Good morning everyone. Welcome to the newly refurbished oversight investigation room. This is the first one of 115th congress. Welcome here and welcome our Witnesses Today. Welcome back to my friend and colleague. This is our medicaid oversight hearing on ways to strengthen the program. The Sub Committee convenes to examine patient and Affordable Care act. Medicaid and Medicaid Expansion. It provides Health Care Coverage for over 70 million americans and accounts for more than 15 of health dacare spending in th United States. The federal share and medicaid spending is expected to rise from 371 billion in 2016 to 624 billion in 2026, ten years. At a time when Medicaid Program costs are skyrocketing it makes sense to ask is it adequately serving our most vulnerable populations . 20 and 40 cents of value for each the government spends on their behalf. Further, reports by nonpartisan watchdogs, two of which are here today show that the Program Remains a target for waste, fraud and abuse. Because of the size and scale improper payments including payments or for services not provided are extremely high. For these reasons med dicaid ha been designated as a high risk program. Despite the longstanding problems the patient expanded medicaid to a whole new population. 32 states medicaid benefits have been opened up under the age of 65 and make less than 133 of the Poverty Level. Since open enrollment began in october 2013 roughly 11 million have signed up under the new eligibility per ram tam ters. It means they have enrolled instead of purchasing private health care. The costs have been far more expensive than predicted. A report found that the average cost of expansion was nearly 50 higher than projected. Medicaid expansion costs 6,366 in fiscal year 2015, which is 49 higher than the agency predicted the year prior. It means not only are expansions but the costs are difficult to predict. The vast majority of expenses. Unfortunately reports show states and federal government cannot effectively oversee Medicaid Expansion. The jail found determination that could lead to misspending of funds. They found troubling evidence that they failed to recommend requiremen requirements. We knowledged there are serious weaknesses and we recognize the responsibility of the federal government to previed a safety net. It means ensuring it is to help improve outcomes and serves the medicaid population. We want this to work, not hinder services. I hope we can support its strengths, knowledge problems and together find some solutions. Tomorrow the health Sub Committee will discuss to strengthen medicaid. As we move forward we must be careful not to repeat problems that already exist in the programs. We have a lot of work do. I would like to thank witnesses for appearing today. Thank you very much, mr. Chairman. It is good to be back for another session of congress. We have two new members on our side of the aisle this year. I am so happy to welcome them. Dr. Ruiz is here with us. He is an actual emergency room doctor. He will be able to bring us so much great perspective on issues like this hearing and other hearings. Scott peters who is not here at this moment, im pleased he is here. He and i comprised twothirds of the nyu law graduate to congress. Im happy we are loading up this committee with law grads. I think i would be deceiving myself if i thought todays hearing was intended to actually strengthen the Medicaid Program. I hope its not so. I fear that this discussion about medicaid is intended to lay the ground work for drastic cuts to the program and eventually to repeal the Affordable Care acts historic Medicaid Expansion. I would like to talk about what Medicaid Expansion has accolished for the American People. Today more than 70 million low income americans including sen kbr seniors have access to contrary to what they think it delivers this care efficiently and effectively. The cost per beneficiary are substantially lower than for private insurance and have been growing more slowly per beneficiary. It has shown it helped improve access to primary and Preventive Care and by helping americans manage and treat serious disease. In fact the Medicaid Program literally saves lives. Research reported that previous expansions for lowincome adults actually reduced deaths by 6. 1 . The acas historic Medicaid Expansion helped states build on this record of success and provide insurance to millions of americans who otherwise would not have had access to health care. Last year and we need to think about this. More than 12 million low income adults had Health Care Coverage because of the Medicaid Expansion. This is astonishing. Combined with other important provisions this has helped drive the uninsured rate to the lowest level in our country east his rhode island it history. It is not people that shifted from private insurance. This is people who had no insurance and were using Emergency Rooms as their primary care facilities. In colorado the rate of the uninsured was cut in half and through the expansion of medicaid. Aside from the benefits that have accrued to the people medicaid has actually resulted in tremendous savings from the states. They have seen their uncompensated care burden drop since the aca became law. Denver Health Medical center reported to my office their uncompensated care claims fell by 30 . This is real savings. Also we know that medicaid is helping people get access to Vital Health Care services. I had a listening session last week in denver about the aca. I had 200 people show up at this listening session. Most of the people who told their stories talked about how they were employed but they couldnt afford private insurance. Due to Medicaid Expansion they now had drug treatment services. They had services for catastrophic accidents they had had and on and on. It got to the point where i literally had to take a packet of kleenex out of my purse and put it on the podium because we were in tears listening to these story. This is what the majority wants to take away and this is what we are talking about. We can all talk about eliminating waste, fraud and abuse in the program. We are all for that. I would support that 100 . Taking away Vital Health Care for so many millions of americans is wrong. We must fight against taking that important benefit away. I yield back. You yield back and we dont have anybody else on our side that wants to give an Opening Statement. I think mr. Walden will come back later. Thank you. It is great to be back in our room here today. It looks really nice. For seven years now Congressional Republicans have railed against the Affordable Care act with a city drum beat of repeal and replace. For seven years they sabotaged implementation of the law. Republicans are misleading the public with falsehoods that the law is failing. It could not be further from the truth. The truth is after seven years of claiming they could do better they have no lan. The Sub Committee should be evaluating how it would impact the people. They are holding another hearing to highlight ongoing opposition to the Medicaid Expansion despite evidence it has made it affordable and available for the first time to 12 Million People nationwide. Tomorrow and thursday they are Holding Hearings on what republicans consider the first pieces of the Gop Health Care replacement plan. The fact is none of these bills will prevent 30 million from losing Health Care Coverage. None will reduce chaos in Health Care System that will result in republicans successfully appeal. Republicans are creating instability in the individual market. This will ultimately result in higher premiums and will endanger health and welfare of americans. The republican made chaos has already begun. Of course we are seeing the same thing but the president S Immigration executive orders, i just hope that at some point our gop colleagues join us against what i consider reckless actions and oppose President Trumps actions. Congressional continue to ask them to trust them and they have a plan that some how everything will be okay. They repeatedly assured the American Public no one will lose covera coverage, a claim they also continue to make. Recently released audio at a closed door meeting from the republican retreat last week confirms they simply have no plan. At that meeting republicans admitted repealing the Affordable Care act could we vis rate coverage now covered through state and federal marketplaces as bewell as thoug covered under medicaid expans n expansion. One said we better be prepared to live with the market we created. They tried to claim it is already collapsing under its own weight and it will rescue the American People from obamacare. It could not be further from the truth. Americans today have Better Health coverage and Health Care Thanks to the Affordable Health care act. It helped improve the quality and affordability of millions of health care. If they took blinders off they should realize they should not be repealed. I say this because i dont care about the idealology. The fact of the matter is real people will be harmed. I hope at some point my republican colleagues will admit that and we can Work Together to improve the Health Care System. I yield back. I want to ask consent that the members Opening Statements be introduced into the record and other documents be entered into the record. Now to introduce five witnesses for todays hearing. We have caroline yolkham. We welcome ann maxwell next we want to welcome mr. Paul howard who is senior fellow and director of Health Policy at Manhattan Institute as well as josh last we welcome Timothy Westmoreland welcome to all of you. Thank you to all of our witnesses for being here today. Look forward to hearing from you on this important issue. Youre aware they are holding a hearing and when doing so has the practice of taking testimony under oath. Do you desire to be advised by council . If you would please rise and raise your right hand ill swear you in. Do you swear the testimony youre about to give will be the truth, the whole truth and nothing but the truth . You have all answered the affirmative title 18 section 1001 of the United States code. I will call upon you each to give a five minute summary. Is there lights that will go on for them when they are well see. Is there something in front