Transcripts For CSPAN2 Health Insurance Outlook Part 2 20170410

With the failure to pass the bill in congress, some states are looking to expand medicaid, some additional states. Menstruates are talking to cms about what might be possible in the way theyre talking about waivers, what can be done. And so today well talk about our our goal for this panel is to both talk about where we are going into this next year, so where we are, what the aca did, where we are with medicaid, what is under discussion, and well talk about the considerations and possible implications moving forward. So, we are lucky to have with us today three exceptional panelists. Theres one empty estate and that belongs to trish riley, but because of the crazy weather in trish wont be able to get into town and so she will not be with us but fear not, our three other panelists here watch what is happening in the states closely and will be able to give us a full puck picture. First we have Diann Rowland from the Kaiser Family foundation. Diane was also the inaugural chair of macpack, which at advise congress on medicaid poll sir. Then josh from the foundation for government account abilityity. And josh works former gov mitt romney. And the end of the panel we have judith solomon, Vice President for Health Policy the center on budget and policy priorities. I you have their full bios biosn your packet. Id like to start off by ask dianne if you would please happen everybody in the room to understand what is our starting point here . What happened with that was created by the aca and just where are we . What is our starting point . What we have spent much of the last few years talking about medicaid in a very narrow way. We have been talking primarily because of the Affordable Health care act about medicaids role as an Expansion Program to cover additional adults who are very low income but didnt previously qualify for the program. And i think to remind you, that goes back really to the history of medicaid and after the 1965 as the program that was intended to provide coverage to the welfare pop someplace a has expanded tremendously. In that era the deserving poor were considered the aged, blind and disabled, children and adult width dependent cheng children and we have expanded the role of medicaid to be more of an insurer for many children and longterm support for the elderly and disabled and children with special needs but states were unable to obtain the federal matching funds to afford coverage to adult is without dependent children because they were not a category of medicaid. What the Affordable Care act did was say that eligibility should no longer be based on whether or not you fit a category but based on whether or not you can truly low income, and define that as 138 of federal Poverty Level or 23,000 for a family of three. The big change in the Affordable Care act was to reframe medicaid as a program for lowincome individuals that would provide Health Insurance and health care and they intended to build on the map debt under place in the medicate of covering up a children up to 100 of poverty and be by 138 by stepping that to adults which would rates eligibility for the parents of many children who were will below the Poverty Level in terms of state coverage and also to try and provide for a National Standard of how low income people be covered. Obviously when the Supreme Court weighed in it said that should be for adult coverage, a state option, rather than a requirement, even though initially the federal funding was 100 . And so i think much of the discussions that the states are going to expand, and states escaped, what whats impact, what did it cover, what kind of individuals were covered with this expansion, andow that in the 32 states that expanded, some 11 million individuals became newly eligible for coverage. When we look at where this debate is going today its not justining what to do about the expansion population but instead in the g. O. P. House bill that we just saw brought to the committees and then possibly some day 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 healthyearance program that takes care of some 74 million americans, including many of the 20 who are medicare byissues who need medicaid to help supplement medicare and provide for long, Term Services and support. It takes care of many of the Mental Health and other challenges one of the frontline programs today on the opioid addiction problem and has been structured over time to provide states federal matching funs 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 coverages. So the propose sal so end that openended federal financing to some sort of per capita cap has been reduced over time. The federal government says 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 g. O. P. Proposal. So we have two issues here. What happens to the expansion and the expansion population, and then wants to the broader Medicaid Program its role another our States Health safety net. Lets take that one at a time. One is the broader conversation of do we move to a per capita cap or a block grant . What do we do in the longterm, if anything . The first let talk about me 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 theyll 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 . Start with josh on that one and then others can weigh in. Sure. So, thank you for having me this morning. First, would say with a new administration, it is from a state perspective 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 officers theyre thinking differently what theyre going to ask for, for flexibility from the federal government. We can unpack that as we go but theres a big discussion about plan designs and what kind of how you set up these programs out of the financing. The second question on medicaid expansion, we have seen already a couple states look at expanding, kansas being most recent one. That it is a multiyear campaign by hospitals and insurers in the state to find candidates who are more sympathetic to that so that should not be viewed in isolation. Colts down if the house bill moves. If the house bill moves as currently structured and the senate makes tweaks but largely stays the same, the first managers amendment restricted new states from expanding toso that would end that conversation if it became law. Then we moved to that bigger question about financing, so, the expansion debate is active in a couple of of states at the moment, not as active in others pause theyre still just waiting to see will this house bill actually move as its currently conceived and by how much witness that change. Sure. Thank you for having me. Let step back on waivers. We go full speed into that conversation without 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 waiver. It is a very Flexible Program and waivers are on top to give some additional things states can do but what they really are is we have a medicaid statute 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 to provide health care to lowincome and Vulnerable People in the country, then well let you try that for a limited period of time and look at and it test it. So if we start there, i think its a good framework for thinking about 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 requirements and we can get into the detail why we believe these are bad idea for medicaid and the rejection of them in the past has been right. Theres really no evidence base. Even things like premiums where the medicaid statute says we have a low income people were covering here that cant afford to pay premiums songs so you shouldnt charge them them premiums. So giving them waiver and we in the we have tried that and have seen that waivers can keep people from participating in the program. So if you go back to 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 low income people, put particularly working people in jobs that didnt provide health care, and to say, now were going to do something that we know will increase participation i think is not really consistent with the purposes of the waivers, and i think its just always important to think about these as demonstration projects and that hare supposed to pursue the objectives of the program. I think its really interesting that sometimes waivers precede legislation and thats the case with the expansion. 