Forward. Thank you. The chair recognizes the gentleman from louisiana, doctor cassidy, for five minutes. Effect in arizona. Would you disagree with the table, which im looking straight at. Would you acknowledge, indeed its only one state specific, indeed if we were to look at maine we would see an increase in mortality after Medicaid Expansion. I will happily look to you looking at the table. As you know, as a clinician, you never want to take the conclusions too far. One study or two study. Were in an environment people are looking at one or two studies. I accept it. So i appreciate your clarification. Secondly, i will point out, you were careful in the testimony to say that medicaid prevents people from having financial occur res. You didnt make the claim it improves health. As we both know, the national what is it the National Bureau of Economic Research found in the oregon study, im quoting from the conclusions, the randomized control study show that medication coverage generated no significant improvement and measured physical Health Outcome in the first two years. But reduced financial strain. So also made clear that the best study from nber shown Medicaid Expansion didnt improve Health Outcomes. Lastly i will say , by the way, i enjoyed everybodys testimony. I dont mean to challenge. I just want to point it out. You seem to suggest in your testimony that the choices is die cot mous. Everybody somebody is uninsured or on medicaid. Ill quote another study by a big backer of obamacare who point out that 60 of the children that go ton a public Insurance Program actually formally had private insurance, but the expansion of the public insurance crowded out, if you will, the private insurance. Its not the employer or the family paying the bill, its now a taxpayer paying the bill. Thats 60 . Any comments upon that . Again, its not you know where im going. Well, i do have to begin by commenting on your characterization of the first study. First of all, were there, as you know, demonstrated positive effect on depression. So its important. I dont think it shows it did not improve outcome. I think it didnt show that it improved outcomes, and i think those are actually quite different. But we take the we really cant claim a benefit unless a benefit was shown. I completely with you agree. We cant that doesnt equate with the absence of benefit. It simply means we were unable to show a benefit. Since you are careful, im going ask we are being equally careful in the regard. The literature on crowd out which used to be a very hotly debated topic and faded from view for some time has great complexity about what you count as the e number rate en aerodemon nateer. We know low and moderate income families, the income fluctuates and gain different sources of coverage. The pref lens of private coverage. I have a minute left. Im sorry. My sense could be i adopt think we can state on the basis of the study that 60 of the children would have private coverage if they didnt have maybe. I will say that they have 400,000 observation. And its one respected and to two a big backer of obamacare. T not like something hes trying to trash himself. If theres a philosophical difference if a state is going to manage care and cap at a time payment to the Insurance Plan. There any difference in fact that the federal government gives a set amount of money to the state . Which in turn gives a set amount of money to the Insurance Plan . Is there any kind of difference in that. Yes, a plan organizes and finance the delivery of care. A state organizes the policy environment for that finance and delivery. There, again, i think they have different effects. But if you give 100 to the state to care for somebody, and the state give 90s to the burns plan. 100 of the cost were there capitation and who wrote the bill. I would agree its not the same. Thats not how i see the program. Okay. It may be an issue of perception. I yield back. The chair thank the gentleman. Did you want to respond to the remarks regarding reforms . I apologize if she had to leave. I want to give you an opportunity to respond quickly, please. Thank you, mr. Chairman. I appreciate the opportunity. In my testimony, i referred to the florida reform pilot. The facts, clear. The florida reform pilot outperformed in 64 percent the cases. It higher level of patient sphoox. Perhaps the best validation of how this approach of pay centered pro patient protaxpayer is working the fact that the Obama Administration approved the waiver. T a proven bipartisan approach that saves money, improves health, and produces more satisfied patients. And i would be happy to provide further information to the congresswoman. The chair thanks the gentleman. The chair recognize the gentlelady from the virgin islands. Thank you, mr. Chairman. Thank you for the hearing, welcome to our panelists. Doctor, my first question is about medicaid flexibility, i think your testimony and the answers you have given demonstrates the flexibility and innovation and not only possible but happening in different states across the country and improving access. And actually in some of the cases you sited improving outcomes as well. And ill improved outcomes is what were looking to achieve here. Im sure that you are familiar with the 2002 report on equal treatment. A report that demonstrated bias in the health care. Study more recent study since dpon straited the same it relates the cardiac care and other medical conditions. We know that racial and ethnic minority make up at least 68 of the nonelderly medicaid enroll lee. Its providers and even when there were providers, some of them needed ancillary services were not available in the neighborhood because how medicaid was paid for before the Affordable Care act. So, to you think the factors have some impact and import on weather even with medicaid being available and access to health care being available, dont those factors