of you . Green means keep talking. Yellow finish up and red means stop. Chairman murphy and members of the Sub Committee, its a pleasure to be here today to discuss actions. Medicaid finances health care for a diverse population including children, adults, people who are elderly and those with disabilities. It offers a comprehensive acute and longterm Health Care Services. Medicaid is one of the largest programs in the federal gubudge. In fiscal year 2016 medicaid covered about 70 Million People and federal expenditures were expected to total about 363 billion. Unfortunately over 10 of these expenditures, over 36 billion, are estimated to be improper. That is made for treatments or services that were not covered by the program or not medically necessary or were never provided. The program size and diversity make a particularly medicaid is a federal state partnership and it states is the first line of defense. They have responsibility for screening providers and referring inspected cases of fraud and abuse. At the federal level they state Program Integrity efforts. In 2010 the Patient Protection and affordable gave states additional provider oversight tools. The act provided millions of low income americans new options for obtaining Health Care Coverage through an exchange. A marketplace may compare and Purchase Health insurance. My Statement Today focuses on four key maedicaid issues we hae identified, steps they have taken and the related challenges they continue to face. First, with regard to ensuring only eligible individuals are enrolled they have taken a variety of steps to make it more data driven yet gaps exist to ensure the accuracy of federal and state enrollment efforts indeluding enrollment for those as a result of the expansion. As one example we found federal and selected market base approved federal Health Insurance coverage for nine of 12 fictitious applications during the special enrollment period. Efforts to improve oversight cms provided states with more guidance of methods of identifying improper payments and hasnt acted in response to recommendations on requirements for states to audit managed Care Organizations and providing states with additional audit support. Further actions are needed, in particular data which allows them to track Services Received by beneficiaries that are enrolled in managed care and are not always timely or reliable. Third, cms has taken steps to strengthen the screening of providers. There are new risk based initiatives. These are important steps. There are additional challenges that remain to ensure that the databases check eligibility and states share information with each other our work identified some duplicate coverage and started conducting and intends to perform at least two times per separate year. Cms need to develop this plan more broadly and make sure they are accessing the sufficiency of these checks. Medicaid is an important form of health care. Its longterm sustain blt requires state oversight. Members of the committee, this concludes my prepared statement. I would be pleased to respond to questions. Thank you. Good morning. Thank you for the opportunity to appear before you today to discuss how to protect taxpayers and medicare patients from fraud, waste and abuse. I wanted to give you a sense of what it looks like. It can include very different kinds of schemes. For example, in one instance we indicted the owners of a network of over 30 networks that billed for sources patients didnt need. Expensive drugs were sold in the black market or billed for medicaid. It is these types of schemes that highlight medicaid against providers who steal at the expense of taxpayers and put patients at risk. Today awant to highlight actions that we can take to better protect medicaid from these types of fraud schemes and others facing medicaid. Agencies and centers for medicare and medicaid share responsibility for funding as well as protecting medicaid. We recommend they focus on three straightforward Program Integrity principals, prevent, detect and enforce. First and foremost cms must pro vent fraud, waste and abuse. Medicaid some times fall short and end up chasing of providers or to recover overpayments. They should know who they are doing business with before they give the green light to start billing. To help with that we recommend states fully implement criminal background checks and collect accurate data about providers. In addition we recommend states learn from past administrative errors to prevent improper payments. Medicaid should only be paying the right amount for the right service accurate data is an essential tool for doing this. As we have just heard National Medicaid data including data from managed Care Companies has deficiencies. Further, states cannot see the whole picture. For example, we found providers enrolled in one state Medicaid Program that have been terminated by another state without shared data states had no way of knowing this and had to find out the hard way they had enrolled fraudulent providers. Finally, its impairtive to take swift and appropriate enforcement action to correct problems as well as to pro ve prevent future harm. On thousands of wrong doers each year. However states face challenges in taking full advantage of administrative authorities including suspended provider payments. In addition it lacked a key authority. Currently these units can of patient abuse that occur within institutions. If that took place in a patients home or Different Community setting they cannot. Medicaid patients receiving services in their home should have as many protections as though in institutions. In particular a heightened focus on Program Integrity principals of prevention, detection and enforcement will help protect now and as it evolves. It will ensure medicaid funds are used as intended to provide needed Health Care Services and longterm nursing home repair for those who are in most need. We appreciate the attention. We have seen it strengthened in the last year thanks to the efforts here in congress and we hope that our work will continue to be a catalyst for continued positive change. Thank you. Thank you. Thank you. Thank you. Medicaids undoubtedly of the safety net for low income populations. An openended formula has had vast fiscal consequences for the state and federal government often crowding out funding for other Safety Net Services and supports it might have a bigger impact on the measured health of these populations and their prospects for continued economic mobility. As you know, medicaid is a hybrid program that pays approximately 62 through the federal match although the upper limit is around 80 and the lowest match is 50 . It encourages states to maximize the draw down of federal dollars through a number of some times legally questioning funding designs it makes it difficult to oversee integ tiff. It encouraging wealthier states to draw down more federal dollars. Mark pauly highlighted the states spent 90 more than the lowe lowest. When it comes to waste, fraud and abuse we see new york state which has spent much more than other states it has spent approximately and spends 44 more per enrollee. Over a period of 20 years the state had an improper payment rate for statement developmental centers. It was overpaid by 16 billion because of payment structure that agreed to was never updated to reflect that the state had in fact moved the disabled into community supports. To the States Credit created a redesign team that began first by con seeding that the program for beneficiaries and taxpayers. Since then through a number of highly aggressive reforms including capping most of the state spending outside of the population, lowering that from 6. 2 to 4 it saved hundred of millions of dollars and begun to address behavioral components of poor health that lead these to Emergency Rooms. The right way to view our Health Care Dollars is not to say that medicaid has per unit cost that are very low unless its more proficient. The question is might they be better purposed to other programs Supportive Housing for the seriously mental ill or any other support or service that might have a bigger impact on improving measured health outcomes. We put out a very important study that noted from the period of 1975 to 2012 our spending on low income supports had doubled but 90 of the increase had gone to health care. He estimated that if our median spee spending either by enrollment was nationalized we could save as much as 100 billion annually and could be placed elsewhere in other programs. In short we have thickened one strand of our safety net alone while neglecting others. If it feels thread bear in places it is because we encounselore encouraged states to overspend on health care. Im not saying medicaid has no value. It has an extraordinary return of rate on Maternal Health and child health. Large experiments have shown no increase in measured health outcomes. Other studies that the social determinants of health have a much bigger impact on mortality, obesity, asthma, and mortality from cancers like lung cancer than simply spending more money on Health Insurance per se. Id like to address a few ways we can address this disparity in conclusion. We should agree ofrn broader safety net goals that hold the states responsible for meeting them in ways that are transparent to the states and the federal government. We should reform the financing incentives of the program to make sure were not Incentivizing States to automatically funnel additional federal dollars to health care. They might choose to do so but we shouldnt effectively bribe them to do so. And finally cms should continue to give more leeway to the states in programming, designing, and spending medicaid dollars including on nonhealth supports. I believe that these reforms would serve both conservative and liberal ends and should be the focus of the 115th congress. Thank you very much. Thank you, mr. Howard. Mr. Archambault, youre recognized for five minutes. My name is josh archambault, i work at the foundation for government accountability. A think tank active in 37 states specializing in health and welfare reform. Id like to note how the acas expansion has worsened problems for the truly needy. And id like to start with a video. For nearly her entire life shes one of