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 disables but dont yet meet the disability threshold for coverage so it was really a series of demonstrations that led to the argument that extending comp through the legislation is possible. I think thats generally one of the purposes of the waivers, both to see if states can test new methods and to into if those new methods should be made available more broadly, maybe through legislative change or through broader adoption by the state. The family waivers are a got example, provide Family Planning services that were not otherwise eligible for the program that was schoop shown to prevent pregnancies that were not desired a at the time and also so that is the kind of approach of that requires rigorous evaluation. Perhaps i can offer a slightly different perspective here on waivers. In our experience, regardless of the political stripes of a state you can fine a whether you 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 there are couple of different ways states can get flexibility, whether its a state plan amendment which is using a shorter pros and rules, or the 1115 waiver process which is usually the bigger medicaid waivers. What is not told about the flexibility is ugly takes the. A is well over a year for approval for those sorts of award. Ive im a medicaid director the stately and i have to balance my budget every year, unlike congress i know but the state level i have to balance my budget and takes me a year to get a yes or no on whether i can do something dramatically different . Thats not flexibility. And from their standpoint. The other thing is have to go to d. C. To ask if i can do something yes or no. Weep im partially funding the program. But not soley. Depends on the state. This is a state and federal partnership. I want to reflect theres a lot of frustration the state level how this praise out and the fact they simply have to come you have states and probably more republican governors more interested in a block grant situation to say let me wash mishands of the process and let me determine how i want to do it. If it means have to put more state dollars on the table ill consider. It mean is can design my coverage and cover the populations i want to cover. Theres a bigfordism discussion and were bouncing around the funding piece but i do want to be heard that a lot of people the state level dont think its actually that flexibility a process, even though hey can ask for a lot, it just takes a long time. The waiver process is differ from the process for not having to ask for kitting which option you want to adopt. And in the Medicaid Program and theres multiple options in terms of benefits provided, like what kind how you want your desired Delivery System. When we talk about the 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 states could just do 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 the programs and these are really important protections around premiums, cost sharing, continuous coverage, all of that who is covered, hundred, and i dont think sunshine apologize for the fact that permission needs to be requested. So, lets take a half step back now and talk about flexibility and how much flexibility already existed and what can states do currently and well start atlanta. How flexible is the program the base line. One of the most flexibleaires what to do for home and Community Based services and services so the elderly and the disabled. You can get special sometimes a waiver own a limited gain, good coverage, children with special needs for whom private insurance is not sufficient to help cover the children. A lot of states have liked to use waivers nat case because they can limit the population and hat slots for home and Community Based services servict have to open statewide. So thats anaway that is very important. The only requirements for the elderly and disabled for ben fed are more nursing home care and states have broadly used their authority for Optional Services and for waivers to expand what they can do about keeping people in the community and rebalancing longTerm Services and support. Give us an idea how widely waivers are used . Every state has them. Multiple waivers. For the home some Community Based services, multiple waivers targeted at different possible layingses and the reason is basically, has diane said, nursing home care is a required service in medicaid. Providing services in the home, which is in moredred a vong yous and more desired and is half of longTerm Services and support is basically optional and what the waivers do is allow states to design packages of services that are statistically targeted to the population so may have waivers for the people with intellectual disability, seniors, children with special needs, different packages of services, some of the things that are knowing 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 medicare is going. So all of those things and a tremendous amount of innovation taking place over the last years, and a lot of that has been facilitated by states being able to get some upfront federal dollars to allow them to improve their Delivery System, set up better means of coordinating across providers integration and Mental Health service, all of that improving delivery for people with substance disorders and that is what would be at risk if the federal matching system is changed to a capped funding stream. Then well 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. I think this gets at a bigger issue about medicaid. Is it Health Insurance or a Welfare Program . Defending hop how to answer the question is how you think how to design it you have republicar governs wrote look at ick like a welfare entitlement program. So if youre going to follow that logic can things like work requirements, time limits, become things to look at for certain populations on medicaid. So i think theres actually a decent amount of research on other Welfare Programs showing that for certain populations, atrium through helpful. If you view it like Health Insurance you want it to look like Health Insurance so this discussion about plan design, deductibles, premiums, copays that when you slow up to the emergency room and its not emergency you have some financial skin in the game. Then the actual benefits mandated, a lot of state just to give one microexample. Nonemergency medical transport. So, do states have flexibility how to set that up . Could they work with uberor lyft and say you live near bus route, take the bus or the subway, but theres not a lot of flexibility in how States Imagine around those. The authority is quite wide but for the Obama Administration in particular and the bigger problem not trying to knock the Obama Administration its the interpretation at cms at that moment for what you can do and thats the bigger criticism. Think republican governors are seeing a political window their ask for things. Know that cms folks there now have been welcoming them and sent out letters saying wed like to grant additional state flexibilities. Well have to wait and see how flexibility they are or put in a lot of stings and waivers are temporary and perhaps that is a good thing but perhaps others see it as a bad this bug political winds change in d. C. I dont like that, take it off. If its proving to work i think we want it to continue, north be ideologically driven. So those are the certains of conversations that were hearing in state capitals, cushing already has work retirement, arizona is about to put in one, time limits limits limits and wk requirements, med and kansas are working on waiver requests and have a bunch of new things. So very certainly well see the details fleshed out in actual waiver goods. Those are