were not even we havent even talked about the sober determinacy of health that are not changing in those communities. Well, i appreciate the question and the observation. Im struck by how frequently i hear people repeat the phrase that medicaid is aa lousy broken because people on it and they fill in the blank. They are poorer, and sicker and disproportionately nonwhite. As you indicated, theres a strong Evidence Base in all of those areas that help outcomes or worse regardless source of coverage. And very rarely do people make an effort to actually control for it. And [inaudible conversations] income level and education level. We know, for example, that lower income americans are less likely to use health care services, whether they have private or public coverage because they are left on average, they are left comfortable with the system,less able to navigate it. And providers seeking payment are less likely to locate in the places where they live to indict the Medicaid Program for the outcome seems to be a bit odd. I agree. When they are addressed, and the socioeconomic addressed and foreign, racial, and ethnic communities and Rural Communities and some of the reforms you cited in a different states are more widely adopted. I think well see those changes. Were seeing changes where those things are happening. They are making a difference in improved care for vulnerable patients for whom medicaid has been the lifeline. The Affordable Care act recognized we need to make medicaid a stronger safety net. Along with safe changes, is already beginning to make a difference. The republican recommended reforms really are not designed, as i see it. Im i was a practicing family physician. I think they run the risk of reducing access to care and leaving some of the most vulnerable out of the Health Care System entirely. Let me see if i can fit in one other question. It includes a provision that will provide primary care services. What impact on access of pry care care do you believe the policy will have . And what other steps can we take to improve access to these Important Services for our most vulnerable . . Well, higher payment is certainly a positive, although its temporary nature, i think is going to limit the behavioral response on the part of physicians. Its unlikely they are going to fundamentally change where they practice or how they practice for an incentive that will last a short period. I think its important to think of it as a step, an imperfect step in broader efforts to reorient system spending toward primary care, and in of i. T. Is not going achieve. Its two years, probably, because we have reduce the cost of the bill. We have to reduce the cost of the bill because we could not score the me venges, the savings prevention, which is something we still need to do. Thank you, mr. Chairman. The chair thank the gent the lady. And recognizes the gentlelady from North Carolina. Thank you, mr. Chairman, thank you to the panelists today. I want to talk about the North Carolina programs that are moving forward. Im very proud of the work theyre doing in North Carolina, you know, over over the last decade from less thanked billion annually a decade ago to more than 14 billion annually as of 2012. North carolina spends more per person on medicaid they than any of the seven state enables. Recognizing North Carolinas medicate failure, the governor proposed reform outlined in the state partnership for healthy North Carolina. And i commend him for his work, and also North Carolina human health and Human Services chairwoman for the work she has done. I echo the words of representative burt jones in North Carolina calling it a winwinwin situation celebration because it benefits the patients, the Health Care Providers, and the taxpayers of our state. With that, i want to expand a little bit on the florida issue because North Carolina is looking at florida, and i have a question for you in relation to some of the discussion that has already gone on. Is it not true that floridas medicaid reform demonstration was approved eight years ago but only last month did the state receive final approval to go forward with the state reforms . Is that part of the situation that were talking about . Thank you for the question, congresswoman. Florida started a reform pilot in five connecticuts. Counties. They covered 300,000 moms, individuals, and kids and ssi. And two years ago, the legislature voted and the governor committed a waiver to expand the reform pilot to all 67 counties. It was expansion . Correct. Great. Okay. Basically, you know, obviously were talking about tough times here. Scarce resources, drastically growing enrollment levels, states need to know they with move forward with the reform. I know, thats part of the discussion that we have been having today. Unfortunately, they are currently forced to live under the maybe or wait and see approval flail Agency Process that takes years to find out whether or not they can be approved. From your perspective, what can be done to improve by the cms . Im sure its a broad answer. Thank you are the question. I think first and foremost states need predictability. You have in the state plan and administrative filing. You have predictability. There are et is time frames if the federal government doesnt act and deemed approved what happens with a whatever there is no time limit. And therefore, cms can drag the feet. In the case of kansas, cms approved the waiver two days before implementation began. What were seeing is states are playing a game of chicken with the federal court federal government hoping that cms will act or ore theres a wasted effort. I knew i was do you want to explain on that at all . Is there anything you would like to add to that . Ic that i think this is one of the things that has bipartisan or nonpartisan issue. Which is how can you improve the innovations that are happening in the state faster so