Thank you so much. Good morning. Thank you, kathy. Thank you everybody for having me here. Am met salem. We just got them with their own annual meeting here in d. C. Not only am i exhausted, but today is veterans day which means all of my kids are off from school and daycare so i had to make all sorts of arrangements to get here. But this is an important opportunity. I was thrilled to put the pieces together to make this work. I can talknytime about medicaid and people actually listen for more than three minutes is great. Especially when i get to talk to a group of folks for whom this really does matter and who can make a very important difference in the things were talking about. I guess the question or the title of the session was medicaid, did it survive repeal and replace . I guess the short answer is, yes. Should we do questions and answers now . We will say a little bit more. Is a very interesting year in Health Policy sphere. You had a great session right before this talking about some of the political angles on it from a couple of great speakers. I think it is safe to say that we have never or suddenly not in my recent memory, had the Medicaid Program as much in the spotlight in the highlight, in the hot seat, if you will, as we have had over the past year. We certainly we certainly expected that. I am kind of thinking about our conference, which is conveniently timed to be on election day every year. Twoall election day with gubernatorial races, but a very big one last year. The results of the election last year laid out a pretty clear plan for what congress was going to address in terms of Health Care Reform and that was going to impact medicaid. There were two big threads of that. Repeal and replace of the Affordable Care act, which despite the attention on the focus that premiums in the individual mandate and Everything Else gets from people, the Affordable Care act is mostly medicaid at least 50 medicaid. If you think about how much money according to the cbo, if we still trust them, how much money the Affordable Care act spent over a 10 year window, it is about 1 trillion. Literally half of that was in medicaid. So that was a big component of the debate. The other big component was the wholly unrelated discussion around entitlement reform and medicaid financial reform, including whether or not we should take the open ended nature of the Medicaid Program, the openended federal Financing Partnership that we have had for 50 years and convert that to a per capita cap. Saw how thate all played out. We came within a hairs breadth or a dramatic john mccain thumbs down on the floor at 1 30 in the morning from doing from that passing. But that certainly doesnt mean any of these discussions are over. Certainly, congress is going to turn and is turning out to tax reform. We will see how that plays out. But i think the impetus in the political and fiscal desires in congress and the administration to continue to make those changes, whether to the aca or to the underlying Medicaid Program, are going to continue. And i think you heard from the last session that how that plays out, what the numbers look like, still a little bit uncertain. But this is not a time where we say, it is all behind us. We are done. Lets focus on something else. I would like to relate a couple of things that we focused on over the past year. By and large, we have mostly remained sort of on the sidelines of a lot of the debate. The big picture decisions should you repeal the aca, should you block grant or per capita cap the Medicaid Program . Those are highlevel political questions. That is generally about the pay grade of state medicaid directors. So what we really try to do over takeof the past year is the opportunity to try to educate and inform people about what medicaid actually is. And this is kind of a lifelong journey for us. Because if theres anything i have noticed in almost 25 years now of doing medicaid policy work, medicaid really does have informationnificant and appreciation deficit amongst Public Policy makers. Theunfortunately, amongst general public as well. Although, i think that is starting to change and i think that is a very good thing. You would would not be shocked if youre too kind of walk away from some of the debate that was happening around medicaid and should be changed, should be reformed, what does that reform look like. You would not be you would not be blamed for thinking, it ismedicaid serves the Health Policy program for incomer, therefore, low working age adults would make up the majority of either the population or the spending. And one of the things we really try to do over the past year is sort of say, well, not exactly true, though. Up graphsing to throw or charts or a lot of data at you, but i will throw out some figures just the kind of put things in context. Medicaid is a big program. It is big and it is important and it has been that way quietly. Not a lot of people really appreciate or understand how much it does. 70 ofr more than americans. Larger than medicare. We also are going to spend year, 600 billion this combined state and federal. It is a very big program. It is 25 or so of the average state object. But when you killed act the onions or say, what is underneath this . Where does medicaid actually spent its money . That is what surprises a lot of people. And that is the information that i think is really important to impart upon Public Policy makers as well as the general public. If you think about, again, where do we spend our money . All medicaid spending is spent on medicare beneficiaries. That number continues to shocked and stunned people. And largely, this is the result is also big program, serves a lot of people, spend a lot of money. But the problem is that for low income, frail seniors, and people with disabilities who are on medicare, medicare doesnt really give them what they need. Limits on acute care coverage, Mental Health