Transcripts For CSPAN3 William Werkheiser Testifies On Falsified Geological Data 20161213

Once they walk in the door, drink from the fire hose. Whether democrat or republican really doesnt make much differ. 45 trillion Dollar Agency to run and a lot going on. Big issue of repeal and replace, what do we do, nothing like that i saw in aviator 2001 one of the top National Issues. Im not sure where they are going with it but secretary price who i have known for years, these guys have, too, new administrator going to be they are way ahead of the game. What are they talking about now, my experience 88 transition a long time ago. Im actually 106 years old. We didnt do anything. We got people confirmed. Nobody sat around anderson talked about health care policies. I talked to Tommy Thompson, president bush, wanted to do it, privatizing medicare, medicaid in may. Gave a list of things to do, changed the name of the agency just to make people mad. Through part d maybe in may. December ive never seen anything like this. This is way out of the normal time schedule in my experience. Do i want to go to leslie. Tom, you remind med you were the individual for changing to cms. Answer the question everybody has, why is the center for medicare and Medicaid Services cms. Whats going on with that . I changed the name largely, i was hoping leslie, if i changed the name on the building she would get confused and couldnt find her way to work. At one time i had an explanation an old friend, believe it or not, in the cms world. Everybody, pretty small world, Everybody Knows each other in both parties and friends in my opinion. I knew nancy and she replaced me in the white house when bush lost to clinton. When she came in, they would been through a rough year with y2k and stuff. For some reason i was running big hospital association, it was perceived to be big and bureaucratic. People loved acm but didnt like the agency. I said to Tommy Thompson, lets change the name. He said, youre nuts, youre going to get killed. Why do you want to do that . You want to hear the real tore. I said, youre right. Were going to get killed. I said what do you think about the name vin corps, a Nursing Agency in wisconsin. He said i hate those guys. I said youre terribly right, they are horrible people. I said what do you think about this . They are the same people, they changed the name. He said, okay. You can change the name. Nothing in the statute. Made up by secretary of health from baltimore, nice guys. Trying to get fresh perspective. Why one m. I havent heard an explanation for one m. I already mumble you can tell. Center for disease control, started out at cmms. I argued, basically me and secretary thompson, you werent there, i dont go, maybe it up. The one he liked mma, mama wasnt going to be popular. Came up with cms, cdc, lets drop. I apologize, that was not the question you asked. Leslie, let me turn it back to you. In terms of transition, maybe alter the question a little bit because in my experience i think both you and tom in terms of really implementing medicare, being responsible for Prescription Drug implementation, i think theres obviously going to be some sort of change thats doing to come about. What describe your experience leading transition in the standing of a new benefit, what that might involve, look like in terms of some sort of significant change to deal with when she takes over. If i were to give her advice, i think it would be several fold. First of all, in as much as it involved changes critical would be Health Insurers and making sure those companies are on board, appreciate the changes, appreciate if cms does something its going to have a reaction externally. That could set up success or failure of whatever the change may be doing forward. I know its a lot of what i suspect all of us are reading now in the press, making sure whether Companies Like care first or humana, aetna, anthem, all of them can really focus on if were going to have an exchange, how is this exchange successful. If youre going to have medicaid managed care, if youre changing medicaid in a way you could participate successfully. To have a marketplace, whether medicaid, medicare, or the insurance the individual Insurance Market work means that Health Care Providers can also get paid. If Health Care Providers are getting paid, youll have networks and individuals, beneficiaries will be able to participate in those programs as well. At the very least, if youre looking at changing medicaid and obama care, which i think most people see as the exchange the next session here entitled physician assisted death balancing rights of patients and other stakeholders. Im a member of the health law section. I served as cochair of the executive committee, among other things, and assistant dean for assessment at Manchester University college of pharmacy, natural and health sciences. I was asked to moderate this panel and i teach a course in bioethics. This is going to be a very interesting discussion. The panelists are going to introduce themselves. Each of them will talk for about ten minutes and well have a few remarks up here and then well open to questions from the audience at the end. If you will, please do save those questions until toward the end of our session. So going to turn the podium here or microphone over to the colleague to my left palm kaufman. Good morning, everybody. Can you hear me well . Good. Thank you. Thank you very much for having me. Im a partner at hanson bridget in san francisco. Ive been practicing there 28 years in our health law department. Over the years the emphasis of my practice has moved to senior care, longterm care settings. So i used to do a lot of hospital law, now i do a lot in the senior care space but the issues are extremely similar. So im really delighted to be here today to talk to you about what some people call death with dignity laws and other people do not. That reflects a certain bias i would say. Im here to talk about end of life laws that are beginning to get passed throughout the country. I love this topic. Ive been speaking about it since Governor Brown signed the bill in october of 2015 in california, which was a surprise to some people. It was a hotly debated law in california. So i am going to exercise as much selfcontrol as i can and give you 10 minutes of background on whats easily an hour and a half or twohour topic. This will be about my 25th presentation this year on this subject. So i really do love it. So there is a short power point that will be available through aba but i have a bias of not using power points. Hopefully this will be more of a conversational session for you. So i want to talk to you a little bit about this very decided movement thats going on throughout the country. We now have five states that have statutes and one case a state that has case law supporting the right of a terminally ill adult to take his or her own life through the use of aid and dying drugs. I practice in california but not exclusively in california. My clients are throughout the country but certainly more are on the west coast. So the trendsetter was oregon, and we have someone here today from compassion and choices in oregon. So if you want to learn more about it, you can also chat with him. So the first law was called death with dignity act. It took effect in 1998 and it was a voter initiative. And interestingly, the oregon law was actually considered by the United States Supreme Court because then attorney general ashcroft was trying to prosecute both pharmacies and physicians who were participating. Thats the magic word, participating. Youll hear more about that, who are participating under oregon law. The Supreme Court determined that the controlled substances act could not be used to delegitimate a state standard of health care. Kind of a states rights issue. I dont think Supreme Court was interested in commenting on the substance of the law but more about whose turf it was. That cut the Supreme Court, which is interesting. Followed by that was washington, also a voter initiative. That took effect in 2009. Vermont, 2013. That was actually through legislation. And the governor actually made the issue part of his Campaign Platform before the 2012 election, so that was noteworthy. Montana very interestingly has this right under case law. You might disagree with this statement, but the court in that case said theres little difference between removing life support and taking aid in dying drugs. I think there are people who would disagree with that statement. There have been many efforts to codify that or to overturn it in montana. But so far none of them have succeeded. That brings us to california. By the way, in november colorado also voted to pass this law, so they are next. Ill be talking to their trade association about our california experience next year. California has an end of life option act. It only took effect in june. At its heart, like all the the other statutes i mentioned, it allows a terminally ill patient to end his or her life by aid and drugs with an attending physician. Pretty much every word has a specific meaning. It the most recent and probably most refined second most recent and most refined of the laws. The same organization that put forward the oregon law put forward washington and vermont and california and most recently colorado. We keep on we, they, keep on removing the nits, so its becoming a more refined law. Very interestingly you must selfadministrator drugs. It not euthanasia. Other things you hear about are induced coma with too much morphine. Theres ways people can control drug intake. Im not a pharmacologist but presented with physicians who described that. This is very much about selfadministration. You must have affirmative, conscious and physical act of administering and in guesting the drug and you must have an express intent, kind of the normal informed consenttype dialogue with your physician. You must be mentally competent. So in my space working with seniors thinking about who that might exclude, people with alzheimers or dementia and your agent cannot request the drugs for you. So your spouse, partner or sibling of many decades could be request this for you so it has to come from you directly. So in california, and this is extremely indicative of other states, you must be a resident much easier than it sounds. You can die in california more quickly than you can get married or divorced as long as you can show you have some kind of id, like a voter id, drivers license, couple of other forms youre a resident. Theres no time requirement. You must be a resident. You must be 18. You must be able to understand the nature and consequences of the decision and the benefits and disadvantages which are pretty evident. And you must be diagnosed with a terminal disease with reasonable certainty is expected to cause your death within six months. We all know thats an art not a science. Theres a book written by art buck wald, his experience in hospice for two other three years after being eligible. The book is something funny like not dead yet or still alive he continued to entertain glitteratti until his death. Theres quite a lot of procedure in this and reflects the tremendous tension between the supporters of this law and the the detractors. The detractors included two maybe obvious and maybe one less obvious group. Certain religious organizations such as Catholic Health Care Organizations were opposed to it. The veterans hospitals and other governmental hospitals were opposed to it. Theres actually a federal law that prohibits the use of federal funds to fund any kind of i think use the term assisted suicide, goes back to 1997. The third group that may surprise you, certain parts of the disability rights movement. The feeling among those groups that oppose the law, its bringing us one step closer as a society to euthanasia. That was unacceptable to them. This is not about euthanasia but that was a fear they had. So in exchange for having a v y very well, to address the balance, to address the tension between these two groups, there is a very large amount of process that you have to go through. So just to give you the highlights, you have to make two oral requests 15 days apart for the drugs. You have to make a written request. It must be witnessed by two witnesses and certain obvious people cannot be one of those witnesses, people who stand to benefit from your will, spouses, siblings, so on. You then need to go to a cast of three characters. Number one is your attending physician. He or she must confirm your terminal diagnosis, your capacity, residency and informed consent. This is interesting, the doctor must tell you have the right to change your mind, other options such as hospice and palliative care. The doctor can recommend but not require you to tell your family of your plans, to have someone present with you at ingestion and not to consume the drugs in a public place. This has created a quandary for my clients because residents are not required to tell them they plan to take these drugs. A big part of my practice is trying to get my clients to have an environment of open disclosure and open discussion, because you want people to tell you they have these plans. Unlike the hospital where you go in for a few days and leave, this is home for my clients clients. That makes a big difference how they confront this law. You get through number one, doctor two is consulting physician, basically second opinion, goes through the same steps. Both doctors if they see a Mental Health issue have to recommend Mental Health. If i had six months to live, im pretty sure i would feel a whole bunch of emotions and im sure one would be emotion, anxiety, fear, confusion, a lot of emotions. I dont think they are really necessarily focusing on that group. There are people who have chronic depression. There