thousands on a waiting list that state leaders are looking for ways to trim. Tonight jason peters shares some ideas. Jason. A year ago Schuyler Overman was given nine months to live. The rare prognosis after a lifetime of difficulty racked by a rare neurological condition. She requires 24 hour care. Im in bed right after her, people dont understand how much care they need but also dont understand how worth it it is. Take care of her and having her in my life has been the best part of my life. Parents like lindsay cant just call a babysitter, and specialized care is expensive. A medicaid waiver would help pay for that. Over 4,000 arkansas families have one. Nearly 3,000 families including the overmans are waiting for one. And its a long wait. Shes still 670s. Shes moved less than ten spots in nine years. Thats the sad fact, at the rate its going there are people that will die before they get to receive their services. Sadly skylers story represents just one of nearly 600,000 individuals currently sitting on waiting lists for medicaid services. Individuals with developmental disabilities, traumatic brain injuries, Mental Health disorders who are less likely to receive the needed care now that medicaid has been expanded. The aca expanded medicaid to a brand new population, which consists largely of childless ablebodied adults who are working age and have only dimmed the hopes further for families like skyler. But the problems go much farther beyond situations like hers. The governor of arkansas due toex pangs costo expansion costs has proposed nearly a billion dollars in cuts to traditional medicaid, primarily from patients with expensive medical needs, the developmentally disabled and the mentally ill is what he said. So why is this happening around the country . The new obamacare expansion population is awarded a higher match rate. This funding formula has pernicious unintended consequenc consequences. If a state needs to balance a budget which they all need to every year state officials have to turn to medicaid because its the biggest line item. Also growing faster than revenue. If you want to save one state dollar in state funds on average you need to cut just over 2 from the traditional medicaid population, the aged, the blind, the disabled, pregnant women and children. But if they want to save the same 1 in state funds for the expansion population this year they need to cut 20. I know you all can guess who faces cuts first, and its heartbreaking. Overenrollment under obamas Medicaid Expansion will encourage states into even deeper cuts. Data has shown enrollment has been more than double initial estimates. The cost overruns have been significant. Just to name a few. California found themselves 222 over budget. Ohio 4. 7 billion or 87 over budget. These enrollment and Budget Trends mean fewer resources for the truly needy. Now, history could have warned us of this. Arizona and maine both expanded medicaid to the same ablebodied childless Adult Population before the aca, and both had to make measures to rein in costs. Arizona had to stop a number of organ transplants. Maine capped enrollment, created wait lists. This happened even without the lopsided extra funds that follow expansion enrollees. Which brings me to my last point. Concerns over eligibility issues. Fgas work around the country has found deep systemic problems. First, states need to be checking eligibility far more frequently. And second, states need to be checking more data when they check eligibility. Life changes such as moving out of state, getting a raise, or death or going unnoticed for far too long and meanwhile states continue to cut checks to managed Care Companies for cases that no longer qualify for the program. My written testimony highlights a couple of those states that have had bipartisan success in tackling this waist and fraud but much more is needed. Thank you. Thank you. And i recognize mr. Westmoreland for five minutes. Mr. Murphy, ms. Degette and members of the committee subcommittee, thank you for the invitation to speak today. I take a back seat to no one on Program Integrity issues in the Medicaid Program. People who care about federal programs have to work tone sure that federal funds are well used. Program integrity problems are, however, not new. Military contractors cheated the union army during the civil war. Where money is being spent, whether it be private, state, or federal, and no matter how good the cause, there are bad actors trying to steal it. Program integrity efforts are especially important in medicaid. This is because billions of dollars are at stake as are the health and wellbeing of the most Vulnerable People in america. This importance is well illustrated by the fact that at the same time the aca expanded medicaid coverage. Also made significant improvement in Program Integrity efforts. But as pofrnlt as combating fraud and abuse in medicaid is, policy makers should keep it in perspective. As big as they are, the numbers must be viewed as what they are and as a whole. First, we should be careful about our terms. Not all of what is labeled improper payments in the vernacular is fraud or even mistaken. Most are appropriate but simply badly documented and may even be underpayments. And the actual loss to the government is much smaller than it may appear. The oig and the gao footnotes in my testimony cite to this terminology. By as the prepared statements of gao and oig witnesses at todays hearing have outlined, hhs has already implemented many efforts to address the more Serious Problems of Program Integrity. Some of these efforts are longstanding and some of them are just under way. But there are many efforts focused on making sure that medicaid is spending its money well and they are having an effect. But im especially concerned today that policy makers often respond to waist, fraud, and abuse with blunt instruments aimed at the wrong targets. Any review of the actual Medicaid Program dollars that were stolen or misspent will reveal that the major culprits are unscrupulous providers. Pharmaceutical companies that price gouge. Equipment suppliers that dont deliver. And medicaid mills of doctors and clinics that provide Unnecessary Services if they provide services at all. But all too frequently the political and legislative response is to institute cuts or restrictions on beneficiaries and the providers that care for them. Theres simple nothing in the recent reviews of Program Integrity that justify the policy proposals that are now on the table and before this committee reduced, capped federal funding does nothing to improve Program Integrity but it does shift the cost to states, localities, providers, and charities. This is wrong. Program integrity problems are meaningful only when theyre considered in the context of the many successes of the Medicaid Program. For example, the Medicaid Expansion of the aca means that 11 Million People have medicaid coverage who did not have it three years ago. The merge of people without insurance in america is at an alltime low of 8. 9 . The burden of uninsured care in hospitals and expansion states is down 39 and costs to those states are commensurately lower. Rural hospitals in expansion states are at half the risk of closure of those in nonexpansion states. Community Health Centers are seeing 40 more patients. People are serious Mental Illnesses are 30 more likely to receive services in the expansion states. Services for opioid addiction are available to workingage adults often for the first time. The Medicaid Expansion of the aca has fundamentally repaired longstanding mistake in the program. People always had to fit in some sort of category but this category has never made sense. Poor women need Health Insurance both before and after they have babies. Poor children keep needing Health Insurance even when they turn 19. Poor people with chronic illnesses need Health Insurance before they become disabled. Poor older adults need Health Insurance when theyre 64, not suddenly when theyre 65. The real problems here are poverty and uninsurance. In the 32 states that have adopted the Medicaid Expansion where making this part of the insurance system finally makes sense and be fair for Vulnerable People. Please done turn back this response. Lincoln did not give up on the civil war because the government was sold bad mules. We do not stop buying drugs because drugmakers charge fraudulent prices. We punish the wrongdoers, correct the price and get the treatment to the people in need. That is what should be done here. Dont reverse all this progress by rationalizing the Program Integrity problems demand wholesale legislative changes in medicaid. There are real babies in that bathwater. Thank you. Thank you. And now i recognize myself for five minutes of questioning. Ms. Yocom. Your october 2015 report found gaps that limit cmss ability to check for different eligibility groups. Newly eligible under expansion the newly eligible under expansion and previously eligible are appropriately matched with federal funds. In the federal facilitated Exchange States cms will not be able to assess the accuracy of el jiblt determinations until 2018. Does this create the potential for improper payments . Well, it certainly creates a lot of uncertainty about what is going on with eligibility and whether progress is being made. The decision to suspend the estimate of eligibility was based on trying to give states time to understand the new rules and new range of matching rates that could be applied. From our perspective, though, transparency is a process and how it is proceeding would not be a bad thing. It would be good to know whats going on. Okay. Thank you. In states that determine eligibility gao found eight of the nine states audited identified eligibility determination errors. Are those errors reflected in the cms eligibility determination error rates and does cms correct these errors . Why or why not . Right now they are not reflected in the eligibility rate estimates that cms puts out. Instead there is a rate produced a couple years ago of 3. 