That is the discussion we need to be having. Is it fair to say most of the people who are in the waiting list who are develop mentally disabled traumatic brain injured people and those with serious Mental Illness are on medicaid, a different type of population and what has been your findings with the governors with respect to how most of them would like to take care of this population if there are consensus among governors, what is the governor, the legislature to deal with respect to the population. I will say there are exceptions to that rule. How did they do it. And they are focused on those that are the most needy and made that a priority in their state and their waitlist. We need to explore the states that found ways with little or no wait lists. And the application to cms for medicaid waiver to continue suyears. And outstanding program, it is a way to save and help, it can be replicated. It is an incredible model that can work, we have a waiting list in indiana. I hope the new nominee to lead cms, we could get all of medicaid stronger and better programs with controls in place, i worked with the units, we need to do more to support them, and they are protected and i yield back. Now recognizing miss clark. Thank you, mister chairman and ranking member. I want to respond to Mister Howard. And the impression left by characterization of the empire state. New york states Medicaid Redesign Team is a National Leader in controlling costs and improving quality for medicaid members. Selfdescribed as fiscally conservative think tank and government watchdog. In december 2016 medicaid spending per recipient dropped from 10,684 to 8781 or 18 from 2010 to 2014. Nearly twice the national average. According to the control office, and the medicaid spending growth, only 1. 7 annually during the period of fiscal year 201013. This is a significant reduction over the trend to the previous ten years of 5. 3 . During the same period medicaid reenrollment grew by half 1 Million People. Spending has been cut. Fiscal year 1415, a total of 15. 4 billion was saved next to the m rt initiative. This track record led to the Controllers Office to declare mrt represents the most comprehensive restructuring of medicaid systems since the Program Began in 1956 and we have no waiting list. I turned to Mister Westmoreland. In Mister Archambaults written testimony he cited concerns about Medicaid Expansion. He ignores the fact there was a positive impact on the quality of life and help, he ignored the fact of cost savings from preventative medical examining, Early Detection of disease and future cost savings to the state and government. Im a strong supporter of Medicaid Expansion, significant value of the program. Im interested in improving the program. Miss archambault claims Medicaid Expansion funding threatens the truly vulnerable. Can you clarify why this is not the case. I begin with first challenging the discussion as i did in the testimony of who is truly vulnerable. Not all people with disabilities, any of those discussions that have been ongoing, and in receipt of ss i and many people who we consider disabled, and the Medicaid Program until enactment of the aca. Lets start with those people. Secondly, there have been macroeconomic studies by Business Schools, economists showing states have significant budgets and revenue gains. And Medicaid Expansion in their state so it is clear states benefit on a financial basis, and the financial basis in ways i outlined in my testimony. Mister archambault and Mister Howard claim Medicaid Expansions have an unsustainable burden. Can you clarify why this is not the case . Why have most states that expanded medicaid experienced budgetary savings. And fewer uncompensated care costs. And a reverberating multiplier. And able to provide as you suggested preventive and Early Intervention services that might not have been available to uninsured adults by ongoing healthcare costs. My understanding numerous studies have disproven the myth that Medicaid Expansion i yield back the balance of my time, mister chairman. We recognize a new member, gentleman from michigan, mister tim walberg. I appreciate the safety net, we want to have safety nets, we dont want to have safety nets forever. And working at us steel, going out and being responsible to take the plug out of a heat of molten steel. And have a fall protection strap on me. I appreciate that. I dont want that strap. I wanted to move on, the goal to find ways, the people who truly need the safety net have it. We make sure we dont waste it on others who dont and encourage and move on in a positive way. And ms. Maxwell, would like to comment after Esther Archambault your testimony references waste and fraud issues, individuals that passed away two decades ago using high risk for stolen Social Security numbers, tens of thousands moved out of state and medicaid. There are a number of things we would recommend, the first is a a change that states could only redetermine eligibility once a year in case they were given a reason to recheck eligibility, to access data internally in State Government and thirdparty vendors. On a quarterly or monthly basis they are finding individuals have life changes like all of us, they move or die or get a significant raise we need to make sure we find that sooner rather than later, otherwise we are wasting money and i believe there is bipartisan agreement on that, need to make sure. The other thing is we need to make sure the federal databases which we havent talked a lot about, the quality of the data is so poor. And complained constantly how late the data is, out of date, making sure states are looking for dual enrollment and the food stamp program, we should be doing it for medicaid. Just to be sure we are not wasting money as a result of individuals. Ms. Maxwell, can you add to that . I would definitely echo the crucial need for better medicaid data. We have to understand programmatic issues for policy decisions and also to find fraud, waste and abuse. In addition to that path of protection, we need to think about fraud happening in the first place. In addition to the data, to work with states, to make sure providers get in and want to pay. An audit in arkansas, 43,000 individuals on medicaid, and 7000 with any record of living there. 