are people who are bipolar and have psychosis. Maybe they are not on their medication and maybe they are not going to make a sound decision because of the magnitude of the issue. So once you go through all those steps, youre able to get the prescription. And then the question for my clients and your clients will be will we participate in the act. Its probably the most important term in the statutes. It means sectionally are you going to prescribe the drug, handle the drug, deliver it, dispose of it, receive it, have your hands on any part of the chain of custody of the drug and will you be present at the moment of ingestion. Thats really what it boils down to. There are other details but thats the heart of it. So you can diagnose it, give people information about it if youre a dr. You can tell them what their prognosis is. The real key is are you going to, as health care provider, let your if youre a company, let your employees and your contractors be present at the moment of ingestion . And are you going to handle the drugs. And just to give you a sneak preview, most of my clients are not participating. Ill explain more when i get into the q a why that is. Another very interesting part of this law is theres a provision protecting you whether you participate or not. So if youre a physician or hospital or School Nursing agencies, hospice or a number of other health care provides you can let your employees and contractors participate or prohibit them from participating providing you give notice and tell them the consequences which could be discipline up to including termination. If you are an individual, and you want to take these drugs in accordance with the act, it is not considered suicide, assisted suicide or homicide. Why is that so important . Insurance is a very big issue. It doesnt invalidate Life Insurance or Health Insurance or any other insurance. Insurance companies cant discriminate against you based on these plans to take these drugs or not take these drugs or rescind your decision. Thats also essential. Its kind of a live and let live law, to live or die. You it parts eight or not participate. I tell my employers if you dont participate you have to give a disclosure and acknowledgement to your people. The last point i want to make is that there are very interesting utilization data coming out of these states. Every state is required to maintain this data. Just to tell you the highlights, this is basically an old persons law. Most of the people who are taking these drugs are over 65. Most of them have cancer, they might have copd or another very serious illness. For the most part they are telling their families, 90 to 95 telling their family of their plans. Interestingly the vast majority are white people with college degrees, which might have something to do with how information gets conveyed. And the other interesting thing is almost everybody is dying at home. So that also raises interesting issues when you represent hospitals as to where this is going take place. Medicare will not pay for these drugs but medicaid, the state portion of medicaid may depending on your state. In oregon the state component pays for it. California has already set aside money for it. But medicare will pay for end of Life Counseling you get from your physician. So im going to turn this over at this point to father grogan and hes going to talk much more about philosophical issues involved. Thank you very much. If i can get this organized, it will be for the day but its not working for me. Ill tell you a little about who i am. Im father William Grogan attorney in chicago. These slides will be downloaded so follow the good example of pam and just speak from my text. I work as an ethicist. I go around the country answering questions around ethic committees. While theres a lot of questions in Health Care Related ethics both clinically also many questions organizationally. Im going to speak, as it were, at the start at the 10,000 foot level and drill this down to the matter at hand. I think the first thing we have to keep in mind on this conversation is we provide advice and council to people. So individual clients and my presumption in this regard as were speaking about organizations, some of which are secular in nature, some of which are religious in nature including not only catholic sponsored ministries in health care, which are an expression of religious teaching, they are not businesses or social Service Agencies but rather also other religious communities within the christian continuum, protestant side, for example, Adventist Church has Extensive Health care ministries in this country as well as other religious communities. And like pam said, these are often dealing with an aged population for the most part, in contrast to shortterm hospital says, those of us who represent acute Care Organizations experience. So providing advice and counsel means at the same time we have to be aware of the identity of the client an how that identity is reflected in the culture and culture represented in practices, policies and procedures. Now, i raise this because often we see especially i would say in the last 15 to 20 years a tremendous shift in the identity of attorneys professionally from being counsel to their clients on matters that include values, other than commercial ones, to largely a commercial operational model. So as an ethicist who practices law. I agree with pam what were discussing is not legally suicide. Thats clear in the statutes. On the other hand morally it is a suicide, it is a killing. How we counsel our clients to be engaged or not engaged in this arrangement reflects back especially in our competency and understanding the identity of the client with whom we are interfacing and what role, what level of cooperation or engagement we wish to have in that type of setup. In ethics there are two dominant dialects in the language around what should or should we not do. One is very common in the north Atlantic Community that is very popular in many of the colleges and job Training Programs and health care is around essentially comes out of the 18th century, 19th century british writer jon Stewart Mills around the single concept liberty. So in his famous essay he advanced liberty principle which indicates i should be able to do what i want to do as long as it does not directly harm another. That in turn is translated into the concept of selfdirected living or autonomous living, selfdirected. In health care right next to us in georgetown, we have the famous georgetown four, principles which partner. That is the dominant concept. With that our stepchildren were all familiar with from our Legal Training around due process, rights of privacy matters along those lines. The other dominant philosophical approach comes from our heritage that emphasizes all of us that took criminal law, whichof what is the intentionality, what is the motivation, not to inflict plain, whats intentionality of any action, mens rea, are they emergent or chronic. And finally, what is the moral intentionality behind in this case an intervention, whether its medication or counseling or some matter like that. Those are the two dominant ethical approaches. So when a person hears and argument that essentially is framed only in one, its not an adequate argument. Because it fails to appreciate in our culture today what i affirm, that is the diversity of the perspectives that shape our world. The austrian philosopher who had not always a stellar career, argued that words we use house our identity. Words house our being. If were using we should have a conscious grasp as counsel to what is the frame of reference, the story or the narrative our client is using. That way were able to affirm or help shape or correct what the implications are of that story. Both good implications like we have with informed consent, we all encounter when were asked for something as simple as a blood draw or other implications which require, in my opinion, a more sophisticated and more reliable form of moral analysis. Pam makes a very good point that when we are involved with counseling our clients, we have not only from my perspective a need to grasp the clients point of view but we need to know it and know what implications are so full disclosure to any person entering into that relationship of health care results. The full disclosure, for example, with a nursing home, applicant should occur before patient or resident appears in the facility itself. Why . Because then one has a relationship of integrity. And that as counsel to organizations allows us to speak honestly to client how they market their services, what services are provided, what services are not provided, and how the services are underwritten. Knowing that a person then can exercise autonomy or dignity in making a determination as to whether they wan to be involved with that nursing home staff. The reason i raise that, frequently understandably, and i cared for a mother who was in a nursing home many years along with my siblings, were often thinking if were going to the nursing home as if theres some generic setting following one standard of care. The reality is certainly since clearing for the agency is often an activity women are involved with more so than men, that is a counter, a set of relationships. Who are these people we are relating to, to whom we are entrusting either ourselves or our family members. So we want to know their story. We want to know implications and how that gets drilled down into what our patients are going to encounter. Now, why does it become important. Living in a diverse society, different organizations through their culture express their values in different ways through these relationships. Thats expressed in either toleration or accommodation for measures that would be in many cases medically inappropriate. What is an example . We hear frequently individuals say i want everything done, or i want to have every procedure made available to me when that is very clearly clinically inappropriate. Its important our client organizations disclose to the patient or residents of nursing home facility what is the approach thats taken with end of life care. Some might choose the position that pam is advocating. Others might say, no, that is not what we are about. And so in doing that, they are living out with integrity the story they as employers are passing onto their associates or to those to whom they are trying to share either their services and or services framed by ministerial mentality. I think its also finally important for us as lawyers to coach our medical professionals. Many of these individuals in a teaching situation, we have 200 student doctors, residents and other nursing students that they are uncomfortable as we all are in dealing with the news. Like pam said, getting the news, im depressed for a while, i hope, and then how do we work through it. How do we coach our colleagues in medicine because we are examples, exemplars, largely in light of our education, to large numbers of the society who havent had the occasion if not to think about this, to articulate that. Not imposing a point of view but working with a person, physician or a nurse to grasp what is the connection between their own personal story of whats important in life and the story of their employer also is significant. We also want to be aware there are implications. If, for example, nursing Home Organization decision to take a posture that is contrary to that of their denominational position, they decided to be contrary to that denominational authority can have censoring behaviors. What would be the impact. If the church had a pension plan, that status would be revoked. That would have significant implications. There would be implications around property tax status at least in the midwest where i come from if those recognitions occur. So as counsel, just to sum up, we first want to be aware of whats the story that frames the culture of the organization with whom we are representing. Its very important to know there is no generic nursing home setup. There is no generic practice of medicine as such. Individual persons are involved with that. Secondly we want to make sure that we are able to articulate at least two different ethical approaches in addressing matters as they come up. Otherwise it would be like ships passing in the dark when we try to have educated conversation with the client. The third aspect is to appreciate because there is diversity, there will be facilities that wish to comply with these types of statutes. There are other with integrity as a matter of free exercise of religion, or i would argue Freedom Association would choose not to go down that path for reasons that pertain to their own integrity. I think were going to see, as pam said, a lot more discussion around this as matters go forward. Several states, as she noted, have passed statutes only. Massachusetts did not. And i think were going to see more and more conversation Going Forward as to what Direction Health care is going to take on this topic as the boomers enter into this very critical period of their life. So thank you. Thank you, father. Pam, before we get into some of the points that weve discussed here, i want to ask you, you had mentioned a little about some of the demographics of individuals who have used medications under some of the existing laws. Can you talk a little bit about the prevalence of abuse of these medications . Yes, i can. A lot of us believe that california being the big, loud, populous state it is will change dramatically and well see a big upsurge. If you look at the data in oregon, if you go back to 1988, 18 plus years, there were 1545 prescriptions of which 991 were used and resulted in death. Thats in 18 years. In 2015, there were 218 prescriptions of which 132 were used. When you look at the entire