1 and thats being applied until 2018. Why is it applied till 2018 . Im not sure the reasoning for that year. I think time i guess. Is that an accurate number . You said is it an accurate number thats being applied . Its a number that goes back to 2013 or 2014. Just continuing that on. So this relates to my networks question. Ive heard that cms has put a freeze on measuring eligibility determinations for medicaid. What does this freeze mean and how will we measure eligibility errors and improper payments . It means were relying on an error rate thats about three or four years old and that we dont right now know whats going on with the eligibility determinations. Were using old data thats not accurate anymore . Were asking a question, whats the error rate . We dont know, were going to use a number from a few years ago . If a parent asked their child how are you doing on your report card and you said got all as, could be accurate. Except maybe youre dealing Way High School senior you that didnt ask specifically. Id just assume the grades i got in third grade im continuing to carry over year to year, so im the valedictorian. That doesnt make sense of course. But youre saying thats what plies here . Right now they are not publishing or i believe even calculating an improper payment rate right now. They are working with the states on a state by state basis. So when people make a statement everythings fine, they seem pretty stable, we just have inaccurate data were working with. See, we want to fix this. But we dont have accurate data to help us know how big the problem is. Is that correct . At this point we dont know. Mr. Archambault, since we cant measure the eligibility improper payments due to the freeze imposed by the administration lets get an idea of the types of errors and how much they cost the federal government. Do you have any examples from your work of eligibility determinations and how that translates to improper spending . Sure. Theres a couple of states that i highlight in my written testimony. In illinois in 2012 they passed a law to hire an outside thirdparty vendor to look at eligibility errors and their track record has actually been quite impressive p in the first year they found about 300,000 individuals who arent eligible for medicaid. In the second year they found 400,000 individuals who were ineligible for their program. And it runs the gamus from individuals who had passed away in the 1980s who were still in the program to individuals simply moving out of state, got a raise, didnt report that information. State of arkansas recently also did a review of their Medicaid Program and found things like 43,000 individuals who didnt live in the state who remained on the Medicaid Program. 7,000 who had never lived in the state. Are those people who are making medicaid claims, do we know . So in many cases this is why its so important. As states have moved toward a managed care environment, it almost doesnt matter. States continue to cut a check to managed Care Companies regardless of whether those individuals are showing up to the doctor or not. Thats why this is even more important now as states have moved in that direction. Its hundreds of thousands of people are in this category that theyre still getting paid even though theyre not alive in the state or getting care . Correct. In some cases its just waste. We want to make sure two states arent paying two different managed Care Companies for their care. In other cases its outright fraud. Do we have a total dollar value for that . When youre not measuring, its very hard to see, but i will say that my written testimony goes through and documents a number of state audits that show eligibility is a huge issue when it comes to applications. My time has expired. Miss degette, five minutes. Thank you, mr. Chairman. Miss maxwell, you talk about the complex investigations that your is undertaking into some of these medicaid fraud issues. These investigations involve large numbers of personnel and also technical support, is that right . Complex investigations. Absolutely. We partner with the state medicaid Fraud Control units. Do you know approximately how many people at your agency are involved in these investigations . In some respects we all are. Even though the Inspector General has a cadre of inspectors were also auditors, evaluators, lawyers and all of us contribute to the fraudfighting efforts of the Inspector Generals office. Are you familiar with the executive order that President Trump issued on january 22nd in which he said that no vacant positions existing at noon on january 22nd, 2017 may be failed and no new positions may be created except in limited circumstances . I am familiar with that. Has your agency determined, will that freeze the hiring at your agency . Given that its quite new, there hasnt been an assessment yet of how that will affect the oig, but i can tell you as you have pointed out, that the work that we do does rely on personnel. We use sophisticated data analytics. Let me stop you, then. If the personnel at your agency, the hiring was frozen, what would that do to your ongoing fraud investigations . We would need to double down and do as much as we could with the resources that we have. Would it impact those investigation pz . Absolutely. We need the personnel to analyze the data in order to fight fraud most effectively. Thank you. Now, i wanted to ask you a quick question, mr. Archambault. And the question i wanted to ask you, you showed that really heartrending tape about the young girl who was on a waiting list for quite some length of time for the care she needed. She was in arkansas, is that correct . And the governors of the states decide whether theyre going to use that money for cases like that or other they decide how theyre going to use the medicaid money that comes to their states, isnt that correct . Within limits. I mean, the federal government sets the guidelines by which but the governor of arkansas decided where that money would be spent, decided not to put it into that kind of a program, is that right . The question and point im trying to make my questions yes or no. The governor decided they have funds that come in and they can and thats the governor. In a nonexpansion state we have seen states buy down their wait list. Thank you very much. Yes or no would have worked. I want to ask you, mr. Westmoreland, a xum questions. Uncompensated care costs are what hospitals pay for patients that cannot pay their bills, is that correct . Yes. Who bears the cost of uncompensated care . Its a complicated question. But the direct costs are usually borne by state and municipal governments because they pay for public general and who where do they get their money from . By and large they get their money from taxpayers. I talked in my Opening Statement about how the aca Medicaid Expansion is driving uncompensated care costs lower. Can you briefly explain why thats correct . Yes. If a hospital is dealing with people who have no source of insurance, it by and large can provide the services and then chase them down and people oftentimes have no more or declare bankruptcy. In the instance in which theyre insured either through the exchanges or the Medicaid Program the hospital can turn to a Third Party Payer and theyre no longer uncompensated care. They can get . Payment from those insurance. Now, some of the states that did not expand the medicaid component of the aca have not experienced a larger reduction in uncompensated care costs, is that correct . Yes. And why is that . Those states are still dealing with the same number of people with no Health Insurance who are low income. They turned to the in the Medicaid Expansion situation largely paid for by the federal government. Great. Thank you. I yield back. The gentle lady yields back. And now recognize mr. Barton for five minutes. Thank you, mr. Chairman. Im glad to be part of the first oversight hearing. Im glad we have some new blood on the subcommittee. We have a new doctor on the democratic side. Were glad to have him. We have dr. Burgess on our side. So when the bloodletting begins we have two doctors that can take caver us and keep us going. I want to focus the panels attention on a few numbers. First number is 20 trillion. Second number is 325 million. Our National Debt ps 20 trillion, give or take a trillion or two. We have around 325 million americans. If you divide 325 million into 20 trillion you get about 67 70 million covered by medicaid. You subtract the 70 Million People covered by medicaid from the 325 million that are citizens it means there are 250 million americans that owe not only their share of the National Debt but also the 66,000, 67,000 times 70 million that the medicaid recipients owe because by definition medicaid recipients are below the Poverty Level and they cant pay it back. Those are big numbers. Were spending at the federal level about 350 billion a year and the states are adding another 150 billion. So were spending about 500 billion a year to provide health care for lowincome americans. That may or may not be sustainable. But we know that we cant sustain adding half a trillion to a trillion dollars every year to the National Debt. We all want to keep medicaid. But we want to improve it. And thats what this oversight subcommittee is looking at. How do we improve medicaid so that we get more bang for the buck, Real Health Care to real people that need it, and yet make it affordable sought the taxpayers who are funding it can continue to fund it . Mr. Howard, you talked about in your Opening Statement a little bit about new york with 6 of the population getting 11 of the medicaid dollars. You want to explain to the subcommittee why thats so or would you like for me to explain it . Thank you, congressman. There is clearly an incentive given the openended federal match for wealthier states both because of ideology and simply because they have a Larger Tax Base to draw down more federal dollars. It also inhibits attempts to pursue Program Efficiency when you think of a state like new york. Lets say new york wanted to design a more efficient primary care program that saved a million dollars. Because of the 50 federal match it would have to cut spending by 2 million. So theres a ratchet inherent in the openended federal match that tends to bid up state spending for the states that have the funds to do it but makes it very hard to turn the ratchet around and correct it and find more efficient ways to deliver care. And i think thats the recipe for fixing the nation