oferage, requires a lot outofpocket copays, premiums and deductibles. Medicaid pays for all of that for a small group we call the dual eligible. And the other important thing to keep in mind is that medicare doesnt really do much in the way of longterm care. And again, that is something that tends to shock or stunned people. My grandma is in a nursing home. Medicare is covering it, right . In all likelihood, no. It is medicaid. So 35 to 40 of medicaid spending is on medicare beneficiaries. Medicare asl 20 of i never adults. , or theiroblem is variety of disabilities. Physical, intellectual, developmental. They are not on medicare, but they require a lot of health. They require a lot of longterm care. That is 20 on top of on kids. One thing to keep in mind is in addition to being the nations longterm care program, medicaid also covers almost 50 of all births in the country. So if youre a fan of west side story, earth to earth. That is what medicaid does. To thoseyou go back numbers and add those up, 35 for the medicare duals, another 20 for people with disabilities, another 20 for , what is the math right there . That is 75 plus percent of medicaid spending that goes on people who are not, and in many cases, never will be in the workforce. So we just wanted to make sure that as people are thinking , peoplegticket items thinking about major, major changes, hopefully, they understand where the actual dollars go. Because i think that is probably generally not true. That people understand a lot about it. We tried educate and i think that is made a big reference. Athink we had a session our annual conference just a couple of days ago where we had a bunch of Health Journalists talking about, recapping 2017 and what it meant. One of the things that were remarking on was, we really didnt expect medicaid and medicaid advocate beneficiaries proponents of the program to iny such an outsized role the conversation and in the debate that was happening on the hill. I think is a very good thing at the end of the day. So like i said, we saw how that played out. Attempted replace was a couple of times. Never quite got over that threshold. The conversation, by all means, is not done. It will continue. But what we would really like to see is the ability to really focus instead on the good that medicaid is doing, has done, and can do in the u. S. Health care system. Because that has been the focus of states and medicaid directors for years, and will continue to be the focus of states for years to come. People asked me, oh, you represent all of the states and territories and what is it like . Isnt like herding cattle . The answer is a little bit yes. Because texas and vermont and california and indiana are all very, very different states. Quite honestly, the easy thing for me is that there are a lot of really strong threads and thesealities amongst what states are trying to do with medicaid. And if i can kind of boiling stickera simple bumper slogan of what medicaid is really trying to do in every i think you have heard reference to a couple of times and i think this will resonate with you. Quite frankly, it is moving away from feeforservice. Mean Different Things in different states. But if i am looking at the , what ishe theme unifying and binding the states together, it is to the efforts. One on the Delivery System side and then another on the payment incentive side. Unmanaged,y from an uncoordinated, unsophisticated feeforservice system. My old friend dennis smith who used to run medicaid at the federal level a number of years ago likes to joke that feeforservice, abbreviated ffs , really should stand for defend for self fend for self. Because that is really what it requires of people who have multiple chronic conditions. Comorbidity, cooccurrence Substance Abuse and Mental Health, homelessness issues, people who need Longterm Services and support. Me . I dont know, im pretty healthy. I dont know that i need my care managed all that well. But im not driving the Health Care System. It is people whose health care it is the 1 of our population that drives 25 of the spending and 5 that drives 50 . And i think what we see from state to state to state is we have got to get away from the old system. Medicaid has been that way and medicare is been that way for a long time. And those are starting to change. Medicaid for much of the past much of the past 50 years has been a passive bill payer. We are becoming an active purchaser of health. And we are working with everybody in the system groups,cos, physician hospitals, nursing homes, everybody else, patient thats try to make this work. We have to figure out how to redesign to design a system of care that is built around the individual. Not one that looks at someone question his eyes and ears and teeth and brain as four different parts of something radical body. But as a whole. I sawe just saw some statistics the other day that said for the first time of allore than 50 medicaid spending is now in a capitated form in some type of. Apitated payment arrangement and certainly, much more than 50 of the people. Now, is this all traditional managed care the way people think about it . No. I mean, yes, we have big ncos, big forprofit ncos. We have smaller missiondriven ncos, but we have lots of other things going on that more relevant and suited and tailored to individual states, markets, and demographics, and political sensitivities. So what is going on in massachusetts . Massachusetts, boston is big. What is big in boston . Big hospital systems. So they got acos. Arkansas. Not a lot of managedcare in the traditional sense there, but they are developing patient centered medical homes to try to do the same thing. And even in states that dont really have any managedcare to speak up at all, i think about places like connecticut. They actually tried contracting out the plans to do managedcare a long time ago. Said, we are small enough, sophisticated enough, were just