20,000 medicaid enrollees in high risk identities. Fake Social Security numbers, etc. Something of interest to me in michigan has identified 7000 lottery winners receiving some public assistance including individuals winning up to 4 million. Those jackpots are something, dont encourage him not to be on medicaid assistance. Do these individuals get approved for and stay enrolled in the Medicaid Program and is it the federal government . Maybe a little bit of both. To answer that question, what is really important is there are policy changes that have happened was the Affordable Care act remove the test for the Medicaid Program. These outlier cases for when and individual wins 4 million and takes a lump sum payment they may not qualify that month but the next month they would qualify for this program. We are not checking for 12 months in most cases. We wouldnt know. We need to make sure gaping holes exists, in a State Government, and the federal government needs, in a regular basis, and Mister Howards point, that is not the incentive that is inherent in the current financing structure. My time is expired. As many of you know, i grew up with farmworkers in the underserved community. I have seen firsthand what it means when a community is medically underserved and when they cannot access care. It is not for medicaid in regions like this across the country that did not have access to healthcare on this day us and families enjoyed. If we repeal Medicaid Expansion people will lose healthcare coverage and stop seeing their doctors because their too high, and 3. 5 that is millions of families losing access to health care. If we repeal Medicaid Expansion uncompensated costs increase straining our nations Healthcare System which will drive up costs for everyone. When people dont have Health Insurance they dont stop getting sick and emergency departments, do not turn someone away, and the hospitals have to make up the cost. In 2014 alone, there was a decrease in uncompensated care by 45 in 2014. All hospitals in my district, in particular a drop in uninsured patients by half. We need to expand medicare even more, make it more efficient and desirable for providers to see more medicaid insured patients. Fraud is bad and political amplification of the problem to wrongfully justify cutting Health Insurance for six patients is bad. Here is the possible common ground. Here is what i think we can both agree on. If we start with the premise that we need to cover more economically struggling families like the middleclass and more vulnerable families then we are on the same page. If we start with the ideological goal, read mistrust and millions of people will be harmed including the middleclass. And sick and injured people getting the care they need. Anything short of this is negligent. To expand coverage to a few struggling, uninsured middleclass families so the question i have if you were to choose one thing you can do to combat fraud, if theres one action you can take that can make the biggest difference in the system what would that be . It is around the providers making sure we have eligible providers in Good Standing and those not in Good Standing should not be providing services. The one thing that will make the biggest difference. I would have to go back to the data. A lack of data across the nation from the managedcare companies. One thing to change to make the biggest difference what would it be . Engaged data transparency, and benchmark to provide performance and engagement. Where does the evidence suggest about how Medicaid Expansion is making health care more affordable. And reducing patient needs to forgo medical care due to costs. Medicaid expansion is associated with a decline in personal bankruptcies and associated with greater Financial Security for those newly eligible. These are middleclass families having Economic Security because of Medicaid Expansion. What does evidence say about how Medicaid Expansion affected Patient Access to primary care and preventative care. People in those beneficiaries insured Medicaid Expansion have higher rates than traditional sources of care, primary care and Preventive Health services. My closing statement, is this leading to expansion for economically struggling families, the ultimate goal is to create a facade and emphasize problems to justify policies that hurt the middle class and increase Health Insurance i am nodding expand more Health Coverage for middleclass families. Recognizing a member of the committee. Ucla former state assembly, congresswoman mimi walters of california. My questions are directed to Mister Archambault. Supporters argue Medicaid Expansion would increase jobs. Has this happened . A number of studies where predictions have been off, and in particular, there were predictions of games and hospital jobs related to expansion and the opposite is taking place. During the conception of the aca supporters argue Medicaid Expansion would stop hospital closures. It stopped hospital closures in a number of states hospital still closed. Important to realize supporters claims it was a Silver Bullet to stop closures. And massachusetts and the number of the states that expanded hospitals. Medicaid expansion was projected to emergency room use. The evidence suggests emergency room use increased after expansion and emergency room visits were deemed to be avoidable. I live in massachusetts, worked on romneycare, one thing that is apparent is the expansion population, and getting coordinated care showing up to the er at a higher rate than those privately insured or uninsured, these are questions to ask about the effectiveness of the program and the quality of care individuals are getting a number of surveys looking, as unavoidable. 