all bat very narrow part of. That is about adults, not children and its not about the aged, blind and disabled who really are where the bulk of the dollars in medicaid are spent itch think most innovation has 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. Certainly the issues that we were raising around how many and Community Based services and those innovations are ones we want see that im going to channel trish we see innovation in payment and delivery and organization of care and i think everyone is always pleased that the states are backward because they dont have enough doctors yet we have seen them move tremendously into managed care and better quality measures now around some of that managed Care Services and to try to do better coordination across the boot. Thats where the promising future of method okayed is, and we can look at who could work and isnt working when we try look the expansion population. The majority of them were working. They were just working in such low wage jobs jobs jobs and dide Health Insurance or were will and couldnt work. We have to look more a if work requirements are put into effect how broadly would they actually apply to that Huge Population that now depends on medicaid. How much money would we spend administering that . If we lead aid sigh ideologyot difference we should be able to agree that spending huge opts of my the kentucky waiver is a great example so that for three months you dont have a work requirement, and then have three months you have to work, its five hours a week or three hours a week and keeps going up and certain kind of activities count and certain kinds dont. Thats going to have to be monitored. Thats going to have to be certain of interacting with people, why didnt you work, because of child care, all another that. Not good use of fund. Same things for complicated systems of accounts. They are there but theyre not because any Government Funds them, and then youre supposed to be incentives. If you can roll over part of the money but what we see clearly in several states is theyre not a understood. So if you dont understand you have this account and cook the money later for somebody else its not an insend tonight do anything because its really as far as to complain to people how these things worked, theyre extremely complicated, yet we have vendor contracts administering these accounts and paying out and making sure that people are not being charged more than the law requires. 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 continue with what met case is posed to do taking away from the ability to innovate on really improving the delivery of care and the quality of outcomes. I think josh is really pointing out the really we do have a big fifth sol cal debate going fill philosophical dedebate. Whether its a health problem, many see the medicaid roots based in welfare but having evolved more and more to be the Health Care Program for the low income population and chronically whether its closer to welfare where theres aged and blind and disabled and the ssi program has work disincentives but i think that is the debate going on. What should we be income 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, and so i think thats an important part of why i see it as a healthcare debate rather than a welfare debate but a die understand some concerned that have come up in the state legislatures around the country. This is not a not an issue that josh head up. Its very real for many of the governors and legislators. I just say a couple of points here on work requirements. This is an 8020 issue. Regardless of your feeling theres political wind behind this. One question to ask is if states want to do this, that is the administrative lift. Many states already have experience in s. N. A. P. Following compliance so its not that big of a lift for them to do that. The issue is do we want folks to move off of medicaid . Is that a goal . Is that success or how many people are on the program is the bowl goal. Youll get different answers. One say we want to know how many people get back goo labor force. Betts way do get the into the force, encourage them to work or volunteer or get education. We learned that folks can work their way off the that are able. Not should apply to everybody. I dont want anybody to say kids should have a work requirement or Something Like that but for the populations the expansion population in ohio, 60 report no income in the expansion population. Shouldnt we look close center do we want them to remain on medicaid . I dont think so. I think we ultimately want them on tax credit or employer based insurance. How do we make our Program Point in that direction for the populations that should . But your points right. This is one subset of the population. Another discussion to have, chip reauthorizing is coming up. Some governors want to move pregnant women and kids off the program. You have people who are on private insurance and the kid are on medicaid. Why not the same plan . Those discussions of being able to move people off, or kids in fishing off, even though theyre relatively cheap to cover butout get more of a handle on your program. Longterm Care Services, Nursing Home Services, when you goo into a Medicaid Agency they area where way than to bang their heads again the wall. But what this fundamental problem . We dont have a robust, private, longterm Care Insurance market. This has become the default. So you have this whole industry of lawyers and other Financial Planners that basically help families take advantage of the system. Is that what we want . Its costing us a fortune. So should we be thinking differently in that do we need to change about medicaid so we have robust Insurance Program for people who need this end of life care which is so important and so expense disbut we have to crack the nut and havent gone there yet and i dont have a ton of conversation about and it the acas attempt to shut down right away was ill conceived. What are the alternatives. We have keised into the discussion of what this purpose of medicaid so were looking longer term. Josh, you rates the question of long Term Services and support and thats dish love to hear from one of you the facts are about numbers and costs for people with ltss and clearly the Affordable Care act did pass theclass act which was a selfsustaining program and that was eventually killed parsage because it was determine it would not be selfsustaining. Lets talk about the other purposes, whether were talking about it being insurance or a Welfare Program. We have groups like the longterm care group. Is its highrisk pool . 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 healthcare policy, and we have had commission after commission trying to figure out what an alternative is. We have had demonstrations and investment in trying to develop the private longterm care market which has never really developed. We have tried partnerships between medicaid and private longterm Care Insurance, and i think part of the problem is just that its a very hard north create a risk pool in and people in Public Opinion polling think that medicare will cover those servicees when they need them. I personally am concerned that we have been talking about it forever and now they really are and its hard to really try and say how do we provide bad interment cares of the alzheimers population and those with really severe needs, and i think many could be maintained in the community but the Community Needs support to do that and we are a very Different Society now with so many people working that there is no one at home to take care of them. So, its a policy dilemma. I think in some ways if we had a change in the financing structure for a couple of reasons. First that baby boomer aging, he think about how you would structure funding you are going to do it based on spending now and spending now is a population of seniors that are on the younger side so they are not, setting your based on 50 years from now when you have to a lot more is going