paying a middleman. We can do those same things ourselves. They do sort of a managed feeforservice. And i think about places like out in the Mountain West where i have ready to medicaid directors in the Mountain West who have no atagedcare to speak of managedcare conferences. I said, what are you doing here . Im learning. Im learning with the plans are doing so i can apply that to myself. So the way it is being done almost doesnt matter, but what really matters is what we are moving away from. Say manageditate to care because i think that tends to evoke images of certain things and certain peoples minds. But when i say managedcare am a im really talking about something it is more about what it is not. What it is not is a managedcare. Again, i think something that has been a relic of the this your goal past and something we need to move beyond. But it is not just enough to change the Delivery System. I think about states like in arizona. Arizona has been 100 capitated managed care ever since they had a Medicaid Program. They have the longest experience with any kind of managedcare arrangement and are one of the more sophisticated contractors out there. But even there, a couple of years ago, they looked and said, what are the plans doing with the money we are cap attending to them . Providers paying underneath that. That is not really managedcare, either. So they embarked on an aggressive effort to say, over time, were going to go from zero to 30 to 50 i dont with the end goal is, but significant portion of that capitated payment are going to have to slow down to the providers in some kind of valuebased arrangement, some kind of shared savings arrangement. And that were seeing across the country as well. In arizona, tennessee, ohio, in arkansas. You think about this from the perspective of i have a theme of herding cattle. Trying to figure out how to change the fundamental underlying financial incentives in Health Care System is kind of like herding cats. To thed is trying to say physicians and dentists and hospitals under zynga homes and everybody else, time to move. Way from feeforservice ding it is 80 her 18 he nations economy of the nations economy, health care in general. The secret answer, if anyone asks, how do you herd cats . You move the food. [laughter] food in this case is the money. About theres a great story coming out of arkansas theye of years ago where were trying to pioneer and there were one of the first real pioneers of a shared savings approach. Toy went out and they talked the primary care physicians in the state. The vast majority of them were one or two person practices across the state. They went out and they had a little pie chart. Not the actual pie chart, but bear with me. That a little high chart of health care spending. They said, can you do these pie pieces . Some are really big and some are small. This big one, hospitals, 35 of all health care spending. This other big when . Nursing homes . 30 . Do you see your piece here . You probably cant because it is 2 . It is a tiny piece. But you know what . We are complicit in that. We have built or enabled a system where we are not paying you to do the right thing. Thei think this is fundamental nature of this conversation. Which is that we have to acknowledge that medicaid and medicare in many cases commercial markets have built up over time and inefficient ways. They have built up in ways that the financial incentives inherent in the system simply do not align with what we Want Health Care to do. What do we want sculpted or do . That is a complicated question. But i think at the end of the day, what we want the system to do is to get people healthy and keep them that way. Hopefully, that is not too radical of a thought. In ahe challenge is that few for Service Model feeforService Model, we dont pay anyone to get zinke people healthy. In fact, when people get and stay healthy, what happens . They tend not to go to the hospital or the nursing home or come in for get lots of services. Some people get paid less or not at all. And we just have to figure out a way to break through that and say, no, no, we have to figure out a way to pay you more when you are doing something that really matters, when youre getting and keeping people healthy, that is where you should be hitting or sweet spot of getting paid more. Approach is not dissimilar to others, but they looked at the shared savings model. They said, look, we contract the patience you have any serious categories or conditions, and we know what they would spend inent any radical change delivery of care. And were going to track them. At the end of the year, as the actual spending is less than what our mckenzie numbers told thewere going to take delta and give you half. This was a huge one or should moment of that could really, really change the incentives. That could really change the Business Model. Key, that inhe order for any of this to really , for the managedcare war for the payment incentives, for the valuebased purchasing, we have got to figure out how to attractive,hanges accessible, and sustainable. And that takes a process. Not only do you have to communicate why the current good, recognizing that people have spent decades building a Business Model, decades old and profit margins, decades building their practice around financial incentives and that were talking about flipping those, so you to communicate why the Current System must change. That you also have to be able to articulate what it is you want to do. Ok, feeforservice isnt good. What are we going to . But it is more than that. It is how do you hold their hands to make sure that the transition from Business Model a to Business Model be can be done . And may be that is relatively easier with a big, you know, Physician Group or hospital practice than in a two rural rural doc in arkansas, the yet to focus on what we call the practice transformation. You have to show people how to b and he