state of oregon, its not that frequent. The other really interesting thing for me as a longterm care attorney is in 2015 only nine people died in longterm care using these drugs. Washington has very similar data. There in 2015, there were 213 prescriptions, 166 deaths. Once again youre seeing about onethird of the drugs not used and i can explore why that is if we have time. Vermont is a very small state. I think in the first year they collected data there were 20 someodd deaths, no more. We expect california will open this up and it will become a lot more public much bigger part of the public dialogue. We do expect numbers will go up somewhat but its not being used willynilly. It really is a relatively isolated thing still. I think thats Important Information to help frame our discussion. You noted that you were seeing some trends in your practice. Noted that many of your clients are opting out of participating. So can you explain a little about that . Are you seeing this more in secular entities versus religiousbased entities or is it a little bit of a mixed bag . Its a mixed bag, and im always surprised. So let me start with the fact that among the hospitals, were seeing a number of hospitals, veterans hospitals are opting out. Weve had at least one secular hospital opt out. A lot of individual physicians are saying i need to opt out, i cant do this. Its mixed with pharmacies. The world in which i live is the longterm care world. As i mentioned before, one of the really important distinctions is this is home. People come into Residential Care facility or assisted living facility, they might live there for a few years. They move into continuing care retirement community, they might live there 10 or 15 years. Even in nursing they might live there two years. That changes the dialogue. The other very important point is the law does not specifically address whether you have the right to die on the premises of the health care provider, but our California Department of social services in california has said in assisted living and Residential Care you must allow a person to take these drugs on campus raising really interesting issues if the provider is, for example, a catholic organization. There it has the option not to participate. But if it tries to prevent resident from storing or taking drugs it will get cited by regulatory body. Nursing a little grayer. The implication is you cannot prohibit the person from taking the drugs on site but it is actually ambiguous. The reality is if you dont participate, and our Skilled Nursing rules say people cannot keep controlled substance at our bedside, youre kind of shutting down the operation. But whats interesting is ive had evangelical patients say im going to turn a blind eye. If the doctor wants to come in or friend comes in and wants to give these drugs to them, just dont ask, dont tell. That surprised me. What im finding is most of my clients, getting to your narrative, father grogan about secular individual versus communitiarian narrative, more of my clients are asking what are other people doing and what is my liability. Even religious organizations, thats what they are focused on. Maybe thats a sign of how much religious organizations have become enmeshed in commercial society. Im not a philosopher but that makes sense to me. But what im finding is they dont want to be in the chain of custody of the drugs. They want to prohibit their staff from having any role in the handling of the drugs and even being present during ingestion. So ive explored with clients, whats the liability risk, whats the exposure being in the room when someone takes the drugs. For the most part its more of a symbolic statement. We as an organization of a particular faith dont want to condone this behavior. But one client pointed out if the employee is in the room he or she might want to help them with administration, which would then have them engaged in homicide essentially. The other point they made, when a person takes these drugs, even though they are not suffering, there is a death rattle people have at the end of their life. It can be a very jarring experience for an employee who might not be prepared for the emotional power of that moment. Then again ive had some real surprises. For example, one client said nobody can participate and nobody can handle drugs, nobody can be present during ingestion except our pastor. Another client said, nobody can be present and nobody can help with the drugs except our medical director because medical director is attending physician for 90 of our residents and we dont want to put them through that extra hardship. What i realized is, i might have gone in with certain presumptions about what my clients would feel based on their religion and for the most part secular religious, evangelical, christian, jewish, they have all come out in about the same place. Father grog ab, do you have any responses or comments to that. I would first off as to t the i concur in that regard. However, we probably as attorneys want to provide educated opinions and should look at the experiences that are coming out of the belgium and holland and netherland and their experience dealing with children and what constitutes in their jurisprudence depression. I agree with pam. This is a movement going on primarily between i think these two narratives around autonomy or the communitiarian perspective. Secondly i cant speak to her practice, thats her own experience, validate the authenticity of that. Thank you. At the same time i could be very clear if catholic facilities were engaged, would have to be court order, significant change to health care of states that take care of the indigent. I think pam makes a good point on how the statute is designed for the individual to in guest a medication. But we also know as we age its not insignificant that many people have strokes or paralyzed in some capacity or lost swallowing mechanism. The conundrum she cited of a nurse or nurses aide comes up and that, in turn, would involve in vocation with the constance clause. In many states for people of goodwill opposed to abortions. In many states cut back by this Concerted Campaign to drive, this is apart from our conversation, the movement to see health care as a commercial business product. The application of the autonomimology is carried over. Im sure we as attorneys have seen this in 40 years of adult life ive been involved with, a movement of being a person whose advocacy around how to enhance justice and fairness in a humanitarian way largely reduced to commercialism and health care as a product to be bought and sold. This is something were going to have to deal with as attorneys in a much broader sense than the topic were looking at today. So thats really all i have to say in response to. I thought well thought out remarks pam was providing. Father you mentioned catholic church. Are there catholic ethical directives on point or do these directives imply the stance of the church with regard to physician assisted dying . Thats a good question. In this country Catholic Health care ministries, because we see them as ministries and not as social Service Agencies, akin to our sites of worship, they are to warrant activity identified with all the attending legal implications around tax exempt status, plans, et cetera, they have to be recognized by local regional bishop. The local regional bishop seeks they are in compliance with National Ethical standards, pointed out ethical and religious directives. They have six parts. Part five deals with questions around end of life. Categorically clear there is to be no advancement. Not talking about euthanasia, advancement of euthanasia or selfkilling. On the other hand theres a strong emphasis and this has been very clear, around provision of hospice care and pailiative care and confirmation of that and doctorpatient relationship. We in our ministries experience anxiety by the physicians over lawsuits if they are not following direction of a patient to refuse intervention, which would come up in this interpretation but demanding when they are if you tile. Theres been a great push in the Catholic Health ministries in the country and last five years especially to advance early open transparency about what the philosophy of care is and to advance conversation with the patient, decisionmaker, what is appropriate end of life services. And thats in part five. Part six of the directives deals with the questions weve alluded to today over cooperation. So a Catholic Health ministry would be hesitant, i would think, to be involved with partnership on continuing care element with any organization that embraces assisted dying or other programs like that aside from traditional hospice model. Thank you. One of the things i want to make sure we talk about before we open up our q a here is when providers do opt out, what alternative care options are you seeing them provide . Father grogan, you talked a little about hospice and palliative care, id like for both of you to remark on that if you will, please. After the law passed, should we get deep in our relationship with hospice agencies in our area. I said absolutely. Most of us are familiar at this point with hospice care. It focuses on symptom management and Pain Management at the end of life. Theres a psychosocial element so theres a lot of emphasis on the mending relationships and allowing the family to grieve. One of the reasons in my mind that only twothirds of the drugs prescribed are used is because people manage hospice care and manage anxiety and a lot of symptoms and pain. Thats a critical one. Its also important for my clients who are in nursing care, they have a legal obligation to provide comfort care. They can provide it or they can arrange it so if they dont want to provide it they can have a pos miss agency or other caregiver, Home Health Agency come in. But the point is, you start getting into academic distinctions. Not going to be present during ingestion but 10 minutes later you will be involved when it comes to providing comfort care. Thank you, father grogan, there is a conscious provision any employee who is not comfortable with any element of participation can raise his or her hand and that person is protected from any kind of bad consequence. We have as a best practice told our clients you should tell employers, volunteers, contractors they likely do not need to participate in comfort care. If they have issues of conscious or faith being there during ingestion, they are probably going to have the same issues 10 minutes later. Clients are either providing or maintaining comfort care but im counseling them to make it very clear to your employees and others this is something they dont need to participate in. Thank you. Father, comments. I agree with what pam said. To add onto it, in chicago we have a system now since we have services across the continuum for home care, starting kiosk in the drugstore to a clinic, doctors offices, partnerships with doctors offices, hospitals, Nursing Homes, et cetera, at this point when a person comes into ed from any nursing home or any facility, that person is evaluated around what they call the lace score that ascertains what is the morbidity quotient. A point of conversation, not anything determinative. Depending on that we have what we call pro active ethics where medical record notes or bedside provider has preidentified roster of predicaments they have given me the ethicist. When they appear this sets off in the Electronic Medical record process around ethical concerns such as early aggressive assertive plans of care conversation with patient or family, what are reasonable prospects post diagnostic test so one of the great fears that has come out out in the literat around this topic is the fear of abandonment. And pam makes a good point. One reason around not using much of the medication is the troops come forward through hospice or some other service to support that patient. So, having these concerted, coordinated programs and trying to figure out often who is the attending physician, who is the consulting and the division of roles has to be coordinated. And those are types of measures we have to pick up on just the concerns that were raised. Pam, have you discerned any differences in key stakeholders, board members, staff, patients or residents of facilities at all . Yes. This has been a really fascinating experience. I frequently will be dealing with the ceo, coo, cfo of the organization. That persons not the board. That persons not the lions staff. Ive spoken now to boards of directors, trade associations, resident bodies, and heres what ive discerned so far. I havent spoken yet to a resident body who didnt want this right. They want the right. Whether they exercise it or not is another matter, but they want the right. I sometimes speak to an executive director or ceo who has is confident that the board will take a particular view only to later have to amend the direction. So in very general terms, one thing ive observed which has really been very interesting to me is the caregivers are often people who are of deep faith. In california, a lot of our caregivers are filipino or from a latino tradition, and a lot of them have very deeply held religious beliefs and are very opposed to the organization being involved and personally want to opt out. In contrast, the executive team may be more secular. And in contrast, again, the board of directors is looking at liability and financial issues. So i often see that the people who raise the conscience issue the most are the people who dont really have a seat at the table, the caregivers, except to tell their supervisors. The executive team can go either way, and the board is generally thinking about liability. And i see that again and again. So last question for both of you. What advice would you give to