to fall short for that. And the trend to providing the second part is the trend to providing more care in the community. This is not just for seniors. This is very important. A role for people including disabilities allowing the home based and communitybased services provided. Because they dont have to provide these services they are optional and its only the Nursing Home Services that are optional. You could see diminishment of the home and communitybased services and leave it up to families to have to figure out what to do. Another thing that i think is worth mentioning that the little bit on that ive been struck by the fact that we talk about coming together of these populations that the adults and there are large share of caregivers of people in home and communitybased services that are recovered on medicaid and someone who has to stay home to take care of their loved ones, so i think all of these threads that you began to look at, it is woven together and i think in the news york times article on medicaid comingofage they talk about it being kind of the fabric and i think thats where for me it really is. When you put all the pieces together until the multiple roles that its playing in a poll on one of those threads you are going to have consequences. If i could speak from a state budget perspective, this is pac manic state budgets. The issue of how much money you have and how much you are spending is now hitting education. Now hitting roads and Public Safety because you go through a state like for instance where i live its over 40 of our state budget. Thats a ton of money so the question then becomes are you getting back for every dollar you are spinning. Im talking about longterm care and its really important. Thats why so many people may be at the state level at least worse to scratching their heads when the ata cabin said wait a second we are struggling to afford longterm care and services. We have waiting lists in her state for disabled kids and other home homeequitybased services now we are going to prioritize more federal dollars towards those with independents. Why . So thats part of the opposition and some of the states that havent expanded. The media almost never tells that story but if you talk to some state legislators that their awareness so for them even though they only have to pay 10 of the expansion population as a ton of money when you have to balance your budget and they are seeing in making these tradeoffs every day. They are heartbreaking. Skylar in arkansas a 15yearold little disabled girl. She can speak and shes on a in a wheelchair on her way to home homeequitybased services. She is number 600. Do you know what she is now . 700. Im not saying we dont want to make sure that folks get coverage but how you do it and the value you get for every dollar you are spending should be the conversation that just giving somebody a plastic card is not access. They need to be more nuanced. Is it giving them an insurance card . There are is no connection between expansion and waiting lists for home infinitybased services and you know that i think you actually admitted it at a hearing. A pasta seriously. Texas and florida havent expanded. Because the Medicare Program is eating up their budget so whether its prioritizing and bringing your weight witnessed down her more money for classrooms or more money for any other Public Priorities there is no relationship. Its onto waiver to have a number. They create the waiting list. Being in a the position to have to do it is my point. They dont have to. Or they have to take money from somewhere else to spend it. There really is no connection. It was given for pinocchios in the washington post. I think you are correct in that there are decisions that the states make every day about what to cover, how much to pay providers. The expansion states cut providers. Thats how they afforded. One of the things they do. Im just saying they are connected. Thats my broader point and than for us to say there is no connection i think you have not spoken to the state audit to have to make these tough decisions. Thats policy discussion but ultimately as a country we need to know this country is 20 trillion in debt how do we provide these resources. This isnt just me because you have Public Schools Health Professors writing in top journals say every health care dollar that is not delivering value for that individual is wasted and taken from other Public Priorities. So this isnt just me oh im going around the state capitols but we have just the very question. I dont understand why people would object to that. It comes to money. It was bound to come to money. Lets talk a tradeoff because right now we are right now in a place we didnt have a big bill, we may in the future so we are talking about waivers. We are talking about some states, some governors trying to achieve what they are saying is greater flexibility and a cms that appears to be ready to talk to these particular governors and what is the tradeoff between flexibility and potentially josh you had said some of the states may be willing to take less federal money to gain flexibility i and i their we have is if we decide to change the we have seen that has been an important part in ohio but that was an important part of what he was able to do. 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 would do and that is around looking at budgets for programs in behavior or health and trying to see how we can better provide those services. I think that has been one of the gaps in the entire way in which the Delivery Service has worked for some of the poorest and most disabled individuals with Behavioral Health challenges. I have many thoughts on that but im going to move in a slightly different direction. Lets start with getting people off the program they dont qualify. Illinois in 2012 passed a bipartisan bill that ended up removing three and 50,000 individuals. Many of them were deceased, moved out of state or had a job change and never reported it. The point im getting at here. If they are not alive ineligible. The concern is how many other states are doing it . I have none of two or three others that are starting to poke around in that. Theyre there are a couple of issues here. The first is they dont really have a reason to do it. They lose a ton of federal money if they do it so how about in this discussion about getting the incentives right they get to keep some of that money. Then if there is some sort of that comes from washington they actually now have the motivation to tackle waste fraud and abuse and let me tell you this is common sense stuff. If somebody moves in a managedcare world which is pretty much dedicated most states if you are enrolled any move across the state line you sign up for another Medicaid Program you are now paying to managedcare companies every month and you cant check eligibility again for 10 months from when they first reentered. Why . We are just wasting money. Theres no way for a state in the federal databases that are set up our terrible. We are now having situations where we are spending money out the door and this is why a lot of republicans in particular saying change the incentives and the state will be really curious about these sorts of efforts. Illinois saved almost 400 million. Pennsylvania did this under a Previous Administration and saved 160,000,000. 