and not just for private insurance or medicaid as well. In an environment where theres no incentive for providers to look excuse me. Outside the box. In new ways to deliver care more efficiently, more cost effectively, they simply dont pursue those areas. I think some of the changes that Governor Cuomo has instituted in new york, if they were done by a Republican Administration i think we would have heard howls of outrage but because it is a Democratic Administration you capped spending, you ended automatic payment increases, you did a lot of things that are very, quote unquote, progressive but are really nonpartisan ways to improve Program Efficiency and i think other states and the federal government should look at ways to give states more federal efficiency and government incentives. Do you think it would be appropriate to look at the way the formula allocates medicaid dollars per state to try to harmonize it with current lowincome populations across the nation. I think thats important. I think states would also really appreciate the opportunity to be able to spend medicaid dollars on nonhealthrelated supports that might actually, you know, in terms of accessing transportation, in terms of accessing other services, that might make those populations both more compliant with care and more effective in the long term. My times about to expire. Im going to have some questions for the record dealing with block granting programs back to the states. I do want to welcome mr. Westmoreland back to the committee. Nobody has admitted it but at one point in time he was one of the brain trusts on the Minority Side and helped mr. Waxman and mr. Dingell actually create the Affordable Care act. And we appreciate your expertise coming to bat before the committee. Its nice to be back in 2123. I yield back. Now we go to mr. Pallone. Mr. Westmoreland, mr. Archambault made some claims illustrated with a video regarding one individuals experience specifically with the arkansas Medicaid Programs communitybased services waiting list. And im concerned that mr. Archambaults testimony attributed a causal relationship between Medicaid Expansion and hcbs waiting lists and that somehow the Medicaid Expansion he claims exacerbates or causes these waiting lists, i dont believe that to be true. I dont think that the facts show that its true. I think that wait lists are a result of state decisions and cutting or capping or block granting medicaid will only make the situation worse. I like to use anecdotes. I remember one year i went to a conference a couple years ago in houston with mr. Green. I think mr. Burgess was there too. And in between the Health Conference i went over to the texas Childrens Hospital at the Medical Center and i talked to the officials there and it was a beautiful place with this beautiful lobby but literally people, particularly mothers with their children, were just literally camped out in the lobby of this place that looked like a hotel. And i asked why are they all here . Because they couldnt access the emergency room because there were so many people that they were literally waiting for hours to use the emergency room with their kids. So you know, this notion that somehow the Medicaid Expansion is causing the waiting lists, i think its just the opposite. I think that its the lack of Medicaid Expansion in these states thats causing the problems in most situations. In any case, let me just ask you some questions, mr. Westmoreland. Can you provide some background on the hcbs waivers in the Medicaid Program . Isnt it the case that deciding to have an hcbs waiting list is a direct result of state choices on the design of their Medicaid Programs and the amount of resources states make available to provide hcbs . Yes, theres no restriction at the federal level of how much a state may turn to hcbs instead of to traditional institutional services. Its a state decision. So if i can just summarize, states decide whether to limit their hcbs waivers couldto a defined number of slots and create waiting lists once those slots are filled. And cms allows states to increase or decrease the number of slots as they wish. And isnt it actually true that in the case of arkansas the federal government will be willing to pay 69 of the cost of care if the state chose into crease the number of its slots and that until january 1st this year the state was spending none of its own funds on the expansion population . I have to admit i dont know the specifics of the last part of your question, but other than that i would say yes. Its entirely a state decision. And arkansas has made the decision of the size of the waiver. And isnt it also true that 12 states and the district of columbia have no wathd lists at all and that the overwhelming majority of those states that have no waiting lists have also expanded medicaid . I believe so, yes, sir. Isnt it also true that the two states with the longest waiting lists are texas and flori florida, which have not expanded medicaid . Of course i use my example, my anecdotal evidence there at the Childrens Hospital at the texas Medical Center. But these are the two states that have the longest waiting list. I know that texas and florida have not expanded. I did not know that they were the longest waiting list. I know that they have waiting lists. I mean, my problem is that i just think theres no evidence that states are choosing to expand medicaid or keep their expansions at the expense of Vulnerable People waiting for hcbs and examining state choices on both expansion and hcbs waivers actually leads to a contrary conclusion. If anything all the expansion dollars only strengthen the arkansas economy and revenues, improfit finances of providers by reducing uncompensated care as has been shown in multiple states around the nation. And i dont think its just i think it just makes basic sense. If states expand medicaid, theyre getting 100 federal dollars and they have a lot more money to care for people. Its only going to be natural that they have more money to spend on people who are eligible. So this notion that somehow by cutting the expansion, eliminating the expansion, theres no way in the world thats going to help the situation with people, you know, who are trying to seek care. Theyre just going to end up in the emergency room. Theyre going to be waiting for the mefrnlgs room. Theyre not going to get preventative care. Theyre not going to see a doctor. None of it makes sense. But if you wanted to comment. If i may, mr. Pallone, id like to juxtapose your comment with that of chairman barton who points out that possibly there will be proposals to block grant and cap the federal funding. And i have to say that if the congress adapts capped funding for medicaid, were going to see more, not fewer waiting lists. Less funding and the loss of the individual Entitlement Services is exactly whats underlying the story in that video. And if the program is capped, federal participation is limited, it will only get worse, not better. Thank you. Now i recognize the new vice chairman of the committee, mr. Griffith of virginia. Thank you, mr. Chairman. Mr. Archambault, get out your money. You ready . So my understanding of your testimony was that you were in fact saying that the states have to make choices with their limited resources and that the federal government under the aca is going to lower its Medicaid Expansion money down to 90 as states find themselves with larger burdens than was anticipated when they expanded medicaid. They have to make decisions on where its cut. And we have created through the aca, and i say we loosely because i wasnt here when they voted on, that but the congress and the government created a situation where the states are rewarded for cutting traditional medicaid, which deals mostly with children and people who are in greater need and that because of that disincentive or that incentive to spend it on the new folks, the newly founder medicaid, under the new categories we create the situation where states are having to make a decision as to whether they quicken the shortage on their the waivers, get rid of those waivers as fast as they can or whether they spend that money somewhere else. Was my uning correct . Correct, congressman. Theres both direct and indirect outcomes as related to expansion. And my point is we are not fulfilling the promises to the most vulnerable in our society. Wait also or not. We are making new promises to an ablebodied population that does not qualify for longterm Welfare Benefits in any other place and states are being put in a situation where theyre having to make very tough decisions in making cuts in reimbursements rates that directly impact those with disabilities, those in nursing homes. The access and quality questions that have surrounded medicaid for decades will only get worse for the truly needy. And so what youre saying is we need to Pay Attention to that and we need to make sure we have incentives that encourage people to take care of the truly needy and the young and maybe the new group we need to refigure that formula out. Is that what youre saying . Absolutely. I think as part of the repeal and replace discussion as were talking about changing medicaid Going Forward it absolutely must be on the table and we would strongly recommend looking at freezing and new enrollment in expansion states and not allowing other states to expand so you can address this underlying issue of refocusing programs on the truly we have a real habit of doing that. Mr. Howard im going to ask you and the reason i said get your money out, i thought the 20 versus 2 was very instructive, mr. Archambault. You touched on this but we didnt get into details. We have situations where even in traditional medicaid we have rewarded states that play games. Virginia elected not to have a sick tax. Thats what it was called when there was a proposal to start taxing the beds of the sick so that they could create that money and then put it into medicaid and then get matching money from the federal government even though with a fairly low match that would have given us those 2 from money that we collected from sick people. But many states have come up with these various schemes to get money by claiming that theyre charging more and then what theyre really doing is creating some kind of a sick tax scheme. Shouldnt we put a stop to that . Over time. Shouldnt we over time be trieth to get rid of that so Everybody Knows what exactly theyre getting and not having to charge sick people money so we can get more money from medicaid . The federal government has capped the amount of provider taxes that states are able to use, but still were talking a very significant amount of money. I think the last estimate from gao was about 25 billion. Many states use these provider taxes, they use enhanced payment rates for stateowned facilities, intergovernmental transfers to draw down and raise their effective federal match. While they may be legal there are some real ethical questions. Absolutely. I want to move on to something else. Heard somebody earlier say that obamacare wasnt collapsing and that was some myth. Weve got all kinds of numbers. 