attorneys as they counsel their clients about navigating through some of these choppy waters and applying these statutes . Well, ill say, repeating what i said earlier and then have a short addon. The attorneys should know well the culture of the organization with whom they are representing. Because we represent to a larger world the perspective of a client and we represent back to the client, the order of the executive team or other parties, the Current Situation in the society. And its important that we are able to articulate that diversity or were really coming with half a bag of tricks to share. The second thing is to encourage the client, if theyre an organizational arrangement, or a Service Going into someones home, like a home care, what the how to develop Educational Programs for employees as to what they are getting into so there is full disclosure. Its a question of integrity and transparency, to build trust in the workforce, but also to have Education Programs for the community as part of a sense of the word marketing, so an individual coming knows what they are going to receive and what they may not receive, not so much in the immediate future, but pam makes a good point, years down the road. And then the third part, and i have put this in the materials that youll get online, that there would be disclosure statements, scripted lines, so that there is a consistency of messaging by a provider, a physician or a nurse toes what the position of the particular client facility or service is, and also some notices, perhaps simple, short statements. And i drafted one this morning for possible use, just saying this is what we are about, this is what frames us, and here are measures that you can use if you want to have further knowledge that we cant provide you just in this moment. So that i think would be important to pass on. So, i agree with everything father grogan has said. I would add, dont assume. Dont use your clients political predilection or faith as shorthand for how your client might feel about the subject. You know, have the dialogue. Im a very big fan of disclosure and im a very big fan of training. And i talk about that with clients. You know, we have a little bit of a dark joke with marketers about, you know, the need to get the information out when people are applying to these communities. They dont really like my recommendation, but you know, get it right up front. This is what your position is. So, i would say i really like what you said about having integrity by raising the issue early, and i think thats the most important thing you can do, or most important thing you can tell your clients they should do for their patients. Weve got a couple minutes here, so i want to invite folks to come up to the microphones and ask questions of our two fantastic panelists, please. Hi. Im thinking about sort of the liability issues in terms of the person whos actually assisting in the suicide, euthanasia, whatever you want to call it. It seems odd that we have the death penalty, which requires an individual to kill someone, and yet, we dont allow physicianassisted suicide. And i just am wondering what your thoughts are about that sort of interesting dichotomy. Well, i want to make sure i understood the question, because i want to give you a respectful answer. So, you cited that in our society, we have on the one hand Capital Punishment, which is statelegitimated killing of an individual, so in the public setting by public officials, consequent to, presumably, justification. So this is a type of punishment proportionate to the bad deed. And thats about all i can think of off hand in response. Thats one type of situation. And then youre citing, how is and this is the part i wasnt clear from your statement what is the concern around this discussion, whether its physicianaided dying or physicianassisted suicide. Are you asking what is the distinction between the two . Or how to harmonize them philosophically . Yeah, more in that vain and then just in terms of im interested how the individuals who actually, you know, inject the cocktail or whatever in terms of executing another individual under Capital Punishment obviously, theyre free from liability. Oh, i see. So, im also interested in that aspect. Ill repeat an argument i have heard, not one that i embrace. The argument on the Capital Punishment side is that this is a public act subsequent upon a bad deed, if we want to call it that, what is the precipitating cause, serial murder, for example. And as a result, the people, in our arrangement, through the government have decided that a proportionate penalty for that bad deed involves state killing, akin to why are we involved, another form of state killing is our declarations of war. It would be another vehicle. Or a Police Officer having capacity of legal force. So just speaking off the cuff, those would be three elements. They deal with the public order. This arrangement is not and this is apart from how anyone feels about it this is not an act of government. So the individual practitioner or organization takes accountability for what they do. Now, just to go back to my point about two forms of ethics so we have the autonomy model. There is a step child, a till taren ethics or consequentialism, and in that we often hear about pragmatism, whats the outcome . Doesnt really matter how we get to the outcome. So, in the point you well raised is what is the distinction . St theres death in both and they occur by persons who are occasion to do it. But on the one, its a governmental action, and then on the other side it is more, if we can use the word private. The awkwardness is, physicians, like attorneys, are licensed to practice, so we are officers of the court. So we have some type of relationship with the government. And i dont want to go off on that because i really dont know what that is beyond that simple statement, but that is what i would say, how i would try to intellectually harmonize it in my mind. And ill defer to pam if she wants to nothing to add. Lets take one last question here. Good morning. Thank you for being here today. My name is john patterson, staff attorney at compassion and choices, the one you mentioned earlier. We are the nations largest nonprofit dedicated expanding choice in improving at the end of life. A few quick comments first. The district of columbia has passed the medical aid in dying law, so i wanted to add that, we have a new jurisdiction on the map soon. Regarding language, physicianassisted suicide isnt the term used, physicianaided death isnt the term being used right now. Its medical aid in dying. I wanted to bring up you mentioned the importance of the educated conversation. And in religious institution, you talked about how they can opt out of participating in the law, which is the handling of medication, prescribing a medication, administering medication, what not. However, theyve also treated giving information, the physicians at those facilities being able to get information as participating in the law. Do you find it problematic that religious organizations are restricting the ability for patients to get information about medical aid in dying as a process, and how has that played out at facilities that youve either worked for, counseled for . And what advice would you give to those facilities who are treating the information alone as a consciencebased objection . So, thank you. Ive actually presented on comparisons among the different laws. So, the statutes vary on this issue, jonathan. But in those states where the religious organization or the organization for reasons of conscience can withhold the information, its a right that was negotiated as part of the very messy legislative process, and i respect that thats the way it was resolved. I think its a little bit of an ostrichs head in the sand when you think about how easy it is to get information in our society and how any senior or younger person can pull up the internet and get all the information they want and more. So i respect my clients rights to say we feel so strongly about this issue that we dont want to give information, but my advice is also frequently, you want them to get correct information, and theres a lot of misinformation out there. So, would it be in your best interests to be the source of some of that information . And thats one of the reasons im speaking to a lot of my clients resident bodies. Illinois, for example, has a statute changing the conscience clause statute taking effect january 1. And in that statute, it says that the individual provider is to give information as to a procedure they are not providing for moral reasons, where its reasonably expected that that service could be provided. I am of the opinion and then the question arises, is that collusion and an immoral act that many would see as tainting their integrity and an imposition on their freedom of speech . So often, the conversation is, well, this is corporate practice in medicine. On the other hand, the physician or other provider can go practice elsewhere if they want. But im not in favor of that. I agree with pam, the information is out there. Anyone can get it readily. But on the other hand, also, the service, whether its religious or secular, that chooses not to engage in it, i do believe there should be some acknowledgement that if we have a diverse society, were going to have different approaches. And if we buy into a commercialized view of medicine, then the customerpatient, either them self or through an agent, can take their business elsewhere. And i do think this is going to be a major issue Going Forward. And the thing i appreciate about our conversation today is its been a civil conversation by people who have two very different points of view on the topic. Please join me in thanking our panelists and thank you to all of you. All right, hello. Good morning, everybody how are we doing . Still alive . Still awake . Want to talk about medicaid . Ill take that as a yes. So, good morning, everybody. Welcome to a moderatorless panel. We are going to make this work on our own. Im matt salo, executive director of the national so, of medicaid directors. Im going to be going first. And following me, as you can see, is david salisbury, an expert in the field and in all things texas. Thats it for my introductions. Im going to go first, talk a little bit. Then davids going to im going to do sort of a National View of medicaid issues. Davids going to dive in, talk a little bit more about texas. Then were going to open it up for q a. And then well get started. And i see my timer here is going, so were on the clock. So, i am always pleased to be anywhere talking about medicaid. The most Important Program in the country that very few people actually understand or know exists, which is a real challenge. And like i said, im going to talk about things from a National Perspective and try to do a little bit of a past, present and future, if i can do that within 20 minutes. We had talked about this session we had developed this session a couple months ago, prior to the elections. Clearly, things are a little bit different moving forward in terms of what the future will hold, and i will try to accommodate or acknowledge as much of the crystal ball that i actually have. But i think its important to do a little bit of levelsetting. As i understand, theres probably a couple of experts here and a number of people who are not deeply immeshed in medicaid. So as i start off at 30,000 feet and dig deep, i hope not to bore the experts at the front end or get too much in the weeds with acronyms at the back end of the hour. So, bigpicture stuff. So you know, i represent the individuals in all 56 of the u. S. States and territories who actually administer on a daytoday basis the Medicaid Program. And the Medicaid Program is one that is very difficult to talk about from a Public Policy perspective. And we find this is true amongst lawmakers in general, amongst the american electorate, amongst any number of conversations. But i like to talk about medicaid as being a program guided by what i call two stickers, the tale of two stickers, one of which is the Bumper Sticker and the second of which is sticker shock, and ill explain what i mean by both of those. The Bumper Sticker first. Its often said in forensics that if you can reduce your argument or message on to a Bumper Sticker, then youre well on your way to winning any argument or debate or election. And part of the challenge for talking about medicaid is that it fundamentally doesnt fit on anybody i Bumper Sticker. It is too complex. And you can try. You know, but compare it to say medicare, a program much more in the visibility of a lot of lawmakers. Medicares relatively easy to put on a Bumper Sticker. Health care for old people. And you can get away with that and people understand what youre talking about. But with medicaid, the challenge becomes how do you put our mission and our goals and our function in the Health Care System on a Bumper Sticker . And the closest most people can come is health care for poor peop people . And thats kind of close, but thats really not very accurate for a lot of reasons. Three of which happen to be, a lot of people that medicaid covers are not technically poor. A lot of people who are poor do not qualify for medicaid. And a lot of what medicaid does isnt actually health care in the traditional definition of the word. So, what is it and what does it do . Medicaid if you, like me, have seen the terrific movie west side story, theres a great conversation in there between tony and riff. Theyre talking about how important their friendship is, and they talk about it being from birth to earth and from womb to tomb. And in many ways, thats kind of medicaids functionality in the Health Care System. We are the birthtoearth program. Medicaid covers more than 50 of all