10 months. You add that up across the whole country, doesnt solve the financing problem but certainly helps. We can then have conversations about where do we redirect that money and that is why republicans are talking about putting something on a budget to tackle things like that. Lets turn to some of your questions. Do we have a question in the audience . We have one. A friend. Please identify yourself. Carl fulcher Health Policy analyst and in disclosure of the client who is aided and assisted living provider. Josh or comment about waivers struck me. Since more than half of the spending for longterm care is now homebased or assisted living care you proposing that they be made a permanent feature alongside nursing home care or should be . That question is broader. If ware going to have these block grants are they going to be mandated benefit to that . People are talking about the hospital care in Nursing Homes gear would be mandated. Would they be able to choose to keep it communitybased and not have Nursing Homes. I mean how flexible are they . Your question is how flexible is 1115 waiver . I think the discussion that i was hearing was actually about carveouts. Would end up at the backend of being carved out from percapita grant makes a big difference to what youre getting at. Also the growth rate. The managers had an increase for order population so that is the funding would slightly influences the structure of how is they would set those up. My point about the timing is just that most waivers are three to five years and can be rescinded at any time. So there are two sides of that coin. One argument is it its not working in the federal government should resend it. I understand that but its not just the federal program. The other flipside is if the state wants to do something for 10 years or if five states have already been approved for a waiver why does it take over year to get approval . Should there be an expedia did process worth already been approved and there has been one of valuation and showing some sort of positive outcome and instantly be approved without having to go through that process. Is that directly get to the niche of what you are talking about . I think it is applied that apply to that population as well. There are examples where we know of individuals who are on the wait lists for home and committeebased services. The only way they can keep up the wait lists is that they were institutionalized first. That doesnt make any sense. We dont want that to happen. We need to change the rules. We need to look at that. Communitybased services arent always cheaper. In minnesota they switched and there were families taking care of their own family members for free and now they are paying them. Its not a Silver Bullet is my point but i do think there needs to be more discussion. Think honestly the republicans in general have not given a lot of thought to longterm care and services. They need to spend more time thinking about it because and maybe democratic governors havent either but i do think there needs to be some more effort and thought around that because there is so much money that is spent in as needed. We want to make sure that people are taking care of at endoflife but how do you deliver that as i said is a real challenge. The devil a size in the detail of what can be done and not done under block grant. Sometimes the last discussion was only applying to children and adults as opposed to the elderly and the disabled. Even percapita swept services are counted in the percapita tax and how its base Going Forward so a lot of questions. Another question . We have one right here. Kim was the American Academy of nursing. I just wanted to point out the question was josh actually three things. Some comments that seem to be very much a big sound bite and it gets great applause but takes one layer down as a whole other issue. For example youre saying the children of parents who arent on insurance then why are they on medicaid . One perfect example is children under 26 on parents insurance that do not have a job so the grandchildren, the grandchild of a person the grandchild has no access if it was not for medicaid. Thats one example. Another one you pointed out is nonemergency transport. Whos to say and when what kind of emergency . Is an afterthefact . An elderly person with a wheelchair and oxygen to the call the ambulance, do they not . Was it an emergency . Thats another question. The third issue that we have brought up is with so many people staying home caring for people for free lets look at the economic. It nobody is doing it for free. Theyre either giving up a job or taking lower hours for themselves or not receiving future medicaid for themselves. Not for free. Thank you for your comments. Im not trying to be glib and i dont think im saying it for applause but. [laughter] my broader point is just that can they explore Different Things . Is a valid concern but are there cases where it could apply where we should move the child off . Sure. Again its point by point but im just raising the issue. Im not trying to say lets take a broadbrush approach here. Im articulating lets allow for nuanced discussion. Sometimes states arent allowed to have that nuanced discussion to dive a little bit deeper. My point when i said it was are there other options . Yeah sure the devil is in the detail. Of course but having a conversation about flexibility are saying you know what, you have had 150 this year and 40 ms. Medical appointments. Thats a real example so what do we do about that . How do we allow states to say we are spending all this money. We are not getting value. I have spent most of my career at the state level and i would say on just those two examples all of that the transportation benefits for people who can use Public Transportation thats what they get. In some cases we are talking about its not an emergency plea dont provide that it will become an emergency so the devil is in the details for sure. I think for kids medicaid provides for poor kids in particular at benefit that is really critical to their Healthy Development and we now have evidence to show as these children are now adults that it is paying off. They are paying more taxes. They are getting more education. So i think there are some sort of sound bytes particularly on the drug testing testing and i y appreciated your comments because i think they are attempting to look at people. This isnt the end of the day real people here and it is no simple to just say you can work in the detail you shouldnt get your Health Insurance. I would say that there has been waivers granted around emergency Transportation One of the important things for that waiver is to also have the evaluation of what the impact has been so we can make better informed choices. Maybe we will see demos of limiting bad and theres a better way to do it. Lets learn from experimentation and not just try and make decisions without some of the facts. I guess as a researcher i believe that matters. We have one more question up here. Lets go ahead and take that and then we will think about transitioning to our next panel. These care arrangements on quality and access. I think we are still learning and we are still evaluating and those are some of the waivers that are the most difficult to negotiate because they have to negotiate medicaid and medicare together which is always a challenge for the eligible population. Some places are seeing the savings are not there and there is a lot of need but i think we are still looking at the impact on that population. That is the high need chronically ill population but we want to get the best values for the services and we want to be sure the services are being effectively integrated so we are not paying. We are going im going to ask the next panel to start working their way up there. While i ask our panel as final questions i would like to know from each of you what is the one thing you will be watching from the Administration Whether you think its a great move for a horrible move. What is the one thing that the administration could potentially do that would trouble you for. Certainly the types of waivers that will be approved around in the detail and the evaluation plan to see what develops and whether or not its all about the waivers right now. I agree with that. One of the things in particular though do they allow grandfathering . Today allow waivers where for you hold one population harmless and the new regime, thinking about pension reform. Do they allow that in medicaid and how quickly do they allow it for waivers . We know chip expires in september. Also watching especially what happens to the role of medicaid for people with disabilities