25 average increase nearly a third of u. S. Counties have only one insurer. Trillion dollars in new tax, 4. 8 7 million americans are had to change their Health Care Plan because they got kicked off of the plan they liked, all kinds of problems out there. But you know what i find instructive is anecdotal. Happened to me yesterday twice. After a church group of us generally go to lunch i try to stay out of politics at lunch and a discussion broke out at the other end of the tabl i was not involved in where they with talking about what do we do as we go forward . And one fellow said look, as a christian i dont mind paying some more money but when my insurance rates for my family have gone from 450, 500 to 1250 a year and im getting less insurance its hurting my family and thats a problem. Later that evening in a Small Group Gathering of different people there was a big discussion about whether or not they could a family could afford to justify spending money for their daughter who had the flu, several families had been ravaged by flu over the last couple weeks because in order to afford Health Insurance theyd gotten such a high deductible it was going to cost them 75 to get tamiflu. And they were dedicate whether or not they should do that if their other kids got it and what they should do is go forward. These are reallife examples of how obamacare is in fact failing the American People. I yield back. Gentleman yields back. Now recognize ms. Castor for five minutes. Thank you, mr. Chairman. Well, thank goodness for medicaid in america, especially back home in florida. 3. 6 million floridians rely on medicaid for their health services. A lot of my neighbors in skilled nursing, alzheimers patients, medicaid is the lifeline for these families. Not to mention 50 of children in florida rely on medicaid to go see the pediatrician and get their checkups along with the state childrens Health Insurance program. Florida didnt expand medicaid. So that 3. 6 million number are really our neighbors in a nursing home or communitybased care or children or my neighbors with disabilities. And based upon what they tell me, medicaid is working for them. It works. Medicaid spending growth is lower than private Health Insurance. Its lower than medicare. Thats because sometimes states try to get by on the cheap in paying providers. Thats one place in can reform we could improve access if we could pay our providers a little bit more and do better there. Medicaid is flexible. Ive watched in florida as theyve moved to a managed care system. I have questions about that. But that was a decision of the state. They have all that flexibility under medicaid. They also began a change toward more home and communitybased services to help keep older folks out of skilled nursing, which can be very expensive. But then we have to remain mindful about the fiscal cost and fiscal responsibility. Thats why in the Affordable Care act we passed a lot of new Program Integrity provisions to improve medicaid. One change is moving tie preventative approach by keeping fraudulent suppliers out of the program before they can commit fraud. All must be screened upon enrollment and revalidated every five years. Think about that as you move toward repeal of the Affordable Care act. Why would we want to repeal these important Program Integrity provisions relating to medicaid . I dont think thats the path that we all want to go down. What this is, though, i think the real fear is that this whole terminology of block grants and per capita caps is simply a stalking horse for less care for my neighbors back in fluor and all americans. For all alzheimers patients, for every child that needs to go see the pediatrician. I want folks to be aware what block grants and per capita caps mean because it sounds good. But what that means is devastation and sabotage to the Medicaid Program. Mr. Westmoreland, describe the impact on the delivery of Health Care Services to americans if this approach is taken, block grants and per capita caps. He. As i understand some of the proposals that are made, the basic point is to limit federal participation and the state costs of running the Medicaid Program. As Health Care Costs grow over time, the states will be left holding the bag for those increased state costs. For medicaid costs. And as changes occur in the population. As the baby boomer demographic enters into the population. As more and more services are provided for services for people with disabilities, as Prescription Drug prices go up the increased costs over time will not be matched by the federal government. States will be left holding the bag. And isnt it interesting that some republican governors believe this approach will have disastrous consequences for their ability to care for their older neighbors, neighbors with disabilities and children . For example, governor republican governor from massachusetts in a letter to congressman Kevin Mccarthy stated, we are very concerned that a shift to block grants or per capita caps for medicaid would remove flexibility from states as the result of reduced federal spending. States would most likely make decisions based mainly on fiscal reasons rather than Health Care Needs of vulnerable populations and the stability of the insurance market. Could you elaborate a little more what this would mean . You would have dish think in my state they may not raise taxes. Thats the choice, though, isnt it . Raise taxes to support if federal participation or cut. If federal participation is limited in these fashions, its the only way that would respond to mr. Bartons concerns about deficit reduction. If federal participation is limited in that fashion, then the states will have a choice either of reducing the number of people they serve, cutting back on rationing services to those people or raising state and local taxes. And mr. Chairman, thank you. Id like to ask unanimous consent to enter into the record if anyone is interested in learning more about medicaid, march of dimes and the number of experts are having a lunch provided Forum Tomorrow or excuse me, february 27bnd, 12 3 to 1 30 in rayburn 2020 to learn why medicaid matters to kids. And i encourage you all to attend. Could you send a copy over to me . Here it comes. Appreciate that. Now i recognize dr. Bush administration dr. Burgess for five minutes. Thank you. Very interesting discussion. Very timely discussion. Ms. Yocom, let me ask you. Chairman murphy was directing some of his questions about improper eligibility determinations and one of the things that has concerned me for some time is the issue of thi thirdparty liability. A medicaid patient who has other insurance but also has medicaid. And my understanding is what happens is sometimes its hard to collect from the party of the first part, the commercial insur insurer, medicaid is more straightforward. So you end up in a situation where the person who should be responsible for the bill, the Insurance Company who has been who has been contracted to provide care for that patient actually is inadvertently kind of let out of the equation. Because it just because easier to chase the dollars in the medicaid system. Is that a real phenomenon . It is. We did some work i believe for your office that took a look at thirdparty liability on some of the issues that the Medicaid Program encountered. Some of its about Information Systems and just being aware of the coverage. But then even with the mat its about the interaction between the state Medicaid Programs and the Insurance Companies and being able to assert the fact that they should be paying first. So to what extent are the states able to address the underpayments by commercial insurers, the overpayments by medicaid . We did make some recommendations to cms to provide Additional Support and data on these issues. I would need to check to see whether or not they had been implemented and a little more about the specifics. Im given to understand that this is not a trivial problem. There are significant number of dollars involved. Is that correct . Yes. Yes. And i think it is safe to say it does vary from state to state, some states do better than others. So you if i recall correctly, back in the mid2000s, 2005, 2006, 2007, you had created a list of states where the percentages of dollars left behind were attributed to each state. There were some significant differences. I think texas was kind of middle of the pack. Iowa did very well. Some other states did very poorly. Is that do i recall that correctly . I believe thats right. And i think some of it is the more health plans involved, i think the harder it becomes. Some of the states that had a Smaller Group of insurers to work with i think were able to establish better relationships. Just gets to the point, that was a gao report of over ten years ago. Is this problem fixable . Is it worth fixing . I think there have been some fixes done. But i am not sure i remember well enough to tell you much more than that right now. I would just let there is some very insightful legislation coming on this subject. And i hope people will join me on that. Miss maxwell, let me ask you, just staying on the Third Party Liability issue, youve discussed medicaid overpayments in regard to providers not reconciling credit balances with the states. Is that correct . Thats correct. So it would stand to reason since states are not active in tracking down Third Party Liability claims theyre aware of beneficiaries with overlapping coverage that might receive services that are unintentionally paid for both by third parties and the state medicaid plan. Is that a reasonable assumption . Correct. Is it possible for states to take advantage of inhouse data like this to approach practices that might not have reconciled their credit balances . Yeah, thats what our recommendation focuses on, the the ability of states to identify those overpayments and then recover them. Were looking at the report we looked at was 25 million in which credit balances were not reconciled. States had not been able to say that number again. 