Abrams with the Commonwealth Fund, and we thank them for their since medicaid was the medicareside program in 1965, it has grown into one of the most farreaching programs in our country, in terms of the number of people it serves as low as their health and life circumstances, and the cost of the program. It is run by the 50 states and territories within federal guidelines and financed by both the state and federal government. So while medicaid policy has National Implications it of course has major implications for states and their citizens as well. As we know, major changes to the Medicare Program have been at the forefront of recent Health Care Policy discussions and are included within legislative proposals in both the house and senate. Today we will talk about what those proposals are, how they would work, and what they would our in practice based on best evidence and projections. I just want to make a special note because while it is really easy for medicaid policy to get very wonky very fast, and as the old saying goes if you have seen one Medicaid Program you have seen one Medicaid Program, this obviously has been an issue in our conversation that hits home for many people. I think it speaks to the need for continued dialogue on the different perspectives that are brought to the Medicaid Program that is what the alliance for Health Policy is about in this briefing is about. We are pleased to have a terrific panel here today to help us with this discussion. Let me go ahead and introduce our panel and then i will turn it over to melinda. Today. Ann is joining us deputy been a administrator at the centers for medicare and medicaid services. She directed the Senate Center for medicaid and Chip Services at cms as well. O my left is josh he is a senior fellow at the foundation for government accountability, and prior to joining that foundation he served as director of the senator center for health care solutions. He also served as legislative director for scott brown in the Massachusetts State Senate and as a senior legislative aide for then governor mitt romney. I already introduced melinda, so next to melindas right is chuck, the ceo at the Community Health alliance in reno, nevada. He worked atg cha the school of medicine and worked as the nevada medicaid administrator. Isally, dr. Richard frank the professor in the department of Health Care Policy at Harvard Medical School and previously served as deputy at the health and human services. Welcome to our panel. Melinda has a few quick opening remarks and then we will turn it over to cindy. Melinda can you hear me . Hello . Great. Good afternoon, everyone, and welcome, and many thanks to the alliance for Health Policy and the panelists for joining us. I have been asked to briefly frame the conversation. As sarah mentioned, dedicate has aken center stage as we have number of proposals to repeal and replace the Affordable Care act have been introduced. These proposals do not just change the expansion, the recent expansion of the Medicaid Program but actually also address the underlying traditional Medicaid Program. Say, what isly to next for medicaid . Before we discuss the implications and hear a range of data and perspectives, it is good to be reminded of some of the basics. Next slide. Thank you. So the ones that are being projected, by the way, are not actually is good as the ones in your folder so if you want to pull out your folder then you can see some of the numbers. So just to be reminded, it is a federal and state program. There are federal standards but ,tates have an enormous amount an extensive amount of discretion on the design and administration of the program. It currently covers more than 74 Million People and that can be roughly, there is roughly four groups infants and children, people of all ages with disabilities, low income seniors, elderly, and other adults. Children represent the Largest Group but the elderly and disabled account for the largest proportion of expenditures. In terms of what it covers, medicaid covers a broad range of services to meet its very diverse population. There are a number of Optional Services that states can cover such as pt and eyeglasses and dental, that it is important to stress that medicaid covers nearly half of all births, 40 of all children. There is a comprehensive benefit whichren known as is particularly important for children with disabilities. Medicaid covers longterm care occluding nursing home care and communitybased Longterm Services and support. As of currently, more than half of the longterm care covered by medicaid is in home and communitybased, spent in the home and in the community, which is enabling seniors and people with disabilities to continue to live independently. The fund has, for a number of years, the Commonwealth Fund has supported research to examine the implications and the effective medicaid on people. So that is what is in this next slide, just some data from some of my colleagues off of our National Survey or by annual survey. Survey. Ual it shows people with medicaid are less likely than those with private insurance or uninsured to skip services due to cost. Other analyses look at how medicaid beneficiaries, their satisfaction with their care and they rate the care fairly highly. But it is not just Commonwealth Fund data. There was recently a paper in the new england journal of medicine by ben summers and kate back andt did a look overview of the implications and effects of the Medicaid Program, and basically showed that those with medicaid had better access to care, more likely to have Early Detection of disease, more likely to be adhering to their magic dedication regimen, have better management of their chronic condition, and importantly but maybe not overly appreciated, peace of mind knowing that they had some coverage when they got sick. So moving on, another area that we tend to look at is not just the implications for the people and the state economies, but also the providers. This is the studied at the Commonwealth Fund did with the Kaiser Family foundation, and shows that among these primary care providers while they were seeing more patients with reported, most doctors no decline in their ability to provide quality care since the Medicaid Expansion. At the Commonwealth Fund, our role is to support rigorous analyses to understand the implications of the various Health Policy proposals. And really, we strive to look at the implications at multiple levels, whether it is on state economies, on providers, on people, or subsets of people. This next slide set a recent analysis done by al docton and his colleagues looking at medicare provisions and hospital finances. What we have seen is that for all hospitals, particularly those in expansion states, can anticipate over the next 10 years an increase in uncompensated care. That is a treatment or service for which there is no insurer and the patients are unable to pay. Anticipated increase of about 78 over the next 10 years. Billion, so a 114 big increase but also a lot of money. In the nonexpansion states, expect about a 10 increase in uncompensated care over the next 10 years, may sound smaller but still 17. 3 billion. Has done a number of analyses that pullout rural hospitals, look at it by state, just the safety net hospitals. There is a lot of analyses are you to turn to. For you to turn to. Another analysis we released yesterday was looking at the implications of the Better Care Reconciliation Act, the senate will, on state bill, on state economies and particularly on jobs. As it says on the slide, if it were to become law we anticipate about 1. 6 million jobs will be lost affecting grossed gross state products as well as the business output. And also, not just looking at this at the National Level but at the state level. Here is my little plug for some new fact sheets that we have pulled together and that are in the back for kentucky and nevada and california, are examples that we have available but actually there is one for all 50 states. Pieces, theed two hospital component and the job component because two of our thekers will look at implications for federal dollars to the state, that will be cindy , and richard will look at a subset of the population, people with opioid addictions. And so with that, i was just going to say, echo sarahs comment about how we really look forward to hearing a variety of perspectives and having data and evidence guide this conversation. Thank you. Thanks, linda. We are going to go right down the line cindy, josh, chuck, and richard. Aen we will have time q and and some discussion. Tag youuse thesh htag whats next for medicaid . It is great to be here. I am going to open up with a short overview of the key changes in the senate bill with respect to the Medicaid Program, and then really focus my remarks on the per capita cap implications its for states and the program and the people that the Medicaid Program serves. I just want to state my appreciation for the support of the Commonwealth Foundation for its support of our modeling work. We have looked at statebystate impacts of both the house bill. Nd senate bill i will draw on both of those analysis as i go through my presentation this morning. If we want to go to the next slide, here is an overview of some there is a variety of different provisions in the Better Care Reconciliation Act that affect medicaid, but here are some of the key changes. The house passed version of the and nobody quite know is you are supposed to pronounce the initials or just say them out loud. Converts medicaid essentially to a capped funding program, very fundamental change as they are identified in the basic structure of the Medicaid Programbcra, and really goes beyond any changes that the aca had with respect to the Medicare Program. 2020, medicaid, instead of a program where the funding is jointly shared by the federal government, the governments part would be capped. Int would go into effect 2020. The bait the government also offers the states the per capita applies to virtually all spending in the program and all people. There are some carveouts for the caps but longterm care, acute care, i think the key point is not just the expansion population. People think we are talking about repeal and replace. The financing changes are pretty much walltowall with the Medicaid Program. The other big change in the bill is that it would phase out and ultimately eliminate the enhanced federal funding that the Affordable Care act made available for states to expand coverage to low income adults. You will see on the slide that 2021,ses out beginning in and has a threeyear dropdown of the match rate. In 2020 under the aca it would , and init goes to 85 2020 it goes back to the states regular match rate. Big changes in terms of federal financing. There is also some big provisions that would provide extra funding for the state that did not take up the option to do an expansion, some funds, 2 billion of funds to the states to be shared among the 19 states , and also it changes the dish cuts so that the expansion states continue to experience or will experience the dish cuts that are expected to go into effect dish means . Disproportionate hospital share payments. It provides funding on a match basis to help provide financing to hospitals that serve a disproportionate share of either medicaid or uninsured individuals. Aca cut the spending on the theory that we would have more coverage and there would be less uncompensated care. And what the senate bill would and notstore those cuts put those cuts into effect. They go in effect in september, for the nonexpansion states but for the expansion states they would go into effect even after the enhanced match goes away. Those are some of the major things. I need to get going on this so if you go to the next slide, it briefly shows you what the reductions are. If you go to the next slide, please. Next slide. No, back. Follow your booklets. It just shows the yearbyyear reductions that cbo has identified in the bcra. Overall and you are probably familiar with the cbo scores the cbo says it would produce a loss of 772 billion over 10 years for the Medicaid Program and of course very importantly, by 2026 cbo projects that 15 Million People covered by medicaid would lose their coverage, would no longer have that coverage. If you go to the next slide, i want to talk a little bit about how the cap works. I am not going to spend a lot of time explaining this. It is a wonderful diagram and hopefully it will teach you, but we can have some time during q and a. Spending isc trended forward by a trend rate and both of those factors are critical in terms of understanding the impact to a states Medicaid Program. What was that spending in the early years, if the state is locked into that spending over time in perpetuity except for the adjustment. What you see in this diagram is there is different trend rates the. Plus one toand cpi bring the caps forward yearbyyear until the year 2025. 2025, all the groups go down to the cpi which is a much lower trend rate. That builds up to an aggregate cap. You have your caps for the individual groups of people. You multiply the cap times the mole the number of people you covered in each of those groups and that builds up to an aggregate cap. That is what the state is going to be guided by in terms of its spending. If state spending those over the cap and it starts to draw down federal dollars beyond the cap, it will have to pay back, there will be a clawback to those federal dollars in the following year and all of the dollars spent over the cap will be 100 financed by the state. So very different notion from current law, where all financing, all costs that are legitimate medicaid costs are shared by the states and federal government. If you go to the next slide. This just looks at how those trend rates compare. I will not go through detail on this but let a just say the trend rates are designed intentionally to save the federal government dollars. They are pegged at a rate that is intentionally below what the states are expected to spend over the next 10 years, and that is one of the main ways in which some of achieves its, the savings and the 772 billion score. If we go to the next slide, please, this one you might want to look at, at your booklet. This shows the yearbyyear this is our modeling where we showed the yearbyyear, and we have this statebystate impact of the caps on this is just the caps, not the effect of the thension so just part of 772 billion and what you see here is the federal loss of dollars. But i also want to point out which is also forgotten often forgotten, is the state lofts of dollars. Loss of dollars. If the state says, i would only spend to the caps, which is what most of them do now. I could spend all their money on health care but they basically spend what they can spend to qualify for a match. If they only spend what qualifies for a match under a capped environment, their state spending will decrease so the total impact to the Medicaid Program is bigger than the impact of the federal cost. It is also the reduction in state dollars. The state does not have to reduce its dollars, it can simply spend dollars without getting a match. On the assumption here that a tote will keep below the cap avoid the clawback and avoid spending 100 federal dollars, you see the total cost. Because the cpi trend rate pops in, in the senate bill in 2025, you see a very deep, a significant jump in the cuts between 2025 and 2026 because of the change in that trend rate. That gives you a sense and cbo has looked at this also a sense of how the cuts will grow over time. They become deeper every year but they will become even deeper after that 2026 period. Let a just try to make one point, if you would go to the next slide. One of the things that we have certainty the lack of of what life will be like. The one thing that we know is that Health Care Costs are difficult to predict, but the other thing is that these trend rates are difficult to predict. So when we have done these analyses, we have taken cbos projections of the trend rates. Cbo says i think medical cpi will be 3. 7, i think it will be 2. 4 over the next period of time. It is as good a projection as anyone might make so i have no quibbles, but over this period of time as these trend rates go up and down. They are volatile so what matters a lot which trend rate congress picks. Whichever trend rate congress picks, we need to understand it is not set in stone and it will fluctuate. One of the things we did was look at what if the trend rate was not exactly what cbo projects . What if instead of 3. 7 for medical cpi it is 3. 2, half a percentage point lower . The total cost due to the cap would change between 2020 and billion, itout 267 would jump to all lost 400 billion just because that trend rate changed and did not turn out to be exactly what cbo thought it would be. Suggest a close, i think that is one of the most important points we want to make about the fundamental change of financing the cap. It produces significant reductions in feder