and the disability population. I think there is a not a a lot of great need to provide services in a more costeffective way. And meet the needs of the population. There other more challenging finding whether someone is disabled and the discussion of the Disability Program and more proudly how that will affect their health care plan. Ladies and gentlemen please join me in thanking our panel for great discussion. [applause] now we are going to turn the mic over to norm levy with the l. A. Times and he went to juicer next panel. Well come on up, folks. Before we have is panel if you need to leave before the end of the program please fill out the blue of dilation for them. Really helps us to understand what you would like to see and hear about and we really did take it into consideration. Im now going to turn this over to norm. We are going to hear from the doctors to hospitals and insurers and patient groups to get all the information and what they are thinking. Thank you and thank you all for sticking with us. Before you rush to the exit i know we are standing between you and lunch so i will make one plea that you stick around because we are very lucky to have for people that are on the frontlines for whats happening in the American Health care system and i dont need to remind this audience but that is a perspective which is optimistic and a lot of the health care debate. Why only have half an hour and it will be lightning fast. Hopefully provocative. Let me introduce our four speakers i guess working this way. Michael owen is president of Childrens Hospital of Jacksonville Florida which is the regions pediatric Referral Center part of the multihospital facet of the Health System. Christian slowness Vice President for policy at the Cancer Action Network where she leads a team of seven focused on access to care emergency sides and prevention. Keisha davis is a family physician at a primary care practice in gaithersburg maryland. She also serves as a consultant to the center for applied research on payment reform and andy chase in his policy director for blue shield of california that covers about 4 Million People in the state. Previously andy serkis counsel for the Senate Republican policy committee where he worked on the Affordable Care act as well as a variety of other issues. I think we will just die right in here. We are in the midst of reviewing the Zombie Health care bill on the hill. Its obviously been a very contentious debate about current laws and what the future holds. Lets go down here and talk about whats wrong with the debate we are having right now. I can tell you one of the observations that i was making and a lot of my colleagues was around who we were talking about if you think about the debate who mentioned that there were 30 million kids that are in the Medicaid Program that will be dramatically impacted . Half of all of the nonseniors in the program are going to be dramatically impacted by this program. Yet they only represent about 20 of the total cost. They will be the ones that will be squeezed out of that. As the demand for Senior Services in all kinds of services. And quite frankly theres a future of taking care of all of us. And health and employment theres not going to be enough of them to take care of them all. We havent talked about what makes Health Care Access of the worst part about this and cutting but we havent gotten that the root cause of why its so expensive. The Specialty Care and the drug pricing out those things that factor into picking health care expensive. Thank you for having me and for anybody who stayed in the Health Policy conversation in california where are you producing uninsured rate of 17 i think thats a row progress. I think we are losing sight and both sides have talked about it is how do we get costs under control. The first phase would be what do we do to provide stability for the market and exchange and for that not making things worse that sounds strange. One of the key areas that we need stability on tuesday cost structure and you forget the panelists talk about that. This is a consumer benefit that helps make coverage more affordable for the lowincome and reduces their daughter the bull and out of pocket expenses. 6. 5 Million People nationwide receive this important benefit. In california if you pull that benefit from what it is 150 of federal Poverty Level has a deductible of 150 because of the csr program. Its a 3000 increase. When you talk about deductibles are too high wed would be going the wrong direction by taking a program away. I would like to make a long few point about this which is i understand the constitutional issues at the house is spending on the lawsuit which is important and they have won that case but from a budgetary standpoint if starting a budget and a baseline so theres no new money that needs to be appropriated. All you need do is pass the funding that started there. If you dont see your point about it will cost the federal government more so would seem as a matter of policy in the medium term for us on the exchanges you need to bring coming you need to address whats driving the premium. It does vary somewhat but nationwide what we have seen our thirdparty payments particularly the funded what they are doing is moving people from public coverage for Medicare Medicaid commercial coverage were repay a higher rate. Thats good for them but its bad for the Overall Health of exchanges and driving up premiums. Thats something we need to address. Certainly our primary concern is pharmaceutical spending pharmaceutical costs and the biggest part of the health care dollar and 22 cents of every dollar when you include physicians goes towards drug spending so thats more than we spend on doctors and more than we spent on hospitals. We are working to bring more transparency to this so we agree with President Trump that we need to bring more balance to the market. I would agree with many things that my panel mates have said that whats really a scene from this debate is the fact that the need for health care isnt going away. Several years ago the American Cancer Society did a study that looks at what happens to the person who is diagnosed with cancer that doesnt have insurance and the problem is the diagnosis comes at stage iii or stage iv when your prognosis is not as good in your costs are much higher. The fact is theres a need for health care that isnt going anywhere. Access is still one of the primary issues that people worry about the predictability is another one that affordability is the third one. Lets dig down on a couple of the specifics. You are talking about specific things that make the marketplace sustainable. Let me ask the three of you specifically you are talking about ensuring that Cancer Patients have access to treatment so specifically i assume you are saying one of the things you dont want to jeopardize is the coverage that exists right now but if there are specific things that need to happen to ensure that access remains what would they be . First and were most a would be subsidies and making sure people can afford the coverage that they get paid a lot of times people will choose a health plan based on a premium. I need to know what my health care is going to cost me. The problem is oftentimes gets cancer and other chronic condition and give him back and cost can be cost prohibitive because you purchased a cheaper plan on the front end without going with the coinsurance might be so one is making sure theres premium subsidy into making sure that other outofpocket costs are affordable and three that predictability issue knowing that the package of benefits that i purchased are going to meet my needs. You hear the words you have cancer in your future is likely going to be a lot of physician visits surgeries potential radiation and chemotherapy drug therapy and a lot of health care visits. You want to make sure that Insurance Plan covers those services that you need so that you can budget those. When you think about it from a primary care perspective what he