Informsion is to policymakers and policy leaders of the most pressing issues and getting the foundation of Health Policy and the evidence and practice and today we here to talk about one of the most resident policy pressing issues and that is the Medicaid Program. Recent legislation would if it made major changes to the Medicaid Program and the discussion about the policy is not over. It will examine medicaid coverage, access to care and Health Outcomes and what might be next in the states and congress and the administration. And i would like to thank our partner, the Commonwealth Fund and we are grateful for their support. And before i introduce our panel, i want to take care of a couple of housekeeping details. Wifiose of you who need credentials, they should be up on the screen. You can tweet to futureofmedicaid. When the time comes for questions, many of you know the drill, but write your question on a green question card or come to one of the microphones on either side of the aisle or tweet your question to future of medicaid. I will go ahead and introduce the panelists. We are still waiting on one panelist. She will be joining us shortly. Our panel, to my left, is sarah, Vice President for Health Care Coverage and access at the Commonwealth Fund. Gail wilensky will join us, she is an economist and senior fellow at project help. She directed the medicareMedicaid Program from 19901992 under george h. W. Bush. All the way to the left is Sara Rosenbaum, a professor of health law and policy and founding chair of the department of Health Policy at George WashingtonUniversity School of public health. Without further ado, i am going to turn it over to sarah collins, and we will get started. Thank you. Good afternoon to everybody, and thank you to the alliance and also panelists for joining us today. As sarah mentioned, our major focus of the American Health care act was the Medicaid Program, both the Medicaid Expansion and also, the traditional Medicaid Program. The bill, likely would have ended the Medicaid Expansion overtime and would have placed the federal funding cap on the traditional Medicaid Program. In the wake of the failure of the bill, the question before us now on the panel and for all of you is, whats next for medicaid . To set us up for the discussion, i will focus on the Medicaid Expansion, refreshing memory about where the states stand on their decisions to expand the program, and looking at the latest research on the effects of the expansion on coverage as well as other key indicators. As of today, 31 states and the district of columbia have expanded eligibility for medicaid. Of those, six have used demonstration waivers granted by hhs. These six states have struggled to reach political consensus on expansion, and found agreement in alternative approaches like enrolling medicaid beneficiaries in market place plans and in the case of arkansas imposing responsibilities like higher premiums on beneficiaries. There are currently four states actively discussing expansion, the Kansas Legislature passed a bill to expand medicaid although has been told that bill although the governor has been vetoed the bill. The legislature is attempting to override it. Governor deal of georgia has expressed interest in expanding medicaid. In maine, Medicaid Expansion is a proposition on the november al at this year. The virginia mccullough governor has expect Republicancontrolled Legislature considering it this week. Other states where expansion has been under discussion might be states to watch this year. They include idaho, south dakota, tennessee, utah, wyoming, and other states. Based on Commonwealth Funds latest scorecard, which was released in march, and numerous other surveys, it is evident by now that with three full years of experience in the Medicaid Expansion, it has made a significant reference in coverage in states across the country, in and uninsured rates have fallen in every state since the major coverage expansions of the x Affordable Care act went into effect but they have fallen the furthest in states that have expanded medicaid. There are nine states that saw declines of 10 percentage ports or more and they were all Medicaid Expansion states. Kentucky has the largest declinen, followed by california, new mexico, and west virginia. Since 2014, coverage gains have been the strongest among adults with lower incomes. It is in this income range where the differences between Medicaid Expansion and nonexpansion states have been the most evident. Uninsured rates in expansion states among adults with incomes under 200 of poverty fell by 14 Percentage Points over 20132015 compared to nine Percentage Points in nonexpansion states. Coverage gains since the passage of the Affordable Care act have a have been associated with gains in access to health care. These gains in access, on average, have been greatest in states with expanded medicaid. If you look at the metal bars in this chart, the share of low income adults reporting they had skipped health care because of cost theyll buy 5. 