh one more question then we will transition to the next panel. There is a lot of growth of managed medicaid Longterm Services are the contractors taking on the populations and they have catalog of flexibility to reallocate the money and do unusual things states have not been able to do. What do we know about the impact of these contracting arrangements with quality and access . Were still learning and evaluating that seems to be the most difficult to negotiate and that is the challenge. In some places they think the savings are not there but were still looking at the impact of that population because that is the height need chronically ill population that Needs Services but we want value we want to be sure that theyre also effectively integrated but not paying for duplication. I will ask the next panel to start working their way as i ask a final question. With this the one thing youll be watching for the administration as a great or horrible move . Cut. I will be watching what will be approved and the details with the evaluation plan whether or not they are evidence based. Would do they allow grandfathering . The waivers to hold one population and then how quickly do they allow that correct. And i will be watching to see what happens in how the children are just their needs to be some actions but also especially what happens to the roles of medicate with people of disabilities. Because there is the great need it to private services in a more costeffective way and there are others who were even challenging. With of the Disability Program more broadly and affecting the health care. [applause] now we will be lightning fast and hopefully provocative. I will introduce our for speakers president of the Childrens Hospital in florida, Vice President of policy at the American Cancer Society she leads a team of seven focusing on access to care in the emerging science, family physician primarycare practice in maryland and serves as a consultant to the center of applied research in big carries 4 million previously in this state where he worked on the Affordable Care act so we will dive right to in obviously has been a contentious and the debate. But one of the observations i was making of the think of the debate to mention 30 million kids in the Medicaid Program . Half level monsignor will be dramatically impacted by this program. Yet they only represent 20 percent of the total cost they will be squeezed out of that as other services to a cold and quite frankly there is a future if we dont get this next batch through into health and employment we will all be challenged because there will not be enough of them around to take care of us. Pedigree point we have left the patient out of the Health Care Debate. Also talk about cutting this or that the we are none at the root cause why it is so expensive with Specialty Care and drug pricing that factor in to make health care expenses. I would bite to say anybody twostage for three hours you deserve a ut wonky bad stuff laugh but going from 70 percent down at 10 was Proof Positive for what we need to maintain. But we are losing sight how do we get costs under control so those three phases but what do redo to provide stability . And for that there really is not to make things worse. So the key areas buses earlier on the ground this is a consumer benefit but six and 1 2 Million People nationwide received this important benefit. So those that have a deductible because the fuss tsr but the deductibles of but 5,000. So having this debate will year going the wrong direction retaking that program away. Lender stand it is the constitutional issue and they have won the case but from a budgetary standpoint it is the baseline so anne hallett cost the government more so in the medium term you need to address what is driving premiums. But nationwide the kidney fund moving people from public coverage because we pay higher rates. It is bad for the Overall Health of the exchanges said it is something we need to address looking at the longerterm issue the primary concern is pharmaceuticals that is now the biggest part and growing the fastest and then include the transeven of survived this with then working so we agree with President Trump but what this low and bill. But what happens to a person diagnosed with cancer with no insurance so there is the need for Health Care Benefit but predictability is another and affordability. We will dig them but i could ask the previews specifically talking about insurance such typically the right but if theres is the 15th that need to happen. Making sure they can afford the coverage that they get pretty of the food and che wan negative but if the budget milk back but if you have a cheaper plan but then to make sure there is premium subsidies but then to another the package going to beat my knees. But then petition alleviation stew make you want to be shared but first we have to talk about access if they can access their doctor. Blair issues and medicaid and private insurance and makes them less willing to uh hm hm in in that they dont have medical care protest till long it but the patient pennons a lump of butter with a mammogram is not covered belvedere i guess sec. What is your big concern . Taking off with the primary care side is still have the program but to be prevention oriented is the greatest challenge. To c400000 emergency visits per year at our hospitals for a 20 to primarycare those who do now have insurance but cannot get access because nobody has the plan the risen to enough providers to take care of the. Theater component is a small subset but the reality is 40 percent of all cost in the Medicaid Program and the this is significant amount of cost. If we dont figure out how to and then to coordinate we will spend a lot of time dealing with the of masses with a lot of the cost is really here and in better care. One of your frustrations was to have so many different players if you want to have dave valle and based the a but but we have had Great Success and bieber the first to operate on exchange so to keep pushing for word we have the new 2. 0 program but with that were working with provider partners. So what i am saying the person of office to go get it the hon so with the cost of welfare we will do that and that is needed to deliver among our competitors as well. You have providers to very much interested moving toward the Value Based Health care model with the arm right turn it can be difficult you have providers as amazed tried to. It is very have been questioned me talked this morning but the freight for the medicare population would about those value based reimbursements . That might be all then there is only investment. Does that affect the patients at all . Absolutely. One of the most important provisions was the creation of the Innovation Center so we have the ability to test for care that we have not tested for before and with those organization but if you load off of the cavern and put it involves all but everything is coming to the table was the most important elements to enable patients to be epicenter of that but i year almost rouge were them but all providers seem to agree that is not the we have seen dramatic improvements the the Cost Reduction and did is a model that makes sense, there is an act introduced in the senate but the unique thing about the bill is he bipartisan but lets focus on what we could change. Isnt part of it a lot of it is the then to think about primarycare this because otherwise were in the same but then the entire country is covered . You know politics. [laughter] how do we get there . But the private market is moving forward for to help move the conversation because we are stuck with a conversation over nine years on the hill before obamacare name and it will come again. But the process of coming to terms of health care purport and the kids and urged different but then to talk about changing the system of longterm savings in the improvement of quality care ahead to pressure. That may not result but the ellison on and pet to live cattle the social issues affecting health per troy havent heard anybody talk about what gives this the resources we know we are impacting with the ability to stay well. The question is so big bet is to be a open to your leaking. So they about a provider that had what they called Care Coordinator said job is to help the patient who didnt have insurance find resources to get their care covered. They would call but most of us have been able to and then follow up. The other but then to spend a lot of time taking care of dad they take care of their homes with the risk that are contributing the be will have to repurchase because if you take the restrictions the vp sent this not need to see the doctor. Be not been be be been adept be dot dot dot dot dot dot dot dot dot dot dot dot dot the president pro tempore the senate will come to order. The chaplain, dr. Barry black, will lead the senate in prayer. The chaplain let us pray. Lord god of hosts be with us yet. Lest we forget that our work on