Training to have medicaid expansion. We did this in Public Housing when i was mayor of charlotte which was effective and we want to know if there is any more flexibility or is that the line drawn in that area. I want to congratulate you on you reaching out for us and the honest dialogue. Sylvia in terms of the benchmarks, that is something we will get back to you and your team directly on. With regard to the question of work and how we think about that particular issue with regard to health, in terms of one of the things that is an important thing that both sides agree on that was an important changes that preexisting condition shouldnt keep you from an ability to get health insurance. Maybe how one gets to that maybe, the idea that health care is not a conditional thing. Health care differ by a number of things. Different from tan of tanf. Having said that, we think that there are incredibly strong ways. Were with you on work. That is a place where we would like to see it would be great to have people working and earning a wage. We would just as soon have people in the market. The concept, we have a number of place where we have worked with a number of you all to get to a place that derives this in a way that will get more people through your Work Training program than you have ever seen. We look forward to be able to have that conversation. We think we can get to a portion of what you want, work and cordage work encouraged. There are ways to do that. Governor fallin, Governor Walker . Thank you. It is a pleasure to have a dialogue with you which is important. You have one of the toughest jobs in america. You have a tough job the past year. Thank you for visiting with our governors. A couple of things i want to commend you on. Paying for outcome versus volume of time someone sees a doctor. We are all about approving the health of our citizens versus just what we hope might work. We deliver services. Thank you for that. And the comment about trying to fasttrack the waivers themselves, one of our requests from our governors was that if we had a waiver that you had approved in the past, if you would consider being able to continue that improvement of that waiver because you have done it several times before. We have a Great Program where we have a threeway match of medicaid money and the person paying a small portion of their insurance. The employer paying a portion of that. Back to the question of working and paying, and you have approved that, which i am grateful for. At one point in time, if we have something that is already working, cant we just make that permanent versus every single year trying to reapply for that . I continue to ask your consideration of that particular issue. On the Prescription Drug abuse we have had a great legislation one of the things we have done is passed prescription monitoring bill to stop doctor shopping. It was hard to do. It took me three years to get that through because doctors did not want to have to spend the time away from seeing patients to check this and check that. Could we not do that for medicaid recipients and other under federal guidelines, if someone is on medicaid that you require a doctor to check it every time, or they get a medicare recipient, opioid that may be there to consider on that track. The last thing i want to mention, we talk about rising costs of medicaid and expenses to our state which has always been a challenge. We are one of those states that we have seen unemployment dropped really low. When our per capita income went up, our funds went down. We had a huge drop to the cost of 100 million. Then we grow our population. More people coming into the system am a from the federal government. Now we are going through another economic downturn with the Energy Sector but we are short of that money. It is just something to consider. I wont touch on all of figuring out how we work in terms of making the program encouraged movement to Economic Health and people being able to be in the private system where possible. That is part of how the reductions in funding about trying to get people to move and encourage economic growth. On the opioids i would mention the Prescription Drug monitoring plans. Almost every state has one. In the conversations ive had around the country with a number of you it is a very important enforcement tool and the ease of the tool, the ease of being able to use it, how quickly it is updated, and some of your states do it and some of them down, the relationship with other states. People border shop. That is another issue we need to work on. Bringing folks together, one of the things we talked to physicians about how easy it is to use or not to use in terms of the system, if a doctor says how many cliques you dont want to spin the time checking. That is one idea of how we can influence people with regard to our payment system. That is what we will look into in terms of what we can do. We will need to get to the space where vision assumes physicians are trained. How much training did you actually receive in terms of treating pain . That is one of the issues. We are working very hard. We have a representative from the cdc as part of your panel. We need to make sure people are trained in them. It is about starting at the point of the physician and the tracking you are talking about. A tragic story of a young woman who had gotten her wisdom teeth taken out, took too much of the Prescription Drug after her wisdom teeth, became addicted, after months it became cheaper easier, and better to use heroin, and the trajectory. Four years clean but if we can stop that journey because there are many stops along the way in terms of what happens in that picture. We are seeing it everywhere. It is not geographic anymore. It is not socioeconomic. The number of people that you probably know whose children have some of these issues, im sure everybody in this room does. It is one we want to work on. Governor walker. More of a comment than a question. Thank you for being here for a second time. I appreciate her presentation. Then began a process with me. I begin the process for alaska to be the 30th state to accept