55 of medicaid visit to the er are unavoidable. The Affordable Care act has been a blessing for so many people in the country. 12 million more americans have access to health care, and governors across the country, with senator mccarthys request, and expansion of medicaid within the states. Im assuming some of these letters. Even some republican governors appear to have positive things to say about the expansion of medicaid. The letter my home state of illinois stated governors say are medicaid population, quote, stands at 2. 2 million, almost a quarter of the state population enters Republican Leaders in congress to carefully consider the ramifications of proposed changes, governor sandoval of nevada stated in his letter to Mister Mccarthy, the Medicaid Program to require managedcare, to implement a statebased Health Insurance exchange, these made healthcare accessible to many nevadans who never had coverage before. Can you briefly touch upon how the residents expanded medicaid under the aca benefited like illinois and nevada. Illinois and nevada, touch on how residents of states that did expand medicaid under the aca. 11 Million People had medicaid coverage, and point out and agree with you, the governors who wrote to Mister Mccarthy none requested appeal and pass 16 of the states governed by republican governors and ohio, one of your former colleagues was most passionate in describing not only how it benefited the residents of ohio to have services and believed it was a oral duty to cover people under medicaid. Can you touch i wanted to mention other examples, that have positive outcomes for their residents and beyond Healthcare Benefits of 12 Million People how is Medicaid Expansion helped states manage their budgets, had a positive impact . I suggested there have been Business School study that economic studies suggesting states expanded medicaid not only had a net increase in federal funds coming into the state but enjoyed revenue increases reverberating effects, providing funds in hospitals. I would also, and productivity improved by people having Healthcare Services that were denied this service. Some of the letters i was referring to seem to raise concerns by republican governors of changes to the Medicaid Program first cost shift. Governor baker of massachusetts in his letter to Mister Mccarthy said, quote, medicaid is a shared federal Partnership Proposal that suggests states are provided with flexibility and control, with substantial and destabilizing costs. Is there a concern with a cost shift under the republican proposal, seeing such a proposal to grant medicaid or per capita spending, should state be concerned about major cost shift . What level will the initial block grant and its formula say that but major the evolution, increase of funding over the future compared to the cost of providing health stock costs to the number of people who need them. States will be left holding the bag to medical inflation and the number of people who have no Health Insurance. What about those receiving healthcare through acas expansion are they at risk to block grant the Medicaid Program . I suggest my colleagues on this panel point out suggest those people should be the first to go. Returning to traditional medicaid populations. Over the last 20 or 30 years. I would suggest people on Medicaid Expansion are the people on the chopping block to begin with. As every state, no expansion experiences the growth in healthcare costs that is almost inevitable looking at cbo or any other projection states the left holding the bag and do not have a guaranty of federal funds. Another new member of the committee, Mister Costello of pennsylvania. You are recognized for five minutes. If i could ask a couple questions, has the number of criminal investigators increased or decreased over the years . The number of criminal investigators specifically . I think right now we are below, still trying to hire more. How many more do you need to hire . We need 1700. True or false. For every one dollar expended in the oig, 7. 70 return to the Healthcare Fraud and abuse control program. Has there been a consistent return. It has been around 7 and same for the medicaid Fraud Control unit have similar roi. Medicaid agencies with provider fraud. They properly suspended medicaid payment providers. We do not make full use of those. To say they do not. They do not, a number of cases where they do not suspend and to clear the provider of wrongdoing. Since your work has repeatedly found cmss oversight of states claiming matching dollars is inadequate to safeguard federal dollars, what more could cms be doing to ensure the integrity of medicaid matching. There are a number of things we believe cms could do in conjunction with the state given cms and states share fiscal risk, they should share accountability. As i mentioned, prevention, helping states implement screenings, helping