Includes medicaid administrators at the state and federal levels. This is about 90 minutes. Hello, everybody, and welcome to todays briefing on understanding whats next for medicaid. Im sarah dash and the president of the alliance or Health Policy. Its a pleasure to be with you here today. For those of you who are not familiar with the alliance, we are a Nonpartisan Organization dedicated to advancing learning and dialogue on Critical Health policy issues. I want to say hello as well to those in the audience are watching us live on cspan this afternoon. And to those are joining us on twitter using the hashtag whats next for medicaid. For moderate today spent with me is melinda abrams, Vice President for Delivery System reforms at the Commonwealth Fund and we think the fund for the partnership in organizing todays briefing. Since medicaid was created alongside the Medicare Program in 1965, it is 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 financed by both the states and the federal government. While medicaid policy has National Implications come it of course also as major implications for states and their citizens as well. As we know major changes to the Medicaid Program has been at the forefront of recent Health Policy discussions, included within legislative proposals in both the house and the senate. And so today were going to talk about what those proposals are, how they would work, and what it would mean in practice based on our best evidence and projections. I just want to make a special note because while its real easy for medicaid policy to get very wonky very fast, and as the old kind of thing goes if using one Medicaid Program using one Medicaid Program, this is obviously, has been an issue international conversation. It does hit home for many peoples i think it speaks to the need for continued respectful dialogue on the different perspectives that are brought to the Medicaid Program and thats with the alliance for Health Policy is all about and thats what the speaking is all about. We are pleased to have a terrific panel here today to help us with this discussion. Let me guide introduced our panel and then and then ill turn over to Melinda Cindy mann is joining us today a partner at phelps and phillips. She has been a deputy administrator of the center for medicare and Medicaid Services she directed the center for medicaid for services at cms as well. Next to my left is trying to, senior at the foundation for government accountability, and prior to joining that foundation he served as director of the center for Health Care Solutions and Program Manager for the middle Cities Initiative at pine institute. He also served as legislative director for scott brown in the Massachusetts State Senate and as senior legislative aide for then governor mitt romney. I already introduce melinda, so next to melinda is chuck duarte, ceo at the Community Health alliance in reno nevada. Before joining them he worked at university of Nevada School of medicine and served as the nevada medicaid administrator. Finally doctor Richard Frank is professor of Health Economics in the department of Health Care Policy at Harvard Medical School and previously served as Deputy Assistant secretary for planning and evaluation at department of health and Human Services as well as special advisor in office of the secretary. So welcome to our panel. Melinda has a few quick opening remarks and then will turn it over to cindy. Can you hear me . Hello . Great. Thank you. Good afternoon, everyone, and welcome and many thanks to the alliance for Health Policy and to the panelists for joining us. Ive been asked to briefly frame of the conversation. As sarah mentioned medicaid has taken center stage as we have a number of proposals to repeal and replace the Affordable Care act have been introduced. And these proposals dont just change the expansion, the recent expansion of the Medicaid Program, but action also address the underlying traditional Medicaid Program. So its a timely to say whats next for medicaid. Before we discuss the implications and hear a range of data and perspectives, its good to be reminded of some of the basics. So next slide. Thank you. The ones that are being projected by the way are not actually as good as the ones in your folder, so if you want to pull out your folder and you can see some of the numbers. Just to be reminded, its a federal and state program. There are federal standards, but states have an enormous amount of, an extensive amount of discretion on the design and administration of the program. Currently covers more than 74 Million People, and that can be roughly, there are roughly four groups, infants and children, people of all ages with disabilities, lowincome seniors, elderly, and other adults. Children represent the largest group, but the elderly and the 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, but its important to stress that medicaid covers nearly half of all births. 40 of all children. Theres a comprehensive benefit for children known as eps which is to comport for children with disabilities. Medicaid covers longterm care including both nursing home care and Community BasedLongterm Services and supports. Currently more than half of the longterm care covered by medicaid is in home and Community Based. It is in the home and the community which is enabling seniors and people with disabilities to continue to live independently. The fund has a number of years, the Commonwealth Fund, has supported research to examine the implications and effect of medicaid on people. And so thats whats in this next slide, some data from my colleagues and also from our national survey, our biannual survey. And essentially what it shows is people with medicaid are less likely than those with private insurance or the uninsured to skip Necessary Services or medications due to costs. Other analyses look at how medicaid beneficiaries, their satisfaction with their care and that they rate the care actually fairly highly. But its not just Commonwealth Fund the date of birth and was recently want to draw your attention, there was recently aa paper in the needing them the new england journal of medicine that did a look back, an 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 Early Detection of disease, are likely to be adhering to the medication regimen, had better management of their chronic condition, and really important and maybe not, 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 implication for the people and the state economies but also the providers. This is a study that the Commonwealth Fund did with the Kaiser Family foundation, and shows that among these primary care providers, while they were seeing more patients with insurance, most doctors reported no decline in their ability to provide quality care since the Medicaid Expansion. So at the Commonwealth Fund our goal is to support rigorous analyses, to understand the implications of the various Health Policy proposals. And really we strive to look at the applications at multiple levels, whether its on state economies, on providers, on people or subsets of people. So this next slide look at a recent analysis done by al dobson and his colleagues looking at the medicaid provisions in the house bill, the American Health care act come on hospital finances. And what we see is that for all hospitals, to those in expansion states, can anticipate over the next ten years and increase in uncompensated care so thats a treatment or a service for which there is no insurer in the patients are unable to pay. Anticipate an increase of about 78 over the next ten years. Just to put a number on that come its about 114 billion. So big increase but also a lot of money. In the nonexpansion states, expect about a 10 increase in uncompensated care. Again over the next ten years. May sound smaller but still 17. 