medicaid expansion. I share the concern about the were pretty rural. Our methods of getting to our those that need care dont always involve a road. We have 100 and 10 airports. I want to thank you for your passion in this area and for your staff and your access. I know you are the person that gets it done. They are the ones that answer the calls. We worm we are removed from mainstream america. We have russia and canada. There is not a lot of options. We do feel when we have a need washington has been helpful to us. It is a process i have begun. We had 45 days to get through before i can sign it. We appreciate your helping us this far and look forward to helping you. Sylvia thank you for this leadership on this issue. Governor nixon . Governor nixon i want to thank you. On behalf of all of us we feel we appreciate it deeply. This feels a lot different than a congressional hearing i would imagine. Sylvia that is on tuesday. I have talked to a number of folks from your states and prepared. Governor nixon we have not succeeded in the task of expanding care to working missourians. Were working on that again. There is no term on the with side of this, as you look at costcontainment looking forward, you have some triggers that are difficult for states and hospitals that are built into the Affordable Care act. Whether it is on reimbursements for medicare, equaling out payments, or the share. Give assistance of what you are under budgetary wise i think some of the the folks dont think that is going to happen. It can cause the delay of those instead of having it smooth then, could cause a cataclysmic effect in states that dont move forward in a timely fashion. If that becomes a cliff instead of a slide, it has a very cataclysmic effect in rural areas and underserved areas. Sylvia my ability to predict on this one, it involves two things that i dont have a lot of say in. One year, five months, 1015 days is all that i would be here. I will no longer be here pretty other thing i will just say is the congress is engaged on these issues. Part of the way to that ability to predict is limited. I think you all know i will tell you. The one thing is we think of it as a nation, Governor Nixon it is an executive branch decision. It is a congressional decision. Sylvia to turn it off. Today it has been turned off. When the congress has taken action to extend, right. The question whether they will do that again is something im not going to guess. Governor nixon the question is, whether the administration is going to ask them to continue to extend the budget document presented to the congress this year or not . Sylvia i will be revealing proposals in the coming months. The broader issue of how we think about the issues of costcontainment, why those provisions were put in is because it was thought that it would be more costeffective to pay for uncompensated care and indigent care through a systemic approach in the states. Instead of the way that we were doing it. There are a number of tools that exist, some of them, you have mentioned a number of them. They have low income tools pools. So that i think is, why it was put in place is about how can we most costeffectively help low income people have access . Those were the decisions about that. How it plays out is something that we have to evaluate as we go through it. Governor beshear. Governor beshear the experience in kentucky could be enlightening on a couple of these issues. Competition. Before we implemented the Affordable Care act and expanded medicaid we had two companies in the state that would sell health insurance. We now have five. That was that obviously is encouraging to us because we have been working for 2030 years trying to get other companies to come in and we just had no six says added. Now we have that kind of competition. The second thing regards Rural Health Care. A lot of folks live in rural areas. We particularly have always had issues with Rural Health Care and rural hospitals, how late they can stay open. As the demographics change. We have gone, and there are hospitals as a whole have gone from 25 uncompensated care to 5 . Our rural hospitals have in a fitted from this because for the first time in their memories and in mine they are in the black. Their bottomline is in the black because they are getting paid for the care that they are delivering. There is still a lot of problems with Rural Health Care. We are going to continue that. From a revenue standpoint, having expanded medicaid is a boon to our providers. In terms of getting more money into their pockets. It has been a boon to our economy and that before we did it we got Price Waterhouse cooper to project what was going to happen and whether we could afford it down the road. They projected that over eight years we would create 17,000 new jobs and have 15 billion infused into our economy. We implemented based on that and after the first year i said lets take another look. Now we have actual numbers. One year of hard numbers. Consulting went back in to take a look at our first year. We are sorry to tell you that Price Waterhouse coopers was wrong. They thought you were going to create 17,000 jobs in eight years. You have already created 12,000 jobs in the first year in the health care area. It looks like youre going to infuse 40 billion into your economy over the next eight years instead of 15. For my friends who are concerned that the federal government may back up at some point and not do their part or that these numbers at some point may change and we cant afford it, my message would be this, you can stop. The court case says anytime you want to we can stop. Either one of those things happen, you can say we cant do it anymore because we cant afford it. In between now and that, if that ever happens, a lot of people 400,000 people in kentucky are having Health Care Coverage most for the first him in their lives. If you can get past i know a lot of legislatures have trouble just because of the name of the act. If you can get past that politics this is a winwin for both your people and your economy. Youre going to create a lot of jobs and put a lot of money into