5 Percentage Points between 20132015 in states that expanded medicaid, compared to a decline of half that in states that hadnt expanded their programs. Likewise, cuba adults fewer adults across the country report that they dont have a regular doctor. These declines have been the greatest in states that expanded the programs. Lets consider the case of kentucky and tennessee. I use this example because these are border states in the south with somewhat similar demographic profiles, but which took polar opposite approaches to their Medicaid Expansions. Kentucky expanded the Medicaid Program and ran its own marketplace for a few years, anyway. Also, they conducted aggressive outreach campaigns to encourage enrollments. Tennessee didnt extend medicaid and didnt run their own marketplace. The states had similar uninsured rates prior to the Affordable Care act. The uninsured rate in kentucky, among adults with low incomes, fell by 25 Percentage Points. It fell by only nine Percentage Points in tennessee. Kentucky also experienced the largest decline in the country and cost related problems getting care. The share of loan income adults lowincome adults fell to 21 in 2015. Tennessee experienced no significant improvement on this measure. Likewise, many fewer adults in kentucky reported in 2015 that they didnt have a regular source of care compared to 2013, and tennessee didnt see any measurable improvement in this measure. Ben summers has been conducting a survey of low income adults in three states since 2013 to track the effects of Medicaid Expansion. He selected arkansas and kentucky, both of which expanded their programs, and texas, which did not expand. His analyses have found significant improvements on key measures of Health Care Use and self reported Health Status in arkansas and kentucky relative to texas. For example, compared to adults in texas, adults in arkansas and kentucky had significant increases in getting checkups and significant decreases in visits to the emergency room. Ben also found low income adults in arkansas and kentucky experienced marked improvements in affordability, including a dramatic drop in annual out of pocket spending since 2013 compared to adults in texas. One of the policy rationales for repealing the Medicaid Expansion weve heard a lot about is the contention that medicaid provides inferior coverage compared to private insurance and that having medicaid is almost like being uninsured. But research hasnt really supported this claim. For example, this study that the Commonwealth Fund did using the Commonwealth Fund biannual Health Insurance survey found that medicaid provided adults access to health care and financial protection that on most measures was comparable or better than that provided by private insurance, and better than being uninsured. Cbo estimates that by 2026, more than 70 Million People will get their Insurance Coverage through medicaid. As sarah said, that many get their coverage now through medicaid. And 15 million of them through the Affordable Care acts Medicaid Expansion. This quick overview that i just went through suggests the value of this coverage in helping people get the health care they need, particularly large numbers of people with low incomes across the country. The program is really a cornerstone at this point in the u. S. Health insurance system, and it really should be the concern of policymakers to ensure its strength and viability over time. In terms of what you might see in the next year in terms of medicaid policy, some of the key questions are will more states move forward on expansion . Will cms grant greater flexibility for states through the 1115 waiver process, and what will be the implications of that for enrollees . Will congress return to pursuing policies that would place state caps on federal funding of medicaid, such as block grants, per capita caps, and if so, what are the potential implications for enrollees . And ill stop there and turn this over to sarah. Ms. Dash thank you. Thank you, sara. So, we may be we may be nonpartisan, but we seem to have a bias towards people named sarah today. Gail walinsky is here. While shes getting settled, let me ask, many of you obviously have been following the debate, but for those who maybe need a little refresher, can you just explain the difference between block grants and per capita caps . And ill let Sara Rosenbaum chime in this on that, as well. That will help set the stage for the rest of the discussion. Thanks. Ms. Rosenbaum good morning, everybody. Can you hear me . Yeah, ok. Good morning. So, a block grant is a model of federal funding in which the federal government basically comes up with an aggregate cap on the federal contribution to state Medicaid Programs. Many factors go into that aggregate cap. The Congressional Budget Office has very useful information on some of the factors that go into, or could go into, estimating an aggregate cap. The Commonwealth Fund has put out a short piece on how aggregate caps are built, but the point is, its an aggregate cap and it doesnt necessarily relate to and certainly over time probably would not relate to actual population growth. A per capita cap is an approach to federal funding limits that would presumably tie to the number of people actually insured. So as the number of people goes up or goes down, the cap, the amount of funds, would change, but as with an aggregate cap, a per capita cap also includes many factors that determine how its going to grow Going Forward. So while a per capita cap might grow in relation to population, it is not it is not necessarily the case that it would grow in relation to changes in service intensity, changes in the price of insurance or the price of health care, and other changes that would affect spending on a perperson basis. Ms. Dash thank you so much. So, im just going to give gail a moment here to get settled. Again, were