25 million. For i believe it was eight states, i believe. But its not an inconsequential number. Its a number worthy of our attention. Even though we deal with big numbers up here, mr. Barton talked about trillions of dollars and dazzled everybody with that. But even going even focusing on these amounts is important, is it not . Absolutely. From the office of the generals perspective, every dollar counts, every dollar that is overpaid or goes to a fraudulent provider means there is a dollar less to provide services. Thank you. Mr. Chairman, i want to point out that ten days ago or so, a day before the inauguration, we had round tables with the governors up here both on the senate side and the house side and it was one of the most impactful days i have seen up here. There is so much energy and enthusiasm on the part of the governors who want reforms in their system. They want this to be right. They want to deliver the care to their citizens. There is not unanimity of opinion whether it is block grant for beneficiary allotment. A lot of discussion around the moving parts. But ill just tell you i was very encouraged about the level of involvement of our governors in this issue. Ill yield back. Thank you, i now recognize the gentleman from new york, mr. Tonko for five minutes. Thank you, mr. Chairman. Welcome to our panelists. Mr. Archambault, i know that in your testimony you addressed the waiting lists and the corresponding decline of services or inability of services. I know that our ranking representative pallone asked you a bit about this or the panel about it. And i just want to dig a little deeper into a claim that you did make where you insinuate that expanding medicaid will lead to the 600,000 individuals on medicaid waiting lists being less likely to receive services. First of all, can you explain what you mean by medicaid waiting list . I assume youre referring to the waiting list that some states maintain to receive home and communitybased Waiver Services. Is that correct . Correct. So i would ask, do you know which state has the longest waiting list for home and communitybased services . It is usually related to population, youre going to have more people who are usually eligible for the program. But thats not there is not a straight correlation that way. Well, my information tells me that texas is the list that has the longest waiting list. Some 163,000plus people in 2014. Do you know how texass waiting list of that 163,000 has been affected by the expansion of medicaid . The data usually is a year or two delayed, so it is hard to draw direct correlation. I would just point out that if we want to make sure that were fulfilling the promises to the most vulnerable, i think getting lost in this discussion is that medicaid is crowding out state spending of all kinds, whether it is education, whether it is Public Safety or infrastructure or the waiting list. I dont want us to i would suggest it depends what states are doing with their Medicaid Program. Texas has not expanded its medicaid. So i that was the answer i would share with you. It is very interesting now that we look at some of the data, mr. Archambault, do you know which state has the second longest waiting list for home and communitybased services . Again, it depends on the population. By category, and there is no correlation between expansion or not. The concern is even states that have expanded also have waiting lists. So for me, it is about priorities. And for state lawmakers, theyre being put in a very tough position where theyre not able to help families like schuylers and thats deeply concerning to me. Well, florida is the second in that list of medicaid numbers, and they have not expanded with their medicaid issue. And, you know, i think we can sense a pattern here, so, you know, we need to cut to the chase, fully 61 of those individuals on waiting lists for home and communitybased Services Live in the 19 states that have not expanded medicaid. My home state of new york, one of the most populous in the country, and one which has enthusiastically expanded medicaid maintains a waiting list of zero individuals for acbs Waiver Services and a track record that has begun to be very favorable about per capita costs for medicaid. It is difficult for me to see the real world correlation that is addressed in testimony like yours where expanding medicaid and waiting lists for home where there is a contrast or choice that has to be made between expanding medicaid or waiting lists that grow for home and communitybased services. Do you have any actual evidence at all that speaks to that expansion and any correlation with acbs . Again, the point is that when you talk to governors and state policymakers, they are being put in a position where in arkansas they have been trying for years to address issues like families like schuyler now theyre having to just yes or no. Is there any correlation that you can cite, and ill remind you, youre under oath, is there any correlation you can cite . What i will say is yes or no, sir . There is no correlation it is not a yes or no question. Then the answer is. There is no correlation expansion or not on whether you have a wait list. So unfortunately, what were seeing from our Witnesses Today is a parade of alternative facts designed to obscure the simple truth. Medicaid expansion is working. It has provided Health Insurance to over 12 Million People. And my colleagues on the other side of the aisle are engaged in a cynical attempt, i believe, to pick good versus good in an attempt to gut this program and Rip Health Care away from millions of americans. I find it unacceptable. I find it shameful. And i dont think we should sit quietly while peoples right to health care is being threatened. With that, i just yield back the balance of my time. Thank you. I now recognize ms. Brooks for five minutes. Thank you, mr. Chairman. I dont think that trying to explore waiting list questions and waiting list issues is an attempt to gut medicaid. In my view its an attempt to strengthen the services and the ability to provide people with developmental disabilities, traumatic brain injuries, Mental Illnesses and ensure those people on the significant wait lists receive care. And id like to go back to you, mr. Archambault, with respect to i do think its more complex than a simple yes or no, is there a correlation, is there not a correlation. So could you please go into greater detail with respect to what your foundation, what you all have found, with respect to the waiting lists, with respect to the people who are on the waiting list, with respect to what the states want to do with the waiting list. Going to let you use most of my time. Sure, thank you, congresswoman. I would just say that to focus on a waiting list is a vacuum. Some states have what do you mean some states have deliver care the phrase im sure youre all very familiar with, youve seen one state Medicaid Program, youve seen one. Some states have decided to take their the people that would qualify for a waiting list and include it into an 1115 waiver request and deliver services in a different way. My point is that the principles by which we have as a country, for our safety net, is that we make sure that a Safety Net Program accomplishes a few things. One, is it targeted and tailored to the truly needy . Are we living up to the promises that we are making to these families and individuals before we make new promises . And is it fair to say those currently on waiting lists in the states are the truly needy . Is there any dispute about that . I think there would not be. And i would be happy to explore it, but im not sure how intellectually disabilities or Mental Illness would be seen as ones that we wouldnt want to people who typically cannot take care of themselves, is that correct . In schuylers example. People who are often not working, is that correct . People who truly are incapable of make of taking care of them physically or mentally themselves. Correct, and this was the traditional medicaid population preaca was the aged, the disabled, pregnant children pregnant women and children, excuse me, that we were trying to fulfill that promise to. The aca changed that discussion. And how did the aca change that discussion . Well, expanded to a population that is the vast majority 82 childless, able bodied adults. So, again, these are individuals that dont qualify for tannive, dont qualify for longterm food stamps, they have not traditionally been a population. And what is important for us to remember here is our goal is not to get people to stay on medicaid. We want to make sure they have Better Health outcomes and i think most of us would agree ideally it is if theyre able to work, out in the workforce supporting themselves and on private insurance. Thats ultimately, i think, where we want to be as a country and thats the discussion we need to be having. Is it fair to say most of the people who are on the waiting list who are the developmentally disabled traumatic brain injured people and those with serious Mental Illness are always going to be on medicaid . Correct. It is a different type of population and what has been your discussion and findings with the governors with respect to how most of them would like to take care of this population, if there are if there are consensus among governors, what is the governors and the legislatures view with respect to this population. Yeah, i think there is ongoing concern by governors theyre not able to be able to support these. I will say there are exceptions to that rule. And if you look at the state of kansas, the state of maine, those governors have been able to buy down their wait lists. I think main has gone