births in this country. We cover more than onethird of all kids up to the age of 18. We also cover the majority of Mental Health services. Were well on our way to covering the majority of all Substance Abuse and Behavioral Health services. We cover the vast majority of longterm care services. And basically everything, every service, every issue, every complex piece of the Health Care System medicaid owns in a very, very big way. But what doesnt it do . Like i said, if youre a pregnant woman, if youre a child, theres a large chance that youre going to be on medicaid, no matter what state youre in. But the way that medicaids eligibility rules work in many, many states historically, if you were the parents of small children, children would be on medicaid, but oftentimes the parents would find themselves left out. And in fact, there have been a number of states, states like a mississippi, i think texas, alabama, where if you are the parents of a minor child or children and youre working but youre making 20 of the federal Poverty Level, onefifth of the federal Poverty Level, as in you would have to make five times as much money in order to qualify to be at the Poverty Level, in a number of states, youre too rich to qualify for medicaid. And historically, in all states, most states, single adults, childless couples or parents of kids who are over the age of 18, no matter what your income is, if your income is zero, you do not qualify. So you can see medicaid does a lot for people who are not poor. Medicaid does not cover a lot of people who are poor. And again, ill come back to this huge, huge role that medicaid plays in longterm care, which i dont think we technically qualify as health care, you know, when youre talking about homebased care, community care, nursing home care, et cetera. So its extraordinarily complexul. It does many, many things in the health care industry. It defies easy description. But we get to the other sticker, the sticker shock. It is a massive, massive program. We cover 73 million americans, and on a combined state and federal basis, we spent 500 billion a year. And the Medicaid Program is generally 25 or so of the average state budget. And by itself, it is 3 of the nations gdp. It is a very large program. A lot of what it does, it does very quietly and people dont know or dont appreciate what it does. So, thats my very highlevel overview of what it is and what we do. Let me talk a little bit about changes and whats coming and what we can safely or not safely predict. So, as i talked about, medicaids a very confusing program. You have all sorts of weird, different ways to get eligibility and then barriers to eligibility. You know, historically, people without kids werent covered, very lowincome working parents werent covered. The Affordable Care act, or obamacare, was intended to fix a lot of those problems nationally. And one of the key pillars of the Affordable Care act was a massive expansion of the Medicaid Program in practically every state. And what it did was to say that every american up to 138 of the federal Poverty Level would be eligible for medicaid, no questions asked. Which would have been a pretty significant expansion and change in role and purpose in a lot of different states. And it was interesting, because that didnt actually get a whole lot of attention during the debates before, leading up to, during and after the passage of the Affordable Care act. And ironically, it wasnt until a significant lawsuit found its way up to the Supreme Court. And the Roberts Court looked at a number of very, very highprofile questions, for example, the individual mandate, which there was, you know, a running bet of, i dont know 50 50 that they say thats constitutional or not. It wasnt until that lawsuit hit the Supreme Court and the roberts decision came out, and they declared that, oh, no, no, no, the Affordable Care act is perfectly constitutional in all aspects of it. Except, except that Medicaid Expansion piece that, frankly, no one was paying any attention to. That, that was the thing that they declared was unconstitutional about the Affordable Care act. And you guys are all lawyers. Im not a lawyer. Davids not a lawyer. So bear with us. But there were some really fascinating legal terms used in that decision. Phrases like economic tribuning ind holding a gun to the states, which had i know this was part of the legal field, i might have gone into law school. Thats pretty good stuff. But it wasnt until the decision came out that people said, what, medicaid . Theres medicaid in there . Yeah. Theres a lot of medicaid in the Affordable Care act. In fact, if you look at the Affordable Care act as a whole, as a law, the Congressional Budget Office looked at that and said this law is going to spend 1 trillion over a tenyear window. Half of that was medicaid. And again, really wasnt until the court came out and declared the expansion unconstitutional, people recognized it was there. Its a pretty important component of that law and of the Health Care System. So, that set in place a number of very, very interesting conversations where with the declaration of this expansion unconstitutional it became an option for states. And there was a lot of questions very early on about, well, what does that mean . What are my options, you know . Is there a menu of things i can do . Id like to talk to you about my options. And as states went to the administration to say lets explore our options, the answer came back was youve got two options you can do the expansion as envisioned in the original law or not. Thats it. And that turned out to be just fine for half the states, and half the states said, thats great, well do it. Were going to get 100 federal matching funds for the first couple of years. That will phase down to about 90 eventually. Thats a good deal for us. Well do it. But other half of the states said, no, thats not good enough. And that set in process a number of very, very interesting political and ideological conversations between states and the administration about different ways to get there. And you saw starting with arkansas, which developed something called the private option, which was essentially expanding medicaid but taking the vast majority of those individuals and actually enrolling them into private coverage in the exchanges, but taking a small number of the sickest, the frailest, the most medically complex patients, keeping them in medicaid tradition and kind of ended up with indiana, which got approval for something called healthy indiana 2. 0, which essentially was a system of Health Savings accounts run through the Medicaid Program, and which for the first time in i believe the programs history, the addition of a beneficiary financial contribution in the form of a contribution towards the hsa, that was binding, as in failure to pay would have actual repercussio repercussions. And those repercussions could include losing medicaid coverage for some period of time. Never really been done before in medicaid. So thats kind of where weve got about 31 of the states who have done the expansion up until now and the rest have not. Which kind of leads us into, whats next . So, we are having a lot of conversations around, well, what is the prospect for expansion look like in the next administration . And as people were thinking about, well, what would a Clinton Administration do to sweeten the pot to get the rest of the states to do the expansion coverage . How flexible would they be . What would that look like . But now were in a very, very different scenario. And now there are two major conversations that are going to be happening, that are starting right now, and are going to be occupying the attention of everybody who is interested in medicaid over the next several years. The first of which is repeal and replace of the Affordable Care act itself. Now obviously, this is something that has been proposed and passed by the house and or the senate, many, many, many times, but was never going to get anywhere under the Obama Administration. But now, very clearly, theres the votes. And you know, on some level, you kind of think about, you know, the scenario is, its sort of like a dog chasing a car. You know, you can chase the car all you want, but what happens when the dog catches the car . I think the scenario here is that the dog has caught the car and the dog has to learn how to drive that car and not drive that car into a ditch and do so in a relatively small window of time, because similar to what the Obama Administration learned, once you know, its sort of the pottery barn philosophy of government. You break it, you bought it. And with the passage of the Affordable Care act, the Obama Administration owned everything that happened in health care, whether it was related to the act or not, good or bad. And what we will find now is that the minute that a repeal vote takes place, the Trump Administration and the congress will own everything that happens in health care, whether its related to that repeal or not, good or bad. And they are going to be highly, highly motivated to figure out how to fix this and how to prepare this in such a way that doesnt completely destabilize the market. So there are going to be a lot of conversations now about what does repeal look like . All of it . Parts of it . Just the stuff we dont like . Will things be rebranded . Will bad things be phased out and good things phased in . Under what timetable . Will it be set around the midterm elections . How much time do you actually need before the insurance companies, who are a pretty important part of this, look at this and say, we cant work in this kind of chaotic environment and were going to pull out, and then, therefore, destabilize the market . One of the things were going to try to be engaged with is to say, you know, to step back and say, some of these questions repeal, replace, should medicaid be turned into a block grant, bigpicture entitlement reform, medicare reform these are very, very highlevel, political questions, and these are way above my pay grade and theyre way above the pay grade of the state medicaid directors. But in many ways, the state medicaid directors are the people who run these programs, and like the mechanic, these are the people who understand how the car works. These are the people who when you open up the hood know where all those various hoses and cords go and need to be at the table to be able to help folks understand and appreciate what medicaid is and what it does. So, which leads me to the second question of because you know, in case the aca repeal and replace doesnt take up everyones attention, there is also going to be a very significant conversation around medicaid reform. And converting it to a block grant, converting it to a per capita cap, making changes. Part of the challenge about talking about this, throwing around the phrase block grant to me, its somehow similar to the six blind men trying to ascribe an elephant. You know that story. Youve got one guy who touches the tusk and goes, the elephant is a spear. Another touches the nose and says no, the elephant is a giant hose, you know, and so on and so forth, you know, touches the ear, its a fan. Depending on where you stand, what a block grant is or does or means could be very, very different things. And so, its very hard to conceptual i conceptualize what it could do, what it means. But again, from our perspective, i think the important thing is, we want to make sure that the people who are going to be thinking about these changes understand how the Medicaid Program works, what its role is in the Health Care System, and how interconnected it is with everything else. I think the fear or the challenge is that and again, this comes full circle because medicaids not terribly well known and often not very well appreciated, it becomes very easy to sort of dismiss it as a simplistic program or a, oh, thats Just Health Care for the poor. And in fact, its easy to look at medicaid and say, well, who are the people on this . A lot of pregnant women, a lot of kids, a lot of lowincome, working families. And its very easy to look at that and say, i know who that is, thats a welfare population. I know how to fix welfare. And you can go back and you can dust off 1996 welfare reform and say, look, heres a welfare program. It was an entitlement. We turned it into a block grant. We gave it to the states. We talked about time limits, we talked about work requirements, we talked about personal responsibility, and it was a grand success. So, lets do that again. But its critical to understand that thats many of the people who we cover, but thats not where the money is. The money in medicaid is in very, very different places. 40 of medicaids budget is spent on Medicare Beneficiaries because medicare and i say this for the purpose of being somewhat provocative medicares largely irrelevant for a significant number of really sick and really poor seniors. And we spend 40 of our budget paying the premiums, copays and deductibles for paying acute care and Mental Health benefits when medicare runs out, and for doing all of the longterm care in this country. And in fact, twothirds of medicaid spending is on seniors or individuals with a Broad Spectrum of disabilities. Thats where the money in medicaid is. Thats what the Medicaid Program does. You have to understand that in order to make changes, and you have to understand that when you start to open up the hood. So those are the questions that are going to be going on. Those are the conversations that are going to happen. I view our role as being educational and informative, trying to lay out the reality of the World Without getting into very highlevel, above my pay grade, political questions about should you or shouldnt you, because again, that will be for other people. So, let me stop there, turn it over to david, and then wed be happy to take questions from all of you, so. David. Thank you, matt. My name is david salisbury. Ive been chief Financial Officer with various health Care Organizations, large systems, mainly academic and or Public Health systems for 25 years. And for the last two to three years, about three years, ive crossed over to the dark side to do health care consulting. So, what id like to do is just take a few moments to really kind of expound on, kind of drill down into what matt stated. We talked about texas and whats that like for texas, one of the states that said no to Medicaid Expansion. So, let me start first by just giving you a little bit of kind of the layout in texas in terms of its Health Insurance coverage. Youll see in the child care population, ages 0 to 18, texas has about 3 million individuals, kids in the Medicaid Program, and about 700,000 kids that have no coverage at all. Thats a total of about 7. 