them drive down payment rates, the data to understand the program and more importantly the data helps us hone in on fraud, waste and abuse and target oversight to get this tricky balance right between trying to have Strong Program integrity but also not put undue burdens on survivors. I want to shift this question to Mister Archambault after he answers, anyone else feel free to respond including what you just mentioned about the issue of enhanced data matching technology. Seems to be if you have technology and you have data, when talking about the aca change the required states to provide one check per year knowing we have the data, knowing we are a pretty technologically advanced society it would be easier to go about detecting in eligibility or fraud or anything of the sort to cut down on those who are in eligible from being accepted into the Medicaid Program. Mister archambault, in your testimony in the first 10 months of operation pennsylvanias awardwinning enterprise Program Integrity initiative identified 160 in eligible individuals receiving benefits including those in prison and even billionaire lottery winners resulting in 300 million in taxpayer savings. What can we do in order to pivot to realtime identification of something that doesnt seem quite right rather than relying on that one moment in time annually to beef up Program Integrity. A number of things the federal government can do to enable states to do this. The first, if they are investing these efforts, in eligible for them to keep a piece of that savings up front, more than they get to save now given the funding formula. The others let them check more frequently and the other is to is time we were allow states to get it. The data is not timely enough. I would agree the coordination and sharing of data is critical from federal and State Governments. They are enrolled or ask what the owners are. And 14 owners told us there were 12. In addition, and the data be improved so medicaid can share that and reduce the provider burden. The eligibility issue. We are technologically advanced society, Medicaid Program truly is not. Data systems are pretty antiquated and a lot of work to do to get good data systems that are more flexible and more agile. The most recently published managedcare organizations, data systems, this committee accelerated the effect of data, i would ask you to keep the nca landmines, the question whether regulations are withdrawn. Data systems need to be improved and the nca does that. And now recognizing the owners of carters pharmacy, where we might em and ellie walker. Smalltown medical care, good to have you on board. Thank all of you for being here and appreciate your precipitation. I prefaced my questions by apologizing if i ask you something you were not prepared for. If you dont know the answer, you can get me the answer. You have some expertise on the 340 b program. I dont want to get into that program but i want to explain to you a situation that exists in the district. I have a hospital in my district that is participating and receiving money from the 340 b program and because it didnt meet the threshold they were put out of the program. They got back in it, two different levels, a Small Community provider and disproportionate share. They get back in it as a Small Community but what the ceo is telling me is because they cant get a disproportionate share, they are losing 300,000 a month. That is significant for them, for this Hospital System it is very significant. The formula used for that, medicaid participation, the medicaid rate is in that yellow. And the disproportionate share. And what i am hearing is those states that did not expand medicaid like the state of georgia, at a disadvantage and we are intelligible for that. Is that the case . The pricing of drugs in this, i know people in our office as soon as we can. That is fair enough the question is twofold, if that is the case, secondly if that were the intention. Was that the intention to penalize states that the expand medicaid to receive these dollars or was it an incentive to get those states to expand medicaid . Please include that in your answer. I will move to Mister Archambault. The video you showed, i spent ten years in the state legislature, health and human services, understand medicaid. We did the hospital bed tax to draw more dollars down, brought up one of my fellow members earlier. They are looking at reauthorizing that this year. You bring up a valid point how states balance budgets because quite honestly we did it that way and that was one of the reasons why and my question is the video you showed. I am a strong believer medicaid shouldnt include the the cost in Medicaid Programs contributed to the abd. What percentage will that be . 70 . 80 . At least two third . We are all in agreement that is most of it but my question, Mister Archambault, why didnt this patient, why wasnt this patient eligible . Seems to me they wouldnt have had to wait on the waiver. Thank you for the question. It is important that we are talking about a couple Different Things here. What we are talking about in particular is there are services she could have access to under these waiver programs with you cant just call a neighbor to babysit. You need certain skill sets to watch her given her condition. This would allow access to those services. Completely off of medicaid, and what we promised individuals in a holistic manner, and these most needed. Understand again, i believe medicaid should be taken care of that group which debate that is covered, healthcare professional that they should be covered. We are extending new promises to ablebodied childless adults before fulfilling that. Be change hhs projects new eligible medicaid patients, 66 per and rowley in 2015 and this is a 49 increase, why are they costing or . It may be the new Expansion Program states have raised reimbursement rates to provide is to get the newly eligible populations, that is my understanding. It would appear to me getting back to the age of the disabled if they were already included they are the most expensive. I know i am running past my time. It baffles me why it is sewed up that much. I yield back. I am going to be directing Mister Howard with backgrounds. New york as we know is one of the highest states in medicaid per capita spending and while new york has 6. 