you can get more people. People can study the result to say it does it work or not work . I think thats one thing that people can come together to look at. How do you speed up the process and allow more innovation at the state level without having the barriers. Coping that in mind, right now with medicare enrollment at over 70 million, one in four americans expect to become a medicaid beneficiary as a result of the aca. Do you believe there are measures in place to ensure proper eligibility okay its after week being back in North Carolina. I cant speak today. Eligibility vertification. I think its actually even before the Affordable Care act the trend has been going in the opposite direction with presumptivetive eligibility, those things move in the opposite direction. I think with the massive complexity of the Health Care Law. I think its important there are some stronger eligibility processes in place. Not only for medicaid but the exchange side as well. Thank you so much. Is there anything you would like to add. No. Great, thank you. I yield back the reminder of my time. And recognize the gentleman from florida. Thank you, mr. Chairman, thank you for holding the hearing. I thank the panel for the testimony. Mr. Bragton, the current law the a reform system to increase outcome and reduce costs typically dont see most of the savings. How can we transform the system to incentivize states and low them to a greater share of the savings . Thank you for the question, congressman. I think this is really a key factor that Holding States back from innovating. States get to keep only about 40 cent of every dollar they save, or in the case of expansion, 10 cents out of every dollar they save. What i think would be a better approach to promote innovation is having shared savings. One of the things that private medicaid plans do they share the savings that coordinated care contributes with providers. So providers have an incentive to save money as well as the plan. It should be the same with the federal government to states. Why not allow the states to keep one out of every three or one out of every two federal dollars they save. For the panels what off medicaid and on to private insurance. What are the challenges the beneficiaries face . I would say, first of all, prioritizing the population. Not everyone on medicaid is treated the same. I think thats for a benefit to the beneficiary. The higher up the income scale, the more access you likely have to private insurance. It should be encouraged. I would agree that medicaid reliance on private plans makes that transition easier when it occurs. And states are currently making significant efforts to try to assure smooth transitions between medicaid and the exchange. Unfortunately the biggest barrier to transitioning smoothly the jobs most people move in to when they move off medicaid dont offer insurance. And the absence of that, theres nothing to transition to. I would agree with both responses. I think that you its very important to look at four individuals on medicaid. Many of them on medicaid for a short am of time. The private plans are prohibited from marketing to them or reaching out and making them aware of the options available. And states need to be more creative to create transition products that arent quite medicaid private plans but arent quite private insurance to give People Protection to not only catastrophic coverage but Preventive Services. Is it a good idea to provide diversity of plan [inaudible] to consumers . Thank you. Yes, and i think that the most strong evidence of that is consumers voting with the feet. When you give them a i Diverse Group of plans with meaning differences ownership to 80 pick a plan different than the one defaulted in to. I see advantages to plan choice. In less populace area of the country. It doesnt mean anything. The real challenge is finding providers and having different administrative structures doesnt provide any value. Unfettered choice or unstructured choices can be very hostile, actually to consumer or private industry knows very well how to structure choices in ways that help people make choices and not but in general certainly choice is a key component of the drive to quality. I would agree with with the panelist and say though that slight difference a choice of the same product across without any differentiation is kind of choice with no choice. Youre not really choosing anything different. I think there needs to be some sort of i did fors indication or ability to offer different plans with additional benefits, et. Cetera in order to really have what choices. Thank you. One last question, if i may, mr. Chairman, mr. Bragton, they the administration seems focused on expanded medicaid issues. How many people are medicaid eligible and are not enrolled . Shouldnt we focus on getting care to those groups before we focus on expanding medicaid . Also the expansion of patients will increase the patient load on the medicaid system. Ha has there been an influx in doctors taking medicaid . I dont think so. What will the patient surge do to the system . I think there absolutely they are real challenges to access for individuals. A card is not access. We need look at can you actually provide access to care. I would point out that with the question of there are many out there i know children, many children eligible but not enrolled in the Program Raises the question what is it that keeps them out . Its obviously eligible. They would qualify. Do they as pointed out having a card may not be the type of care that best suits them. Thank you very much. I yield back. Recognize the gentleman from virginia. Thank you, mr. Chairman. I appreciate it greatly. Mr. Bragton, i was looking at your written testimony on pages 7 and 8 you go through a process. You want to refer to. You probably know it like the back of your hand, some of the Medicaid Programs that rely on private programs