your economy in addition to improving the lives of these people. Our screenings for cervical cancer, breast cancer, diabetes they have gone like this. These people can get these. What that is going to do is it is going to cut down on the big costs down the road because when they were getting screenings the first and we would see them is when they ended up in inpatient days in the hospital. Now we are able to work with these people to teach them how to take care of themselves and take responsibility for themselves. That is part of this deal. Your citizens need to learn how to do this and they want to know how to do this. That is what we are finding. If there are ways you can massage things around and get to this point it is going to be a big benefit to folks in your state. Sylvia thank you. , to virginia for a couple of days. I could use that. We have almost worn out the secretary. On behalf of the organization i want to express our gratitude for all of your engagement with all of us. We really appreciate it. Sylvia thank you. Thank you. I look forward to working with you this year. On a range of issues that i hope all not im looking around the table. I dont have to call any of you about ebola. I hope that we will have a good year moving the ball forward on the many places that we overlapped and the many places we fund. We want to hear from you. They want to know when we are getting it right and when we are getting it wrong. We have much bigger spaces and Common Ground than pieces of this agreement. There will be some of those but i think we can work on a lot of areas where we can move the ball forward. Thank you for having me again. [applause] now, the bottom line is governor tomlin has set a high standard. Now it needs to be beaten. We are and ask governor brad sit to tell us what were going to look forward to in iowa. I want to thank you for your leadership, delivering results gives us a great toolkit on how we can do a better job in each of our states. I want to thank governor tomlin. This is my 50th state. I have never been to west virginia. We have the whole family here and having a great time. If you saw my grandchildren out there dancing last night, we are looking forward to hosting the summer meeting of the National Governors association in our capital city, which is a surprising place, a lot of things going on there. July 14 through the 17, i have been to summer meeting is, this will be the first time for me to host it. We are looking forward to having you there. My whole family is involved in the planning. We want you to bring your children and grandchildren. My children and grandchildren have gone to the last three. Milwaukee, nashville and here in west virginia. It is been a great experience. We want to make it a familyfriendly thing, and we are going to have events, we have a special governors only spouses dinner at our historic governors residence. Were going to have an event at the World Food Prize hall of laureates, a beautiful building restored library in des moines. We have a beautiful historic fairgrounds. There is going to be a lot of fun things to do. Mark your calendars for the 2016 nga meeting. We have a sweet tooth in iowa. We have this chocolate covered bacon [laughter] and the Candy Company in sioux city. There will be a lot of sweet things in iowa to enjoy when you come next year. Thank you all very much. [applause] thank you. We look forward to it. Little known fact for most of you who are too young, my great uncle was the Lieutenant Governor and the senator from iowa for 24 years. Absolutely. I started a group hug in des moines. I can guarantee we are going to have a good time. I want to thank again governor and mrs. Tomlin, what a great host you have both then. What a place, between this afternoons session, there were 30 minutes where i snuck down and bold a game in the basement. There are eight lanes, i doubled again with my son. It didnt go so well for me. This place, there are new things to find, i can envision coming back here at some point in bringing friends and family. A cabinet retreat. I want to thank all of your staff and volunteers. I know how hard they worked. We should give governor tomlin staff a hand. [applause] first of all i want to say to governor brand stand brans tand, we are so pleased you came to west virginia, for many of you it was your first time, we hope you enjoy and hope you found the hospitality to be to your expectations and we would love to have you stay a few more days and come back to see us again. Thank you for coming. [applause] this is my last meeting as share. That is a relief for some of you. Trying to drive those schedules. It has been a great honor to chair this organization. We have accomplished a lot this year. I have been happy to be a part of that. Probably the best part of the whole process from me is getting to deepen my relationships with so many of you. Governor markell and governor fallin act as my mentors on this. Governor herbert has been an active partner. I wasnt sure if i was the chair or he was. Just because of his natural talent, cream rises to the surface. Getting also to know our sponsors and Corporate Partners and holding those relationships and recognizing that for so many of these companies is not a republican or democrat, they are trying to solve problems to make businesses grow and to make the lives of our citizens better. The nga does a great job of threading the needle to make sure we are working in concert and not at odds with each other. Respecting the importance of competition, the productive side of capitalism. The nga is remarkable organization. It has a dedicated staff. I want to take a brief second to thank dan crip it crippen. Is going to stay with us through the rest of the year. Some have started talking about what kind of appropriate gift we can give him. He came in with us when the organization was not in great shape and he has given his heart and soul. A lot of people dont realize he is a south dakota born and bred, born educated. He worked as a domestic policy advisor to president reagan, director of the Congressional Budget Office under bush. Throughout hi