thrilled to have gail with us. She, again, ran the medicare and Medicaid Programs under president george h. W. Bush and has many accomplishments besides that, as do the other panelists, and i hope youll check out their bios in the packets. With that, we heard an overview from the current state of play from sara collins, and i will turn it over to gail walinsky. Thanks, gail. Ms. Wilensky for those of you who dont know it, the metro is shut down between metro center and union station, and we have opening of the ballpark, and so there are a gazillion people trying to drive around, but im delighted to have been able to join you. Fortunately, i had seen sara collins powerpoint, so i know the points that she was making. I have a couple of observations that i wanted to share with you. The first is that it is important to acknowledge that medicaid has been the acas clear success story, and i dont think we can ignore what we have been able to see. The Medicaid Expansion actually accounts for the majority of newly insured. It has been able to do this without experiencing the kind of churn we have seen in the exchanges. But on the somewhat negative side, the spending is running much higher on a perperson level than was predicted. The second year, as expected, tends to be Lower Per Capita spending than the first year somebody is on. Even so, it is way above what the expectations were, so thats one observation point. The second and this is something that is not actually related to the aca, other than in a very peripheral way the medicaid current match structure really makes very little sense for anything other than to start a program. What you have with the aca expansion is the highest match rate covering the higher income of the poor lowincome population. It started, as you all know, at 100 . Its in the process of walking itself down to 90 . Even so, that is way beyond the matching rate that exists for the base medicaid population, which as you know is between 50 and 73 . It not only doesnt make any sense to have different match rates for different parts of medicaid ship, of course, follows into this as well but this seems to really have it backwards. You would think the federal government ought to pay a larger share for the poorest of the poor and not for those that are near the cutoff in terms of Medicaid Expansion. We understand why that happened, to try to lure as many states in as possible, but once we are on any kind of stable footing, that needs to be resolved. We need to find a match rate, probably somewhere between the base match rate and the new match rate, and have it applied for the entire Medicaid Program. Having these three different match rates for different pieces of medicaidship makes no logical sense whatsoever. The third issue that i want to raise is something that i have been commenting on now, probably longer than id like to remember, but at least the last 25 years, which is that the states we dont usually give them enough credit for creative financing and creative thinking but the states have shown themselves very able to find various types of financing strategies. The end result of which is, their part of the money is less than what is statutorily required. It has gone through various versions. The first started just before i was running medicare and medicaid, around 1989, 1990, with something called voluntary donations. It is in some ways because it was the most egregious the easiest to explain and understand. For those of you who didnt recall, this activity started in west virginia, and basically, what happened was the hospitals would put up a state share of the matching rate by donating money thats the voluntary donation part to the state. The state would then use that money as its match money for the federal government. It would get the federal match, and the money would then go back to the hospitals, including their piece, which meant that, basically, the only new money in the system was that that came from the federal government. There are various other strategies. That eventually was sufficiently egregious that it was shut down, but provider taxes frequently function in basically the same way. A tax gets put on a group of either physicians or hospitals. That money is part of what is used for the match. The match comes in. The matched money and the base money goes back to the source, either in its entirety or in large part. There have been more sophisticated ways, which make it harder sometimes to shut down, involving intergovernmental revenue sharing. Since that is a legitimate activity between the state and the counties and state and the city, thats harder to get rid of. Also, not having an upper payment limit that bears any relationship to cost has allowed states to do this. The upshot, and this was has been true as late as an oig report that came out in 2016 for 2014, right before the match started is that what weve assumed was the major constraint, that is the states share of the match, isnt really doing the job in the structure that it was intended to do. One could question if the match was as small as 25 , whether it would have anyway for the poorest of the states, but it is just not a structure that continues to make sense. As an economist, a Public Finance economist, i was actually always taught matching grants are a good structure to follow, because it gets contributions from the person receiving the money and is a way to try to have a maintenance of effort. Good in theory, this ha