6 Million People. We look pretty similar to the nation in this age category. Where texas looks very different from the rest of the nation is in the adult population, the age 19 to 64. As youll see, we have 16. 5 million individuals, of which 1. 2 million are covered by medicaid and 3. 6 million are uninsured, which would give you a 31 ratio in terms of the uninsured versus those covered by medicaid. And the reasons for that, as matt stated, the coverage requirements are very strict and often well below the Poverty Levels. I think we do run a distinction as well, is that in total, we have more individuals uninsured than we do in medicaid. So its been a challenge for the state. If you look at it as a percent of population, youll see about 40 of our children are covered by medicaid, compared to the nation of 39 . So again, we compare fairly consistent there nationwide, but its in the uninsured population where youll see in that 1964 population, 22 of our population is uninsured, whereas compared to the nation, its 13 . Combined of all age groups, texas does run the distinction of having the highest rate of uninsured in the country of 18 in these two age buckets. As far as how medicaid is funded, youll see that the top line there, medicaid is funded, 59 of its funding is from the federal government, compared to 41 provided by the state. That compares a little bit favorably to on a national level, were about 63 of the funds in the state come from the federal government and the state covers 37 . In total, texas has a 35. 8 billion budget for medicaid in 2015. And again, 14. 7 billion provided by the state and the remaining 21 billion provided by the federal government. Because of that, our state is fairly heavily dependent on supplemental payment programs. Youll find that 9 billion of the 36 billion in texas is paid through various supplemental payment programs, the first of which is the 1115 waiver. Texas has the distinction of having the highest approved amount waiver, had 29. 1 billion approved over a fiveyear period that ended september 30th of 2016. Broken up into two pools. One is a Delivery System reform incentive pool, which was used to transform the care provided to the medicaid recipients and the uninsured recipients through about 1,400 different transformational projects that are coordinated and run within 20 regions by various entities. Texas also relies heavily on uc funding. The uc funding replaced what was formerly upl funding. What youll see there in 2016, both of those programs were at about 3. 1 billion each. The state also receives a fairly sizable dish allocation of 1. 8 billion provided for the high medicaid and safety net facilities on that. On the longterm care side, the state had implemented whats called an Impact Program or a Quality Incentive Payment Program that was really meant to try to bring additional funding to the Nursing Homes. As matt indicated, nursing home funding is one of the largest line items in a states medicaid budget. And then finally, theres a program called Network Access improvement. That was developed to allow largely the Academic Medical Centers and the Public Hospitals to try to develop innovative ways to enable access and expand access in the state. Again, all in trying to serve largely the medicaid population, but in addition, this large uninsured population. So, currently, what are some of the hot topics in texas . So, first of all, theres really kind of three areas that texas today sees friction with, with cms over, and that is really among many priorities, but these three tend to stand out. And as i noted earlier, uncompensated fair funding is a significant element of how texas facilities are funded for their uncompensated care. And really, cms does not see that as a longterm solution. They certainly prefer expanded coverage as a solution and see that more of an integrated way to manage care and manage outcomes for that population. Secondly, cms believes the Medicaid Program should pay adequate feeforservice rates. By various calculations, youll find in texas, texas Health Systems are paid between 55 and 65 of costs for care to the medicaid population. So youll find that theres a significant shortfall that acruise to the hospitals when they do treat medicaid patients. And then finally, cms has, i think, been on the forefront of trying to really innovate around managed care and innovate around various valuebased payments options and quality incentives for the purpose of transforming how care is provided to this population. As well. And so, again, the state of texas has been slow to adopt some of the majors that other states may have adopted, and ill talk about that in a minute. Youll see that in large part in 1115 waiver program. So, things that are really on the forefront in texas right now is, as i indicated, our 1115 waiver expired september 30th, 2016. It was extended through december of 2017, and now there is talk with the Election Results of another 21month extension of that program. It is, as i noted, a 29 billion program. And texas has about 1,400 disparity projects that are all geared towards different aspects of care coordination or improper deduction of care utilization or expansion of Behavioral Health and Mental Health integration in the state, but it has largely excluded the managed Care Organizations. And thats a scenario that even the state has recognized that we have to figure out in texas how to bring these two worlds together to try to continue to manage that population. The second area of contention in texas is its large dependence on an uncompensated care pool. As i said, its 3. 1 billion. And cms would like to see that pool reduced and potentially rates expanded on that. That argument has to do with the availability of funding. The second area of contention between cms and texas has to do in the area of how it funds the intergovernmental transfer in order to pull down the matching funds. So in texas, for its uc program, the state of texas does not provide any funding for the uc program. Its state portion is generated through Public Hospitals and other governmental organizations that have the ability to put up in our case, we put up 41 cents and we were able to draw down 1 or 59 cents from the federal government on that. A lot of that funding has occurred through a model called Community Benefit model, where it becomes a partnership or where it becomes a relationship between various private and public entities. And in that case, the private entities or the public entities are, because of that relationship, are able to put up an igt. That particular arrangement has been in place for about ten years, and it has been under fairly significant scrutiny for ten years. And most recently, it rose to another level where the arrangement in the dallasft. Worth area was disallowed and is now going through the appeals process. That occurred on september 1st. Texas filed an appeal on october 28th, and now theyre waiting for the response from cms. Thats a significant issue for the state, because as i said, the state of texas does not provide a lot, if any, funding for supplemental payment programs, which is about 25 of our funds. And so, what youre actually seeing happening now in texas is a lot of effort on a program called an llpf local provider participation fund. Its akin in many ways to a Provider Fee Program that you may see in other states. The challenge in texas is we dont like taxes or anything that looks like a tax. And so, texas actually currently has 11 of these programs in place at a county level, but theyre typically in areas that only have two or three hospitals. But i think whats happening in texas now is that there is a realization that this Community Benefit model thats been deployed for the last ten years probably has a limited life, and that the state has to come up with another model. So theres a lot of effort around the entire state to look at ways of allowing counties to implement this if they so choose and then these counties would then have to work with hhsc and our state to develop regional payment programs to help increase the amount of payment thats achieved through the payment rates. So thats kind of the current areas of focus. Current areas of focus, where matt touched on really the hotbutton issues with the election, on that. In my kind of cfo candid perspective, i think the Health Insurance exchange, i think in one sense, it may have a limited impact in texas, and thats in large part because most of the insurers pulled out of the exchange in texas. I live in tarrant county. We have about 1. 8 Million People, and we have one option in our plan, and thats a blue cross option on that. And so, i happen to think that the optics of pulling out of that are probably fairly attractive from a political standpoint, but as matt noted, the mechanics of doing that are much, much more complex. Medicaids expansion is certainly a whole other animal in itself. Even though texas did not expand, i think its going to be very difficult to come up with a transiti transition, a model to transition to in the short term. I think its going to take a significant amount of time. I found an article the other day that said that states that did expand, the hospitals in these states actually seen an increase of 3. 2 million in medicaid payments and a reduction of uncompensated care cost of 2. 8 million. So you know, the impact at an individual hospital level is fairly significant, but certainly nothing compared to the impact on 15 Million People who became insured as a result of the aca. And so, whatever happens with the Medicaid Expansion, i think a couple things have to be very, very high on the forefront of our elected leaders minds, and that is, how do we protect this large body of people who now have coverage in that . How do we also, though the one thing that we dont talk a lot about is, you know, how do we continue to provide a momentum for the innovation thats been achieved through the 1115 waiver and other waivers within cms in these transitions . Because weve seen a lot of good things happen with patients, particularly in settings where Mental Health and behavior or primary care and Behavioral Health have come together. Been able to improve outcomes, reduce hospital visits, reduce meds, the number of meds an individuals on. We certainly would not want to see the gains that weve had there occur. Now, one might think if you read some of the National Information that the block grant for the states that did not convert seems like its kind of like a winwin. I think people are really starting to drill down on this now and starting to understand that, you know, a block grant approach, is that really a friend or a foe to a state . You know, it was noted on a call was on last friday, where the speaker indicated that theres potential possibility under a block grant approach that the state now has to assume a lot more financial risk for the outcomes and the cost of care for a population than they would under the existing program. And so, a lot of those details, obviously, yet to be favorite out. But i think were going to find that this, you know, has its own set of dynamics and own set of issues related to that. Oftentimes, block Grant Programs result in a replaceandreducetype approach where states actually end up with less money than they had prior to the block Grant Program. And so, the other challenge i think that i think people have even to get to a black Grant Program it takes probably two plus years to get through all the staffish to and other requirements in order to enact such a program and so so we may barely see the impact of such a program before we hit the next election so i think its for a red state, its a its a state of caution and potential optimistic but a cautious optimistic state. For texas, as i indicated, we here in the middle of extension periods for 1115 waiver renewal. It is a large program, as i indicated, in the state youre seeing discussion around the state of some elements of the healthy indiana plan that matt referred to that may serve as potential model for what texas might look to in terms of trying to reform its Medicaid Program so i wanted to just take a few minutes to highlight that plan assuming you may not be familiar with that plan but one i would reference the bottom of this slide i would ercreference a ret put out by the lewin group of the analysis of the healthy indiana plan. As matt said, its the most aggressive type of 115 waiver15 in terms of its expectations of how the beneficiaries behave and how theyre held accountable on that, but we think it does provide some potential clues as to what a future 1115 waiver may look like in texas and some of the elements that we think may line up well with some of the thinking occurring in texas so to give you a high overview, healthy indiana plan has five goals. They want to reduce the number of uninsured low income indiana residents the. Reason is called the healthy indiana plan 2. 