is saying out there that bothers you the most and if you could wave a magic wand what would you ask them to do . I think a lot of it has to do with access and how do we make sure that patients who have insurance or actually able to access their doctors and when you think about access their issues on the medicaid site and issues on the private insurance site as well. The medicaid side if you have an Administrative Burden and pricing structure that makes them less willing to accept the program for patients have insurance but they are willing to treat them so you have created a false sense of security and that they dont have access to medical care. In the individual market if you have created deductibles that are so high that patients have insurance but are afraid to use it and they are still coming to the doctor too late. Occasioned by and to lump but cant afford the doctor visit or the nonscreaming nonscreening mammogram but the screening they have to pay outofpocket for until they meet their deductible. Theyre not going to the emergency room and they are still not accessing care. You have created a wedge between people being at able to access primary can get Preventive Services that would allow cheap and earlier. What would be your big concern . Taking off on the primary care site essentially we have a sick care program. We dont have a program that is prevention, prevention oriented and thats her greatest challenge. In our system we are a small system. 400,000 emergency visits a year at our hospitals. 20 of them are primary care visits. People who now have insurance but cant get access to primary care because nobody has that plan. There are did not primary care providers that want to do that. The other big component is patients with chronic and complex conditions. Their small subsets and in kits is 6 in adults 10 in reality the subset is for key 40 of all the costs in the Medicaid Program and for adults a significant amount of costs and ensure program they are in. If we dont think about how to focus on those patients in a very different fundamental way with medical homes that manage all of their care and coordinate it we are going to spend a lot of time trying to deal with the masses when a lot of the cost is going to be here and better care. Would the talked a couple of days ago one of your frustrations was that you have so many different payers paying in different ways and you want to try to have a valuebased system that rewards you for doing the right thing and is a longterm strategy its very hard in the current environments do that. Talk about why thats such a problem. Its not unusual for complex Health System like ours to have 50, 6070 different managed care plans and managed care models. Everyone is administered differently so in our system half of all of the patients are on medicare patients. We could have one quarter of our workforce that deals with contract compliance dealing with that half of the population. Threequarters of our workforce deals with collection and insurance. How do get is paid and how to get paid correctly. Its a total waste to think about how much they spend in terms of the bureaucratic overhead. That gets combined with Provider Service but at the end of the day we spend a lot of time arguing about getting paid for the service that was authorized. When you are paying these bills not directly but in a manner of speaking you are paying bills and hospitals and doctors offices and how can you guys work this out so you could streamline this up at . I dont think theres anyone in a Health Care System we have had Great Success in california moving to our program which resulted in higherquality care. Theres a lot of transparency and we have saved 140 million for customers for her acl program. We do need to keep pushing forward in this move from volume to value. We have our 2. 0 program and what we are doing at that is we are working with our provider partners to identify the gaps in care and investing in those providers so whether its a piece of Technology Words of cases the person in an office who can provide the higherquality lowercost care than we are going to do that. If that happens to improve the list for competitors as well. Thats how you move it forward as a whole. I think you have providers who are very much interested in moving to more of a valuebased care model and getting away from feeforservice or provider trying to institute those changes is very difficult. As you are trying to make those changes trying to make here and a guy with a system the question of whether that funding is going to be made available even on a panel this morning its in place and thats great for the medicaid population. What about the skypebased reimbursements for the rest of our Patient Panel and the conversation is thats another priority. How do we make that investment for all their patients and not just for medicare. Does that benefit patients moving to a system thats more in line . It absolutely does. One of the most important positions at the aca was the creation of the Innovation Center. We have the ability now to test new models of care that we have never been able to test before. Patient homes the Accountable Care that you have refer to in oncology bundled payment projects thats up in rank enables the government to test and bring to scaled new models and whats really important about that is that involves all the stakeholders insurers positions and consumers and patients in a way that everybody is coming to the table and talking about one of the most important elements of the design that enables patients to be at the center of that and their experience to something that guides the care is provided. Think its critical. What i hear all the saying that we are moving away from feeforservice toward different method of payment that rewards the outcomes that we want that makes the job of providers easier so they can align what they do. I dont hear almost any talk about that here in washington. We are talking about how do we cut money because we are paying too much money right now. I think all of us would agree that that underlying idea is not without merit. Unable to move in that direction fast enough we are shifting more costs onto patients and that a lot of discussion we seem to be having here now. How can we move the discussion to more of what all four of you are talking about and stop talking about higher deductibles are shifting costs onto medicaid patients. All providers would agree it doesnt make a lot of sense for anybody. I can tell you that at the Innovation Center we are participating in one of those multisite hospitals around medical homes. We have seen dramatic improvement in the service dramatic improvement in the outcome and tremendous improvements in cost reduction. Its a program and a model that makes sense. There is actually an act that was introduced last session. They really would create a network of major providers for pediatric with the medical home model and set up a foundation for that. Theres a will and so matteroffact and neat thing about that is we had bipartisan support. Almost half of it was republican half of the wisdom of credit support appealing to move those ideas that are laser focused as opposed to trying to reinvent the entire system. Its thats focus on the things that we can change and manage better. I think part of it also i dont know the policy aspect but a lot of that is changing the conversation. Maybe its that we start to think about primary caregiver land maybe we start to think about how we pay for primary care and Preventative Services differently, carping goes out looking at changing costs and how much value because otherwise we remain in the same conversation. I think the conversation has to shift to just being about who is getting paid what but how are we having the conversation where we are thinking about how it gets covered. Andy you have been in politics on the hill. For too long. Its a great question. Its important or mechanized private market is moving forward regardless of whats happening in