3 billion. We also have an above analyses like rural hospitals can look at a bistate look at just the safety net hospitals. Theres a lot of analysis there. For you to turn to. Another analysis that we released yesterday is looking at the implications of the Better Care Reconciliation Act, the senate bill, on state economies and particularly on jobs. And as it says on the slide, if you were to become law we anticipate about 1. 46 million jobs would be lost, affecting gross state products as well as the business output. So really again, and also not just looking at this at the National Level but at the state level. And so here is my little plug for some new fact sheets that we pull together and that in the back for kentucky and nevada and california are examples we have available but actually theres one for all 50 states. I only covered to pieces, which was at the hospital component and the jobs component, because two of our speakers, cindy mann and Richard Frank, will look at the implications for federal dollars to the state. That will be cindy and thin rigid will look at a subset of the population, people with opioid addiction. And so with that i just will say, echo saros 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. So were going to have, were going to go right down the line, cindy, josh, chuck and richard. Then we will have time for some q a and discussion, and again for those of you just joining us you can use the hashtag whats next for medicaid, if youre using twitter. And go ahead, cindy. Thank you. Its great to be here with everybody. Im going to open it up with a little bit of an overview, short overview of the key changes in the senate bill with respect the Medicaid Program, and then really focus my remarks today on the percapita cap provision and its implications for states and the program and the people that the Medicaid Program serves. And 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 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. So if you want to go to the next slide. Heres an overview of, theres a variety of different provisions into Better Care Reconciliation Act that affects medicaid but here are some of the key changes. Like the house passed version of the bill, nobody quite knows if youre supposed to pronounce the initials or just say them out loud, but the cra i will say converts medicaid essentially to a funding program, for a fundamental change as sarah identified in the basic structure of the Medicaid Program and really goes beyond any changes that the aca had with respect to the Medicaid Program. So it would convert starting in 2020 medicaid instead of program with the financing is doing a shared by the federal government, the federal government share would be limited by percapita cap that builds up to aggregate cap that i will explain. I would go into effect in 2020. The bill also offers states instead during a percapita cap and block grant option but for a limited population to the percapita cap generally applies to virtually all spending and all people in the program. Theres some carveouts for the cap but longterm care, acute care. I think the key point is its not just expansion population to people think we talk about repeal or replaced. Must be but expansion, the financing changes are really pretty much walltowall and 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. Usc i in the slide it phases tht began in 2021, and has a threeyear dropdown of the match rate in 2020 under the aca. It would be at 90 . It goes to 85, 80, said 5 . Then it goes down to states regular match rate. So big change in terms of the federal financing. Theres also some provisions in the bill that would provide some extra funding for the states that did not take up the option to do an expansion, some funds come 2 billion dollars of funds to the states to be shared among the 19th states. Also changes the expansion states continue experience i will expense cuts their skill to go into effect disproportionate Share Hospital payment, its a special of the Medicaid Program which provides funding on a match basis to help provide financing to hospitals that serve disproportionate share of medicaid are uninsured individuals are aca tech edition spending on if there would have more coverage and there would be less uncompensated care and what the senate bill would do is restore those cuts and not but this gets into effect. They go in effect in december for the nonexpansion states but that expansion states they would go into effect. Even after the enhanced match goes with it so those are some of the major things. I need to get going on this so if you would go to the next slide. It just briefly shows you what the reductions are in, if you go to the next slide, please. No . Next slide. No, back, back slide. Follow your booklet. It just shows year by your reductions that cbo has identified in the be cra. Overall and youre probably fully with cbo scores, cbo says that the bill would reduce a loss of 772 billion over ten years for the Medicaid Program and, of course, very importantly, by 2026 cbo projects that 15 Million People covered by medicaid would lose that 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. Im not going to spend a lot of time explaining this. Its a wonderful diagram and hopefully it will teach you but we can have time during q a. But the bottom line is that they percapita cap, meaning the amount of dollars each state gets is based on their historic spending, and then that a stroe spin is trended forward by a trained rate. In both of those factors are really critical in terms of understanding the impact to state Medicaid Program. What was that spending in the early years . Estate is locked into that spending overtime in perpetuity, except for the adjustment. What you see in this diagram is that theres different trend rates that the bill pics medical cpi and medical cpi plus one to bring the caps forward yearbyyear until the year 2025, all groups go down to the cpi which is a much lower trend rate. That all builds up to an aggregate cap. You have your caps for the individual groups of people. You can multiply the cap times the number of people you covered in each of those groups and that builds up to an aggregate cap, and thats what the state is going to be guided by in terms of its spending. So if a state spending goes over the cap, and a start 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 other dollars actually 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 the federal government. If you go to the next slide. If you could go to the next slide, please. This just looks at how this trend rates compare. I wont go into detail on this but let me just say the trend rates are designed intentionally to say the federal government dollars. So they are pegged at a rate that is intentionally below what states are ex