0. It replaced a prior plan that had a small number of beneficiaries so it allowed for a more aggressive approach to that population. It wanted to provide a valuebased Decision Making approach through a Health Savings account. This Health Savings account is referred to as a power account. It wanted to use private market coverage mechanisms to do that, not state hhsc departments. Finally they wanted to have a work requirement that people who are receiving public assistance are actively looking for for work and also have resources for that. So let me just finish here on highlighting just a few of the things that we think again might give a picture to some of the elements of whats in the healthy indiana plan. About a year ago there was the discussion of a plan called the texas way which had many similarities between the healthy indiana plan. Its not been presented or passed through our legislature. And likely wont in its current form giving the new realities of our political situation but there are some things in this plan that get peoples attention. As i said, it does require Health Savings account approach and it uses incentives to around funding of a Health Savings account and the use of that for copays, deductibles and other things in order to allow one to manage their care. Certainly the criticism of it is its not a very large account in the indiana scenario and does it really is it significant enough to change behavior . Again still the question out there it includes incentives to work and generally they do this through giving additional contributions into the power accou account. It also imposes financial penalties so if youve heard one of the challenges texas has had with federal medicaid is theyve been very clear that it doesnt allow the rules do not allow texas to manage very well an appropriate utilization. An example given has been an appropriate edd utilization. In the healthy indiana plan they actually provide copays for nonemergency use of the ed. Youll see here again theyre not significant so one might question whether they have certain impact in terms of changing behavior. Simply because the population may not even be interested in the consequences of not paying these copays, right . From the hospitals perspective its seen as a difficult scenario because its hard to collect these copays even though they are nominal amounts on that. I think another item, though, is that it does require personal accountability for health and wellness and this is one of the areas that the benefit plan, for instance, if an individual does certain things for Preventative Health like gets mammograms on schedule and vaccines and things of that nature then they provide contributions into the fund as well as they give expanded coverage for dental and vision care on that and, again its that approach to try to provide incentives to get people to do some of the thing rights in these programs and so and then finally an element thats not a part of the healthy indiana plan but clearly a part of texas is how do we fund it . You have to have tax dollars to generate igts, to pull federal funds down, we dont like taxes in texas and so, you know they say everything is bigger in texas but taxes. Property owners in texas would not concur with that. Some of you are shaking your head and smiling. Although we dont have an income tax in the state. And as i said the state is looking at an lppf approach to look at a provider fee. I would add this quote, everything looks like a failure in the middle. Everyone loves inspired beginnings and happy endings, its just the middle that involves hard work. And i think we as providers and as a nation have a lot in front of us to try to figure out what our funding for our Medicaid Health system looks like and as one individual who counseled me years ago said, most things in life arent as bad as they look or as good as they look, somewhere in the middle and you have to figure out how to work your way through it, so thats our challenge moving forward so ill end that. Matt if you have any additional comments. I dont. We have a couple minutes left for questions. Who wants to stump the panel . Thank you for your presentations. My question would be my state recently completed a new waiver and extension with cms and i know there are at least one or two other states that are kind of running down here in trying to wrap up discussions on extensions or changes to their waivers. I guess my question would be could a new Administration Come in and say well, thats great, you have a five year waiver but were going to shorten that or make some unilateral changes or even revoke it at a certain point based on new policy objectives. How should we think about these things that have already been approved . Certainly any administration has got a Broad Authority to kind of help to dictate how the Medicaid Program operates. They spend more than half the money. Having said that, i would be i would be surprised to see the Incoming Administration go back and renege on deals that were made. Oiz think generally they would look at how do we start changing things moving forward. How do we allow more healthy indiana 2. 0, how do we allow different approaches but not going back and saying you didnt say what state you were from but, you know, hey, you just agreed to something we dont like, well take it away from you. Thats pretty unusual. Unless theres historically weve seen that but its only been like the administration will come in and say, you know, oh, we really dont like what youre doing from a financial perspective. We really dont like the fact that youre not spending any of your own money, youre just kind of generating dollars through dish or intergovernmental transfers. But generally you dont see much retroactive change on coverage or other types of policies. The other thing i would add is if youre read the Standard Terms and conditions for the 1115 waiver, the ftc, theyre fairly complicated and i think its complicated to unravel some of those and im not sure that scenario is something the new initiatives will tackle with their other initiatives. This morning we heard from tom scully and one of his predictions was that medicaid would move towards a per capita capped but he cited the uneven implementation of the expansion of medicaid and the goodies that already exist in states formulas as being sort of barriers to getting that through in congress. Particularly because a lot of those states are deep red. Im wonder if you have thoughts about that. Tom is always right. [ laughter ] hes a colorful character, hes very insight fful knows as wells anybody that there are a lot of mine fields when you get into transforming how medicaid works. The program is so big, so complex, so intertwined with other programs and core functionalities of the Health Care System broad ly but as youve seen from texas, every state has an enormous complexity with how medicaid runs and is funded with respect to how the State Government itself runs so to come in and say heres one way of doing things and it will be a big change for everybody. The big the detritus you would see through and across the landscape from that would be significant. Any number of issues you raised the food fights or formula fights that will have to happen. What is the base year for any consideration moving forward . What are the trend rates . Are there different trend rates for different populations and what are those . Are you locking in take a look at california and new york. The two biggest states, the two biggest medicaid populations almost two of the biggest disparities in per person spending in the Medicaid Program. New york dont quote me but new york probably spends about twice as much per person as california does. Are you locking in california at their historically low conservative or parsimonious or stingy rates . Are you looking in new york at their generous profligate drunken sailor spending rates . These are very real questions and as you pointed out the expansion itself 31 states have done it. 20 or so have not. If you havent done it, have you looked out. That was a component of one of the original ryan plans youre locked out. Is that sustainable . What is that going to say to the texas and florida . Would they want it . And part of the other question would be as part of repeal and replace what are they going to do about the expansion itself . Will it be eliminated right away which i think is highly unlikely or will it be will they look at it and say well keep in the place, be more flexible but over the next ten year window well phase out the money so it will phase down from 95 federal to whatever your regular state match is. That, again is these things set into motion a lot of very, very difficult state to state delegation to delegation fights that are going to have to happen. And any time weve looked at anybody can look at medicaid and say we dont like at how that piece of it works. But wherever those challenged to come up with a new way of doing it, you find that its so complex that theres no easy way of fixing it in accommodating everybody. Its like im going badly paraphrase the is it the Winston Churchill quote that talked about american democracy which is that the worst possible form of government except for all the others and in some ways you can look at the medicaid financing structure and say thats the possible thing except for all the others. Creates winners, creates losers. When you need to maintain keep in mind, the house has got votes to do a lot of things. The senate can do a lot with 50 because theyve got tiebreaker votes by reconciliation but that doesnt give them much wiggle room and if you start making big losers out of states that who comprise that margin of error, it becomes much more difficult. So these are very real and Difficult Conversations that you only get into when you open up that hood and look at how the car runs. All right. We are at time. I think you need to eat lunch so thanks for having us. [ applause ] this conference from the American Bar Association now taking an hourlong break for lunch. When they come back, a conversation on Health Care Fraud and the justice departments efforts to prosecute Health Care Fraud cases. While we wait, some discussion from earlier with former medicare and medicaid officials. First, let me thank you for joining us this morning for the panel. Whats in store for Government Health care, a diskugs of the postelection future of medicare, medicaid and obamacare with former cms leaders let me give you a little bit of introduction and tell you how the program is going to work. First of all let me tell you who i am. My name is mark pollston, im a partner at the Health Care Practice group at King Spaulding. Before joining King Spaulding i worked as chief litigation counsel for cms and i had the pleasure of working with all the Panel Members here in that capacity. So ill be the moderator of the program. This is intended to be a moderate discussion between me and the panel but we want to hear questions from the audience because when we first set up this panel it was about two months ago so prior to the results of the election so we had a certain concept of how it was going to go and now its going to be a completely different concept so were all very interested to hear what everybody has to say about the potential for the new administration and the transition. Lett me spend a little bit of time explaining who is on the panel. You have collectively in front of you three individuals who have presided over some of the biggest changes in governmentfunded health care in the last 10 to 15 years. Theres the medicare modernization act which brought in the Prescription Drug benefit part d to the Medicare Program which tom scully and Leslie Norwalk presided over then theres the Affordable Care act, known as obamacare and john blum was a major contributor to the Affordable Care act at cms. Let me give you a little background and ill start going down from left to right. Tom scully is a Senior Council at austin and bird. Has practiced health care on regulatory matters and hes a general partner with welsh, carson, anderson and stowe a private equity firm in new york city. Tom is the administrator from cms from 2001 to 2004 and he was instrumental in the designing and passing medicare reform and Medicare Part d legislation. One of his achievement in addition to the implementation of the part d drug benefit was initiating was comparing the quality of hospitals, Nursing Homes and dialysis centers. Before that, he served as president and ceo of the federation of american hospitals. Next is Leslie Norwalk. Leslie is a Strategic Counsel to epstein, becker and green, ebg advisers and National Health advisers where she represents private equity firms. Leslie served in the administration as the acting administrator for the centers for medicare and Medicaid Services after toms departure. She managed the operations of the medicare and Medicaid Programs and the schip program, i guess which is just now called chip and for four years prior to becoming the acting administrator, she served as the deputy administrator to tom and was also deeply involved in the implementation of the medicare modernization act provisions which included many things in addition to the medicare Prescription Drug benefit program last but not lest we have john blum, current kpengive the Vice President of of affairs at care first blue cross blue shield. He works on care coordination policies, pharmacy policies and provider networks. He spent most of his time at cms basically being the chief of operations for the Medicare Program which, of course, regulates not only the fee for Service Provisions and the Medicare Program it regulars the Medicare Advantage provisions as well as, of course, the Prescription Drug benefit