washington. Washington can help move the conversation forward. We are stuck in this conversation we have been having, for me nine years on the hill before obama came so i think this process of coming to terms with what Health Care Reform repealed about what the reality is and what is the fault of the aca and whats not the fault of the aca. We have to move to a better system. I think he is at play right. I think its changing the conversation. We tend to focus on the crisis of the day and shortterm savings and what we are really talking about is changing the system so we are talking about longterm savings and also improvements in the quality of care thats delivered. Some of the changes that we are talking about now may not result in a lot of savings that may improve the quality of care and improve life. I want to leave a few minutes here to offer questions from the audience. Raise your hand if you want to get in on the conversation. Theres one up here. On the policy director of the d. C. Primary Care Association and one of the issues for us is looking at how to utilize the Health Care System on addressing social determinants when we are in this environment of scarcity of resources for fundaMental Health care and knowing that we really need to be looking at these social issues that are impacting health. I havent heard anybody really talk about what do we change that gives us the resources to address the things we know are impacting peoples ability to get and stay well. So thats a little bit of an unfair question because its so big but just really open to your thinking about that. I can give a short on the ground answer. Thinking about a provider who is at the Committee Health center and they had what they called care coordinators and before the aca with their job was mostly was to help patients who didnt have insurance find resources to get their care covered. They would call the hospital said they would call specialists and see who would be able to give them a discount or how could they work that out. Now that most of those people have been able to move to medicate those people are redeployed worked as coaches and called in to see how they are doing on the Tobacco Cessation followed up a nature that they went to the appointment that they were supposed to go to so some time it brings people to work a different roles in the Health Care System. The other elements of this is applications in Childrens Hospitals we been able to redeployed personnel be used to spend a lot of time taking care of them in the hospital for not taking care of them in her home and getting some of the rest as jurors factors that exist in a community that are contributing but to be clear part of your ability to do that is dependent on being in a page in a way that you can recoup some of the savings in those determinants. We are having to repurpose. When you take the restrictions every patient does need to be seeing a doctor and patient does need to be seeing a nurse. There are lots of things in our practices where other personnel can do that work at much lower cost. I think thats what we have been trying to do is repurpose that fixed cost that we have on the front end. Has blue shield dived into somebodys social determinants . We recently in the medicaid business its become important where this is an issue where he have to confront when you are working without population. Its really something that we are expanding and thinking about more. One issue i think we need to think about is the Health Information technology and ability to look at patients no matter where they are getting their care or who insures them. Its an effort to share with anthem patient records and working with providers when somebody goes to the doctor. I think thats another way we could move the Delivery System forward together. We are patient navigators and we support them. Theres something very simple which is asking patients what they need here and i know that sounds like the obvious but i think in the past we have created a lot of programs to try and help patients with some of these social determinants and we found that it doesnt work because we are not getting of the right things. Building into our programs with the simple art of asking a question to patients about what are their care plans. Anybody else . I guess we are done. Under the wire. My name is julie and im a medical student but im in my fourth year. My question is granular and you might not fully understand the specifics of what im saying but if you understand it as part of the ama are you responsible for determining the reimbursement codes and although i understand theres not many primary care physicians on that committee so a lot of the reimbursement for medical care are being determined primarily by specialists. So the potential role of organized medicine to better represent primary care, on that level. I can take out a little bit. There are primary care Family Physicians on the roster. It is skewed toward specialists so primary care does have a voice on the committee but its a smaller voice relative to everything else. I think when you think about shifting costs and health care and how people are paid there is a lot that committee can do to change how people are reimbursed. I can cite the latest survey that just came out on Physician Compensation shows the areas that are not growing or those in primary care and the only one that went down was general pediatrics. We are paying less and nobody gets excited about i want to be of pediatrician when everything is gone down, down, down. See that on that happy note. Thank you very much, all four of you. [applause] great. So we would like to thank you all for being here. We know this has been a long morning. We hope to have a conversation. Once again we would like to ask you to fill out the blue evaluating form before you leave and a special thank you to our 25th anniversary sponsors and also to our insurance summit sponsors blue crossblue shield association of feed feet at a Childrens Hospital association in cvs help and thank you so much. Whatever they pay you its not enough. Thank you all for being here for a lot a very informative morning. Comeback may fit for conventional briefing focusing on a different aspect of health care. Thanks. [applause] [inaudible conversations] to some extent its unsettling to quickly get to view the court as the court as opposed to these members and becomes hard to think of it as involving anyone else. The way people look at their families and how could it be different but you do get new arrivals in both of those situations. Its a tremendous sense of loss. Justice souter is just a wonderful colleague in so many different prospects. We will miss him in our deliberations and we will miss him around the court but thats part of the process of the evolution of the court. We will welcome a new member with open arms and the court will be richer in the course of history because of the gradual turnover but you do get used to seeing the same people everyday and you get used to having lunch with the same people everyday. It will be an interesting part of the changeover. Justice white eyes used to say when a court gets a new member changes everything. Changes everybody. Simple changes. Remove the seats around in the courtroom by order of seniority so therell be a shift there and the same in the Conference Room but more fundamentally i think it can cause you to take a fresh look at how things are decided. A new member is going to have a particular view about how issue should be addressed and may be very different from what we have been following for some time. I have great admiration for a system that works. Next on the communicators, we will talk to congressman mike doyle, the Ranking Member on the subcommittee on commune and technology. Coming up in 30 minutes on booktv, a look at the 2016 president ial campaign in insane clown president dispatches from the 2016 circus. Then doug weed talks about his book game of thorns about the Hillary Clinton campaign. And maureen doubt on her