5 of the nations population it accounts for 11 of the National Medicaid spending but according to a 2014 report to medicare, the chip payment and access commissions using data from 2011 new york spent 44 more for medicaid enrollees on the national average. With fragmented funding streams making it difficult to provide adequate accounting controls for the program. A report from the hhs office of the inspector general, new york systematically overfilled federal taxpayers for Medicaid Services for the mentally disabled for 20 years. New york state Developmental Centers which are for treatment in housing for individuals, severe developmental disabilities, received 1. 5 million annually in 2009 for a total of 2. 3 billion. State centers compensated medicaid payment rates we 10 times higher than medicaid rates paid to develop mental centers. The simple question is how could these payments go unnoticed for 20 years. No financial incentive to police their systems in a way to result in significant decrease in federal funding. New york settle with hhs for 1. 63 billion from 2009 through 2011. The problem was remedied but the reality is the ratchet only goes one way. Congress superwoman clark pointeded out Governor Cuomo had success i noted in my testimony in bringing down the payment rate or growth rate for medicaid. Someone who had an are by their names suggesting what is effective for new york state a cap on growth for a disabled part of the program to be held to 30 effectively below the historical payment rate there would have been cries of poverty and throwing people out of the program. Miraculously new york state providers founways to decrease their spending by hundreds of millions of dollars. The belief significant flexibility or block grants would automatically mean less delivery ignored economist on the right and left center of the aisle that significant opportunities for efficiency in healthcare and until we get better programmatic and financial goals to seek out that efficiency we are not going to be getting the best outcome for every dollar we are spending on health. Being a new yorker, negotiated settlement did not reimburse the federal government for 20 years of egregious behavior which i believe is deliberate. Two times the national average, 20 straight years, this was not intentional. We talk about ours and ds, what if there was a d by the president s name and the governors name or settlement would have come closer to embers the us taxpayers. Another question about new york. The reason i the county executive, largest upstate county, one of a handful of states, have to pay a share. The counties pay 100 , state pays nothing. The case of erie county, the city of buffalo, 100 property taxes went to medicaid. We couldnt raise enough property tax to pay the county sheriff medicaid. It is supplemented with sales tax revenue. In a 2009 report new york state ranked last in affordable hospital admissions, last. Our outcomes are so poor, we have 20 seconds. Healthcare does not equate to better outcomes. If you look at state spending per enrollee it is all over the fat and outcomes are all over the map, increasing Research ConferenceHealth Behavior is not access to care or insurance dictating longterm health outcomes. Couldnt agree more there is no correlation between spending, thank you for your testimony. You are now recognized. Thank you, mister chairman. Our witnesses today, your extraordinary testimony is valuable. I want to focus on data and high risk which my understanding is 14 years running, medicated on your high risk list problem. What is behind that . It is because cms has not collected the right data to begin with . What is the nature of the partnership itself. Reviewing expenditures, expenditures have occurred, prevention ability is challenging. The second piece is about data. You simply cannot run a program this large when you cant tell where money is going ande we nd better data. If you made recommendations to cms to collect data, what is the issue . We have a report in a few days that might answer the question more slowly. Feel free to share it today. It has been focused on this, we follow the evolution of the national data, continue to push cms for when they think the data will be available for Program Integrity. One of the issues that came up is woodworking. Lets get to quality outcomes but offer that for a minute. There is an issue of woodworking. And my question is do we know that answer and getting reimbursed at a higher rate if paying for newly eligible rate, and those individuals were always eligible and should be compensated at a lower rate. Do we know any data surrounding that, have states been reimbursed at a higher rate at a lower rate i can tell you the id has the same question you do and we worked on their way to answer that question. Our state is pulling down reimbursement for eligible beneficiaries as if they were the newly eligible category and should