from 1700 individuals down to 200 how did they do it . Well, they got some budget sanity, they did not expand medicaid and so they have been able to focus on eligibility as we have talked about today, to make sure that their programs are true ly focused on those that are the most needy, the age, the blind, the disabled and made that a priority in their state and they have had success in buying down their wait list. I think we need to continue to explore the states that have found ways to have little to no wait list. I certainly hope today our governor, governor hochom, it is an outstanding program, but i hope folks on both sides of the aisle, it is a way to save and to help those who truly need it. It can be replicated. I believe it is an incredible model that can work. Unfortunately we still have a waiting list. In indiana. We dont want a waiting list, but i certainly hope that with the new nominee to lead cms we seema vermy, a hoosier, we can make all of medicaid a far stronger and Better Program with controls in place. As a former u. S. Attorney ive worked with the units. We need to do more to support them. We need to do more to support all these efforts to make sure our truly vulnerable are protected. With that ill yield back. Okay. Now ill recognize ms. Clark for five minutes. I thank you, mr. Chairman. And i thank our ranking member. Before i get into my actual question, i actually want to respond to mr. Howard because as a proud new yorker, i must correct the impression left by your characterization of the empire state. Are you aware that the new york states Medicaid Redesign Team has been a National Leader in controlling costs and improving quality for medicare members . The Empire Center for public policy, selfdescribed as a fiscally conservative think tank and government watchdog released an analysis in september of 2016 that new york medicaid spending per recipient has dropped from 10,684 to 8,731, or 18 between 2010 and 2014. At nearly twice the national average. According to the independent new york state Controllers Office, the mrt restrained total medicaid spending growth to only 1. 7 annually during the period of fiscal year 2010 to 2013. This marks a significant reduction over the trend for the previous ten years of 5. 3 . During the same three year period, medicaid reenrollment grew by more than half a Million People. Billions of dollars have been saved, and per recipient spending has been slashed. And in fiscal year 1415 alone, a total of 16. 4 billion was saved, thanks to the mrt initiative. This track record of success led the Controllers Office to declare the mrt represents the most comprehensive restructuring of new yorks medicaid system since the Program Began in 1966. And we have no waiting list. Id like to now turn to mr. Westmoreland. In mr. Archambaults written testimony, he cited numerous concerns about Medicaid Expansion. However, he ignores the fact that this program has also had a positive impact on the quality of life and health for millions of americans. He also ignores the fact that many of the positive impacts such as cost savings from preventative medical exams and Early Detection and treatment of disease will result in future cost savings to the states and the federal government. I am a strong supporter of Medicaid Expansion because i see the significant value of the program. Im interested in improving the program and not destroying it. So mr. Westmoreland, mr. Archambault claims that the 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 my testimony of who is truly vulnerable. I want to be clear that not all people with disabilities, cognitive, traumatic brain injury, any of those discussions that have been ongoing, were traditionally eligible for medicaid. It was tied to a 75 poverty and receipt of ssi, and many people whom we would all consider to be disabled have never been eligible for the federal Medicaid Program until the enactment of the aca. So lets start with those people. Secondly, i would point out that there have been significant studies, economic and Macro Economic studies, some by business schools, some by economists, showing the states actually have significant budget savings and revenue gains by having the Medicaid Expansion in their state. So i think that its clear that states benefit on a financial basis, and that their citizens benefit on their financial basis in the ways that i outlined in my testimony. Mr. Westmoreland, both mr. Archambault and mr. Howard claim that Medicaid Expansion poses an unsustainable burden on state budgets. Can you clarify why this is not the case . Why have most states that have expanded medicaid actually experienced net budgetary savings associated with the expansion. Yes, lets start with the Health Care Expenses that as we discussed earlier there are fewer uncompensated care costs within the state. In addition to that, there is an influx of federal funds into the state to pay for services and those federal funds have a reverberating Multiplier Effect on the state economy. Finally, states are able to provide as you suggested preventative and Early Intervention services that might not have been available to uninsured adults before and actually lower the ongoing Health Care Costs for those people. My understanding that numerous studies have disproven the myth that Medicaid Expansion diminishes work incentives. Is that correct . Yes, maam. I yield back the balance of my time, mr. Chairman. Thank you. Now i recognize new member to our subcommittee, the gentleman from michigan, and reverend, mr. Tim walberg. Welcome aboard here to our committee. Thank you, mr. Chairman. Mr. Archambault, i appreciate the safety net illustration that we want to have safety nets. But we dont want to have safety nets forever for people. I remember i never worked over a safety net, but i remember working at the u. S. Steel south works and as third helper going out and being responsible to swing a sledge and take the plug out of a heat of molten steel. And had a fall protection strap on me. I appreciated that. But when the shift ended, i didnt want that strap, i wanted to move on. Thats a laudable goal, we find ways to make sure that people who truly need that safety net have it. We make sure that we dont waste it on others who dont and encourage them to move on in a very positive way. I would like to ask you for further response from your testimony and also miss maxwell, i would like for you to comment after mr. Archambault, your testimony references some of the waste and fraud issues that face our Medicaid Programs. Individuals that have passed away decades ago, individuals using high risk or stolen Social Security numbers and tens of thousands who had moved out of state yet remained on medicaid. What can we do to combat some of these problems more effectively . So there is a number of things that we would recommend and thank you, congressman, for the question. The first one is allow states to check eligibility more frequently. Under the aca there was a change that states could only redetermine eligibility once a year. Unless they were given a reason to recheck eligibility. We have found that states that are able behind the scenes to access data internally within State Government but also through third party vendors, if theyre able to run those on a quarterly or monthly basis, theyre finding that these people individuals have life changes, just like all of us. And so whether they move or they die or whether they get a significant raise, we need to make sure that we find that sooner rather than later, otherwise were wasting money and i believe that there is vice partisan agreement on that, we need to make sure. The other thing is we need to make sure that the federal databases which we havent talked a lot about, the quality of the data in those is quite poor. If you talk to state leaders, they will complain constantly about how late the data is, out of date, and it is not flexible enough. So making sure that states are able to look for dual enrollment, for example, in the Food Stamp Program is moving in this direction, we should be doing it for medicaid, just to make sure were not wasting money as a result of individuals moving across state lines. Okay. Thank you. Miss maxwell, could you add to that . Thank you. I would love to. I would definitely echo what we just heard about the crucial need for better medicaid data. It hampers the ability to understand the program issues. But it is significantly deterred by us trying to find fraud, waste and abuse. In addition to that impact and protection, we also need to think about protecting the program from fraud happening in first place. In addition to the data, would encourage us to continue to work with states to improve enhanced provider screening, to make sure that providers that get in are the providers we want to get in and want to pay. Okay. Thank you. Mr. Archambault, an audit in arkansas revealed more than 43,000 individuals on medicaid who did not live in the state. With nearly 7,000 having no record of ever living there. More than 20,000 medicaid enrollees were linked to high risk identities, including individuals using stolen identities, fake Social Security numbers, et cetera. Something of interest to me in michigan has recently identified more than 7,000 lottery winners receiving some kind of public assistance. Including individuals winning up to 4 million. Those jackpots are something that encourage them not to be on medicaid assistance. Mr. Archambault, do these individuals get approved for and state enrolled in the Medicaid Program and is it the federal government or the states dropping the ball . Well, congressman, maybe a little bit of both to answer that question. And i think whats really important here is that there are some policy changes that have happened. The Affordable Care act removed an asset test for the Medicaid Program by and large. There is some that it still applies to. But as a result, these sorts of outlier cases admittedly but when an individual wins 4 million, takes a lump sum payment, they may not qualify that month, but the very next month they would qualify for the program and can remain on. Let alone were not checking for 12 months in most cases, so we 12 months in most cases, so we wouldnt know. 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