program so he inherited that from tom and leslie, prior to cms john served on the staff of the Senate Finance committee working for senator baucus and he served as Vice President at ableer health before he joined cms. So thank you to distinguish pnl for change us. This is intended to being a dialogue. We have approximately 1 15, probably less at this stage and what i would like to do is start off with a few questions. I think there will be a lot of people interested in whats happening right now with the transition between the Obama Administration and the soon to take over Trump Administration in terms of transition policies. We have somebody who is the nominee for hhs secretary tom price. We have the nominee for cms administrator seema verma and so id like to start off the questions a little bit looking at transition policies and i think wed like to move into more substance. But if any point in time anybody feels inspired to ask a question, raise a question, get it to microphone and well handle it that way. John, you were probably the most recent member of the panel to experience the transition to go through a transition from a Republican Administration to a democratic administration. Give us a sense of what is happening now through the transition from your perspective what you think theyre doing, some of the things im interested in learning is do people come in with a blueprint in terms of what happens to Health Care Policy . To what extent is it created now and if you have any insights about the current transition and the Trump Administration, if you want to give us your thoughts about that . Happy to. I was on the Transition Team in 2008 and 2009. Im sure every team works differently and theyre driven by people running the transitions, their priorities and policy goals but the one observation that i had is they they try to fill the promises made by their candidate and the reality is particularly coming into health care and cms is there is a mix of discretionary decisions at a policy Leadership Team and things they have to do and medicare has very firm statutory deadlines. Theres things that have to be decided upon on january january 22 wherever the new team comes in so a Transition Team has to think about two things at the same time. One is how to fulfill the campaign pledges and i think health care wasnt part of the National Conversation other than to repeal the Affordable Care act there was not a real rich debate about the future of medicare or how fraud and abuse and core cms programs should operate. The Transition Teams need to think about how to implement the Campaign Promises but then, two, how to get ready for nuts and bolts decisions and you may have a very well thought out plan to how to implement those discretionary decisions but youll get hit with crises from day one. And coming into cms in 2009, there were Public Health crises we had to respond to and medicare regulations that had statutory deadlines and pentup decisions from the previous teams that had to be decided. So Transition Teams need to be staffed, they need to be prepared to function, prepared how to make day one decisions so a team will come into cms on january 22 or so and theyll be faced with decisions that first day they come in. And some advice to the Transition Team is absolutely think through how to fulfill campaign pledges and promises but get ready from the first day youre in the agency to start making decisions and get ready to deal with things you hadnt planned to deal with. Public health crisis, things will pop up on a day to day basis and teams have to be ready from day one to react and handle those things that just pop up. John talked about Campaign Promises and pledges. When you transitioned into in the Bush Administration i guess i have a twopart question. What pledges and promises did you thought you had to keep and skdly whoo do you see as the current pledges and promises that the Current Administration has made in terms of i guess were limited to medicare because of course theres an enormous number of other proms that have been made about Affordable Care act changes. Totally different this time. I had two transitions, i was in the 88 transition because we won that and picked gail linsky to be the administrator probably in march or april. So it was a whole different skag. We have some Health Issues but i was not involved in the 2,000 campaign. I worked for president bush, senior and i got called out of the deposit in 2001 as an old bush flunky to go to the cms job. But first time i ever talked to Tommy Thompson was in late january, i got nominated the last week of january so as the cms administrator nominated before the secretary of state, one of the first two nominations show that health care not only did we have big issues but repeal or replace whether you like it or not is one of the top two or three issues. You cant escape it. John is correct. Once they walk in the door they find out that you drink from a fire hose and whether youre a democrat or republican, it doesnt make any difference, theres a 1. 5 trillion agency and theres a lot going on. But the issue of repeal or replace, theres nothing like that in 88 or 2001 when you were one of the two or three top National Issues secretary price, our new administrator, theyre way ahead of the game. So in my experience i worked on the 88 transition, a long time ago, im actually 106 years old. We didnt do anything in the 88 transition. We got people confirmed and then sat around and talked about healthy policy. I started talking to Tommy Thompson and Medicare Part d and president bush who really wanted to do it and revitalizing medicare and managed care in april or may. Gave them a list of things they want to do. But ive never seen anything like this. This is way out of the normal time schedule in my experience. I want to go to leslie but tom you reminded me you were the individual who was responsible for changing hick have to cms. So maybe you can answer the eternal question everybody has. Why is the center for medicare and Medicaid Service just cms. I chachk it had name because i was hoping leslie would get confused if she saw the name on the building and get confused and not go to work. In the cms hick a world, we know each other and are friendly. Nancy replaced me in the white house after bush lost to president clinton. Hcfa was believed to be big and bureaucratic and i said to Tommy Thompson, lets change the name. He said youre nuts, you want to get killed . Why do that . I said, youre right, well let me ask you what do you think about vencore which i knew was a Nursing Company in wisconsin. He said i hate those guys. They threw people out in the street because they wanted to get rid of medicaid patients. I said youre right, theyre terrible people. I said what about kendra . He said i like those people. I said guess what . Theyre the same people, they just changed their name. To the hcfa name is made up by the secretary of health. The question is why one m. Oh, because i already mumble anyway, as you can tell its cdc, center for disease control. So we sta it was me and secrey thompson thinking it up. And he liked mma and i did a poll about that and we found out that mama was not going to be mop you already a so we came up with cmms and it didnt sound right so i said cdc, lets just drop the m and make it cms. In terms of transition, maybe ill alter the question a bit because in my experience in terms of being responsible for Prescription Drug implementation i think theres obviously going to be some sort of change that will come out. Can you describe your experience in leading the transition in the standing of a new benefit, what that involved and what that might look like in terms of some sort of significant change that ms. Verma will have to deal with when she takes over . Well, if i were to give her advice i think it would be several fold. In as much as it involves the exchange, the critical component to make them successful would be Health Insurers and making sure that those companies are on board, appreciate the changes, can appreciate if cms says something it will have a reaction externally around that could set up success or failure of whatever the change may be Going Forward and i know its a lot of what i suspect all of us are reading now in the press is making sure whether its Something Like care first or humana etna and all aetna ca really focus on if were going to have an exchange, somehow the exchange successful. If youre going to have medicaid managed care, are you changing the program in a way where you can participate successfully . And to have a marketplace, whether it be medicaid and medicare or the insurance the individual Insurance Market work means that Health Care Providers can also get paid so its and if Health Care Providers are getting paid youll have networks and individual, beneficiaries can participate as well. So if youre looking at changing medicaid and obamacare which i think most people see as the exchange, if youre looking at making fairly significant changes to those programs, really involving industry, whether, again, insurers or providers and how the changes will impact those players will be critical in success Going Forward and also listening to your staff because in large part a lot of the things that happened, if you dont listen, for example, too the actuaries who will have an often a role in determining what something costs from a score keeping perspective, that can be a very Important Role in determining whether or not a policy is successful in Going Forward or whether there are fights about something cost, something tom and i know too well from determining whether or not the drug benefit was going to go forward and once it did the controversy surrounding it afterward. So i think if i were to give fema advice, it would be listen to industry, listen to your staff and be prepared for what will happen coming at you from both sides Going Forward but ultimately the goal is to be successful with whatever the new policy is which is more likely to be determined by congress than to be determined by cms. Well, and thats a good transition to some substance here because ive been asked what can we expect out of the new cms administrator designee and my response is we dont know what cards she has in her hands let alone whats in the deck for her to deal from so that will be set by congress. And we could spend a lot of time, i think, on the panel kind of thinking about and theorizing about what Congress Might be willing to do but lets take as a premise lets talk about medicaid for a second and take as a premise that theres no major change to Medicaid Program. It didnt get converted into a block Grant Program by congress so ill throw that question out to john. John obviously the new administration is going to want to do something with medicaid but medicaid has also been over the last fur a surs of coverage, extension of coverage to a large number of individuals what sort of thoughts do you have or what sort of things do you see in terms of legislation that the new administration might want to do with the Medicaid Program. I think from most cms perspectives the Medicaid Program is in large part run by the states, obviously. The governors have a lot of discretion, they have a lot of thoughts about how to reform medicaid. And what the nominee says to me is that its going to be a very high priority placed upon working with governors, working with states to modify Medicaid Programs and to shape them to meet different state priorities theres nothing in law like Many Medicare that requires the agency to do anything with medicaid. That states determines medicaid and in large part eligibility role consistent with federal guidelines but i think the choice to with the cms nominee is to me that the new team wants to work with states, wants to listen to governors and have him place much more flexibility to determine the future of the different state programs. I think what is happening right now, both on the exchanges but also in the state Medicaid Programs is a tremendous coverage growth obviously but theres also tremendous need and so we can see from a care first perspective that those who are signing up for the Exchange Products have Greater Health care needs that are general populations, they kbruz high cost drugs. They use the hospital more often than the care first population. So in addition to thoughts about working with providers, what the next team needs to reals is that those that did sign up for coverage are sicker on income or lower income on average or and they have to think about transitions that if the care is disrupted or change theres a lot of people going through cancer treatment, a lot of people going through serious chronic illness so how you think about transitions and the continuity of care and the disruptions in addition to the provider plan concerns, those will be real and very tangible for the next team. So let me ask you the same question, john talks about obviously people on medicaid, states would like to have flexibility in determining what their programs are. I think theyre seen as somebody who managed to use what flexibility was being offered with Medicaid Expansion with the state of indiana and sort of create Medicaid Expansion on indianas terms. Medicaid expansion, every state means basically id like to expand and use 100 federal dollars or as they said on the radio yesterday, what governor romney, who i love, the massachusetts wonderful expansion with them with with 100 federal dollars and zero massachusetts dollars so the problem is in the past, you know, medicaid is a Great Program and i hate to disagree with john but this is going to be a complete and total policy war for the next four or five years. Republicans didnt like the expansions, none of the republican states did. Im a fan of Medicaid Expansion up to 133 of