have enrolled in medicare. That work will be forthcoming. You have a timeline when you might have answers . We have four states we are looking at, the next we do in the next couple months will be out in the other two later. I can if you give me a minute. We did issues that looked at this question and we did identify some issues and people were not accurately categorized the 100 match or state expansion a regular, and the recommendations still outstanding in this area has to do with the fact that cms adjusted eligibility differences that did not circle back and correct financing, we need to be related, a few ineligibility issues. Of the matching rate is up it should be at that. Could be a big number but it is important. We spent four years on Community Hospital board when the federal government decided to go after virtually every hospital and alleged billing this behavior going back eight between 9, ten years and the threat to the hospitals was we will use the statute because we engaged in criminal practice because of multiple cases, just strikes me that they were willing to do that, everybody had to settle because nobody wanted to go down that path. You know the government sometimes gets it wrong. What is happening with these states is a legitimate question when you have people who are disabled waiting to get on in a limited resource and we dont have the data. That is what you are telling me. We will have data. They are kentucky, california, new york and colorado. Your timeline again to conclude your analysis. The next month or two, the others are later this year. If we could do one thing for cms to do your job the way you want to do it what would that be . I hate to keep saying it but it has got to be the data. I would agree. Specific items, please get those to us and i will work with the incoming cms administrator and we will do our best to get you the data. It is important for all of us for decisionmaking. We got to get the waste and the fraud out. Thanks for your leadership. I want to ask Mister Howard, this relates to ways of saving money and medicaid. It has to do with payment models. Hospitals are paid to take care of the patient as opposed to feeforservice. Like paying a carpenter, put a lot of nails whereas an alternate payment model making calls to the patient who check up on medications, counsel them to keep them out of the emergency room, those approaches i am thinking linking with the medicaid amount, hhs estimates improper payments for medicaid, 30 billion in 2015, hovering around 10 . It will not result in Better Health outcomes as we tried before. What about alternative payment models as a way of saving the skin in the game. Doing all they can to keep the patients healthy. To understand the best provider, estimates for potentially 30 of care is an effective. They are doing terrific job that a fraction of the cost, hospitals across the street from other hospital providers, we have data transparency to encourage more Competition Among those across the payment models. Give us some information on how that works. A couple comments. The first thing, here is something we can agree on in a bipartisan way, getting the data you need. I will echo what Mister Walden said. Whatever specific questions let us know and i am assuming you need that staffing, that is the problem. I want to make a couple comments about the Medicaid Expansion. First of all a lot of people, i keep hearing people today, we want to make sure people have chronic and severe diseases, that is absolutely true, people talking ablebodied adults. I would point out 80 of the people heading the Medicaid Expansion. They might be ablebodied adults but if they had jobs, they were uninsured before because either their employers didnt offer insurance or because the insurance they could get was to the extent of, these people were going without health care which as Mister Westmoreland and others that increases the cost for everybody because of the cost of uncompensated care. I was just talking to this brooks about this, ways that we find efficiencies, all of us are for more efficiencies than delivering health care in a more costeffective way not just with medicaid but private insurance. And Medicaid Expansion, these people are, quote, ablebodied adults is not expanding who is getting it. I want to close with and email from my best friend from South High School in denver, colorado, we are not Spring Chickens anymore. Here is what my friend said to me a couple weeks ago. They sent it to me. I want to add my story to others hearing about the portable care act. I was laid off during the recession and lost a lot of retirement stability. At age 54 i looked for a job for three is without success. I had no Health Insurance which finally i fell back on my journalism skills and landed work writing for several neighborhood papers. This has worked out fine but only because getting insurance through the aca. I make modest honey and qualify for the expanded Medicaid Program. What a godsend. Too old for the job market, i dont know what i would do without this help. This is what we are talking about. We have to figure out how to get healthcare for the 11 to 12 Million People who have gotten healthcare because of the Medicaid Expansion. That is what we are talking about. That will bring to a conclusion this hearing, subcommittee oversight investigation was i think the witnesses and all members who participated in todays hearing and remind members ten Business Days to make requisitions, witnesses all agreed to respond. Thank you so much for being here. The subcommittee is adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations]