This is 90 minutes. Hello, everybody. Welcome to todays briefing on understanding whats next for medicaid. Im sarah, the president of the alliance for Health Policy. Its a pleasure to be with you today. For those of you that are not familiar with the alliance, we are a Nonpartisan Organization dedicated to advancing learning and dialogue on Critical Health policy issues. To say hello as well to those of us watching on cspan this afternoon, and to those that are joining us on twitter using the hash tag whats next for medicaid. Collaborating with these Melinda Abrams at the Commonwealth Fund, and we think the fund for their partnership and organizing todays briefing. Since medicaid was created alongside the Medicare Program in 1965, it has grown into one of the most farreaching Health Programs in our country both in terms of the number of people it serves as well as their health and life circumstances and the cost of the program. Its run by the 50 states and territories within federal guidelines and is financed by the state and federal governme government. While medicaid policy has national implications, it of course also has major implications for states and their citizens as well. And as we know, major changes to the Medicaid Program has been at the forefront of recent Health Policy discussions, and are included in the legislative proposals in the house and senate and so today we are going to talk about what those proposals are, how they would work and what they would mean in practice based on our best evidence and projections. I just want to make a special note because while it is easy for medicaid policy to get very wanted very fast as the old kind of saying goes if youve seen one Medicaid Program youve seen one Medicaid Program. This has been an issue in a National Conversation and it does hit home for many people so that speaks to the need for continued respectful dialogue on the different perspectives that are brought to the Medicaid Program and that is what the alliance for Health Policy is all about and what this briefing is all about and we are just really pleased to have a turkic panel here today to help us with this discussion. Let me go ahead and introduce the panel and then i will turn it over to melinda. Cindy mann is joining us today. Shes a partner and has been a deputy administrator of the centers for medicaid and Medicare Services and directed the center for Medicaid Services at cms as well. Next to my left is josh archambault, a senior fellow at the foundation for Government Accountability and prior to joining the foundation he served as the director of the center for Health Care Solutions and a Program Manager for the initiative at the Pioneer Institute and also served as the legislative director for scott brown and the Massachusetts State Senate and astate senate r legislative aide for then governor mitt romney. I already introduced melinda. So next melinda is right is chuck duart. And he worked at the university of nevada as the nevada medicaid administrator for the planning and evaluation at the department of health and Human Services as well as a special adviser in the office of the secretary, so welcome to the panel. Melinda has a couple of quick opening remarks and then we will turn it over to cindy. Thank you. Good afternoon everyone. Welcome and many thanks to the alliance for Health Policy and to the panelists for joining us. Ive been asked to briefly frame the conversation. As mentioned, medicaid has taken center stage as we have a number of proposals to repeal the Affordable Care act as introduced. These proposals dont just change the expansion, the recent expansion of the Medicaid Program, but actually addressed the underlying traditional Medicaid Program. So, it is timely to say whats next for medicaid. Before we discuss the implications and here are the 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 as good as the ones in your folder. So if you want to pull out your folder and then you can see some of the members. Just to be reminded it is a federal and state program. There are federal standards but states have banned enormous amount of discretion on the design and the administration of the program and it currently covers more than 74 Million People and it can be roughly four groups, infants and children, people of all ages with disabilities, low income seniors, elderly and then other adults. Children represent the largest group. In terms of what it covers medicaid covers a broad range of services to meet its very diverse population. It can be covered but its important to stress medicaid covers nearly half of all births. 40 of all children. There is a comprehensive benefit for children that is particularly important for children with disabilities. Medicaid covers longterm care including both nursing home care and communitybased Longterm Services and support. Currently, more than half of the longterm care covered by medicaid is an home and communitybased is being done in the home and in the community but its 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 effect of medicaid on people. So that is what is in this next slide is some data from some of my colleagues off of our National Survey on our biannual survey, and essentially what it shows is that people with medicaid are less likely than those with private funds or the uninsured to skip Necessary Services or medications due to costs. Other analyses look at how medicaid beneficiaries, satisfaction with their care and that they rate the care actually fairly highly. But its not just Commonwealth Fund data. There was recently a paper in the new england journal of medicine by ben summers and gave it a look back at an overview of the implications and the effect of the Medicaid Program and basically showed those with medicaid that have access to care are more likely to have the detection for the medication regimen. Its not overly appreciated they may have some coverage. So, moving on, another area that we tend to look at is not just the implication for the people and state economies but also the providers. Most doctors reported no decline in the ability to provide quality care since the Medicaid Expansion. So the implications of the various proposals. So to look at the multiple levels whether it is on the state economies and providers. This looks at a recent analysis looking at the American Health care act on hospital finances and what we see is that for all hospitals particularly in expansion states can participate and increase in the uncompensated care so that as a treatment or a service for which there is no injured for and the patients are unable to pay so it is about 78 over the next ten years. It is about 114 million. In the long expansion states expect about a 10 increase in uncompensated care again over the next ten years. They look at it by state, the safety net hospitals. There is a lot of analysis for you to turn to. Another analysis that we released yesterday is looking at the implications of the Better Care Reconciliation Act on the bill on state economies and particularly on jobs. As it shows on the slide if it were to become lost we anticipate about 1. 46 million jobs would be lost as well and is the business output and so not just looking at this at the National Level but the state level and here is my plug for some of the new fact sheets that we have pulled together that are in the back for kentucky and california but theres one for all 50 states. I only covered two pieces, which is the hospital component and the jobs component, because two of our speakers will look at the implications for federal dollars to the state that will be cindy and ben Richards Will look at a subset of the population of people with opioid addictions. With that, i will echo the comment about how we look forward to seeing a variety of perspectives and having the data and evidence guide this conversation. Thank you. Thanks, melinda. We are going to go right down the line. Cindy, josh, chuck and richard. Then we will have time for qanda discussion and again for those of you just joining us, you can use the hash tag whats next for medicaid. Cindy, go ahead. Its great to be here with everybody. Im going to open up with a little bit of an overview, short overview of the changes in the senate bill with respect to the Medicaid Program and then focus my remarks on the provision and its implications for states and the programs and the people that the program serves. I just want to state my appreciation for the support of the Commonwealth Foundation for the support of the modeling work. We have looked at statebystate impacts at both the house bill and the senate bill and i will draw on both of those analysis as i go through my presentation this morning. There is a variety of different positions in the Better Care Reconciliation Act but here are some of the key changes. Like the house passed version of the bill nobody quite knows if you are supposed to announce the initials or say them out loud. But it converts medicaid essentially to a Funding Program with a fundamental change and as it is identified in the basic structure of the program it really goes beyond any changes with respect to the Medicaid Program s said it would convert starting in 2020 instead of a program where that financing is shared by the government, the federal government share would be limited by a per capita cap that goes up to the aggregate and i will explain that would go into effect in 2020. The bill also offers the states instead of the per capita Block Grant Program for the limited population it generally applies to virtually all spending in all people in the program. The key point is that its not just the expansion program. Its pretty much walltowall in 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 did make available for states to expand coverage to lowincome adults. And you will see in the slide that it phases out at the beginning of 2021 and it has a threeyear drawdown of the rate in 2020. It would be as 90 of it goes to 85 and goes to the rate. Theres also some provisions in the bill that would provide extra funding for the state did not take up the option to do an expansion. The expansion states continue to experience orwell experience with is scheduled to go into effect. It is a special feature of the program that provides funding on a matched basis to help provide financing to hospitals for the uninsured individuals. They cut spending on the theory that we would have more coverage and fed up with the less uncompensated care and to what the senate bill would do is restore those cuts. After the enhanced match goes away those are some of the major things. I need to get going on this. If you go to the next slide, if briefly shows you what the reductions are. If you go to the next slide. It shows the reductions that have been identified. Overall coming at you are probably familiar with the score it says the bill would produce a loss of 772 billion over ten years for the Medicaid Program and of course very importantly, by 2026, cbo predicts that 50 Million People covered by medicaid would lose that coverage and would no longer have that coverage. Go to the next slide. I want to talk a little bit about how the cap works. Im not going to spend a lot of time explaining this. Its a wonderful diagram but hopefully we can have some time during qanda. The bottom line is that it is a per capita cap. Its understanding the impact to the states Medicaid Program. What was the spending in their early years the state has kind of walked into that spending in perpetuity except for the adjustment is different trend rates the bill picks to bring the cats foreword yearbyyear until 2025. All groups go down which is a much lower trend rate. That builds up to an aggregate cap and that is what the state is going to be guided by in terms of its spending so if the state spending goes over the calf and starts to drive down the dollars it will have to pay back. There will be a clawback in the following years and all of the dollars actually spent over the b. Financed by the state. So a very different notion all costs are shared by the state and federal government and if you go to the next slide. This looks at how the trend rates calmed hair. I wont go through the details on this but let me say the trend rates are designed intentionally to save the government dollars. So they are paid at a rate that is intentionally below what the states are expected to spend over the next ten years and that is one of the ways that the bill achieves some of the savings. This one an you might want to lk at your booklet. This shows the data by state impact of the caps. This is just the calf, not the expansion, so part of the 772 billion. And what you see here is the federal dollars but i also want to point out that there will be a state loss of dollars and if the state says im just going to spend to the calf im going to spend that which qualifies for the federal match which is what most states do now under federal wall they can spend all their money on healthcare if they want to but they generally say i will spend what i can spend a qualifies for a match. If they only spend what qualifies for the match, the state spending will also decrease. So the total impact to the Medicaid Program is bigger than the impact o impact of affordabt and its also the reduction in state dollars. The state doesnt have to reduce the dollars it can simply expand without getting a match. But on the assumption that a state will keep beyond the cap to avoid the clawback and spending the federal dollars you see the total cut into the other thing i would point out on the graph is because the trend rate top asenap 2025, you see a very significant jump between 2025 and 2026 because of the change in the trend rate so it gives you a sense of how they will grow over time. They will become even deeper after about 2026 period. One of the things that we have modeled his the lack of certainty. One thing that we know is healthcare cuts are difficult to predict that the other thing is the trend rates are difficult so when we have done these analyses, we have taken the projections of the trend rate to say i think that it will be 3. 7. I think it will be 2. 4 the next period of times and it is a good projection as anyone might make. What we are showing us over the last period of time these trend rates go up and down so it matters a lot with the Congress Pics but whichever trend rate we need to understand it is not set in stone. It will fluctuate. What if the trend rate isnt exactly what it projects, its just a little lower. 3. 2. And what you see is if of change between 2020 to 2026 about 267 billion. It would jump to almost 400 billion just because the trend rate didnt turn out to be exactly what the ceo thought that it would be. So to close, but as one of the most important points we want to make about the fundamental change in financing of the cab is that yes, it produces significant federal dollars for the Medicaid Program but also produces a great deal of uncertainty in all of the risk of uncertainty over the trend rates. Thank you so much for the alliance. I want to start with a pole. Raise your hand if you think based on the Media Coverage at the end of the budget window we will be spending less money on medicaid. Raise your hand if you think we are spending more money at the end of the budget window. A couple people. Okay. Im just saying the absolute dollar amount you are spending today versus the future. So, i think what we have found around the country is th use tha coverage used this language around cut. Massive severe cuts. We want to slow the rate of growth yet we have a proposal on the table for the program does down the rate of growth, and the sky is falling. There is a lot to unpack. Anybody that is talking about changes in the bill also has to talk about the status quo from the standpoint of the Medicaid Expansion puts the ablebodied adult that is a part of expansion population against the traditional medicaid population so they put extra money towards the medicaid population to get the states to expand. The challenge is i have to balance my budget every year which by the way, they do, unlike here in washington. They have to find 1 dollar of savings to determine where they are going to try to take the 1 dollar of savings they have a few different options. I