In congress, some states are looking to expand medicaid, some additional states, many are talking to cms about what might be possible in the way of theyre talking about waivers, what can be done. And so to today were going to k about, our goal for this panel is to both talk about where we are going into this next year, so writer we are, what the aca did, where we are with medicaid, whats under discussion, and were going to talk about the considerations and possible implications moving forward. So we are lucky to have with us today three exceptional panelists. Youll notice there is one empty seat, and that belongs to trish riley. Unfortunately, because of the crazywet we had in d. C weather we had in d. C. , trish is not going to be able to get boo town, so she will not be with us. But fear not, our three other panelists watch whats happening in the states very closely and will be able to give us a full picture of whats happening. First to my left we have diane rowland, executive Vice President of the Kaiser Family foundation, also the inaugural chair of mac pac which advises congress on policy. To her left is Josh Archambault who spent time with the heritage foundation, and hes up in massachusetts where he also worked for former governor mitt romney. And at the end of the panel we have judith solomon, Vice President for Health Policy at the centerren on budget and policy priorities. I wont go into further detail, you have their full bios in your packet. And what id like to start off doing is id like to ask diane if you would please help everyone in the room to understand whats our starting point here . What happened with, that was created by the aca, and just where are we . What is our starting point . Well, weve spent much of the last few years talking about medicaid in a very narrow way. Weve been talking primarily because of the Affordable Care act about medicaids role as an Expansion Program to cover additional adults who are very low income but who didnt previously qualify for the program. And i think to remind you, that goes back really to the history of medicaid, enacted in 1965 as the program that was intended to provide coverage at that time to the welfare population, since expanded tremendously. But in that era, the aged, blind and disabled, children and adults with dependent children. Initially, just single adults with feint children. And as weve with dependent children. And as weve seen over time, weve expanded the role of medicaid to be role of insurer for many children, help with Longterm Services and supports for the elderly and disabled as well as children with special health needs. But states were unable to obtain the federal matching funds if they wanted to afford coverage to adults without dependent children because they were not one of the categories of medicaid. And what the Affordable Care act did was to say eligibility should no longer be based on whether or not you fit a category, but instead should be based on whether or not you are truly low income and defined that as 138 of the federal Poverty Level or about 23,000 for a family of three. So the big change in the Affordable Care act was to really reframe medicaid as a program for low income individuals that would provide Health Insurance and health care. And they intended to build on the mandate that was already in place in the medicaid statute of covering all children up to 100 of poverty and for younger children 138 by extending that to adults which would have raised eligibility for the parents of many of the children who were well below the abovety level in terms of their state coverage and also to try and provide for a National Standard of how many low income people one would be covered. Obviously, when the Supreme Court weighed in, it weighed in so to say for adult coverage that should be a state option rather than a requirement even though initially the federal funding was 100 . So i think much of the discussions of which states are going to expand, which states did expand, what was the impact, who did it really cover, what kind of individuals were covered by this expansion x we know that in the 32 states that expanded, some 11 million individuals became newly eligible for coverage. But when we look at where the debate is going today, its not just stopping at what should we do about the expansion population, but instead in the gop house bill that we just saw brought to the committees and then possibly someday to the floor, its now taking on the entire Medicaid Program. And i want to remind everyone here that medicaid is a far Bigger Program than the expansion. It is our largest Health Insurance program that takes care of some 74 million americans including many of the 20 who are Medicare Beneficiaries who need medicaid to help supplement medicare as well as to provide for Longterm Services and supports. It takes care of many of the Mental Health and other challenges. Its been one of the front line programs today on the opioid addiction program. And it has been structured over time to provide states with the ability to draw down federal matching funds to cover the population that they are covering as long as they abide by some basic federal rules about who they can cover, what they can cover. But a lot of builtin Optional Services and optional coverage. So the proposals to change that openended federal financing to some sort of a per capita cap has been introduced over time. The federal government seems periodically to like to say well give states more flexibility in return for being able to limit the federal governments commitment to this program. And that was part of the other debate that was going on around the gop house proposal. So we have two issues here; really what happens to the expansion and the expansion population and then what happens to the broader Medicaid Program and its role as our Health Safety net. So lets take that one at a time, those two pieces. One is the broader conversation of do we move to a per capita cap, or to we move to a block grant. What do we do in the long term, if anything. But first, lets talk about the more immediate question. Without that broader conversation, we are here and now looking at some states thinking about waivers, some states deciding now whether or not they are going to join the expansion. And so id like to ask all of our panelists where are we now and what are we likely to see happen . Why dont we start with josh on that one, and then others can weigh in. Sure. So thank you so much for having me this morning. So, first, i would say with a new administration its, from a state perspective, its a whole new world when it comes to what they can ask for flexibility for. So we have been involved in a number of conversations and heard from a number of governors and medicaid offices that they are thinking very differently than they have in the past about what theyre going to ask for for flexibility from the federal government. So thats certainly, we can unpack that a little bit as we go. But there is a big discussion about plan designs and what kind of how you set up these programs outside of the financing. The second question on medicaid expansion, you know, we have seen already a up couple states a couple states look at expanding, kansas being the most recent one. That is a multiyear campaign by hospitals and insurers in the state to fund candidates who are more sympathetic to that. So that was, should not be viewed in isolation. What i think ultimately it comes down to is if the house bill moves. If the house bill moves as currently structured and the senate makes tweaks but it largely stays the same, i actually dont well, first of all, the first managers amendment restricted new states from expanding. So that would kind of end that conversation if it became law. But then we move to that bigger question about financing. So the expansion debate, i think, is active in a couple states at the moment, not as active in others because theyre still waiting to see will this house bill move as currently conceived or how much will that change. Sure. Also, thanks for having me. I want to step back a little bit on waiver withs because i think, you know [inaudible] into that conversation about really thinking about what they are and what theyre supposed to do in the Medicaid Program. And if we think about medicaid, it has numerous options that dont require a waiver. It is a very flexible program. And waivers are really on top of that, to give some additional things states can do. But what they really are is saying, you know, we have a medicaid statute that was passed by congress and amended over the years, and in some cases if a state wants to try something and wants to try something that is going to pursue the objectives of the statute which is essentially to provide health care to low income and Vulnerable People in this country, then well let you try that, and well let you try it for a limited period of time, and well look at it, and well test it. And so if we start there, then i think its a good framework for thinking about some of the things that are coming up, as josh said. A lot of new things are coming up, things that have never been allowed and things that have never been tried. And among those things are work requirements, and we can get into sort of the details of why we believe very strongly that these are a bad idea for medicaid, and the rejection of them in the past has been right. Theres really no evidence base. But even things like, you know, premiums where the medicaid statute says we have low income people were covering here, they cant afford to pay premiums, so you shouldnt charge them premiums. So giving a waiver when we know and weve tried this in other situations and weve actually seen that waivers keep people from participating in the program. So if you go back to really the beginning and when the aca was passed, as diane described why we had the expansion, it was to have a continuum of Health Options for, you know, low income people, particularly working people in jobs that didnt provide health care. And to say now were going to do something that we know will decrease participation, i think, is not really consistent with the purposes of the waivers. And i think its just really always important to think about these as demonstration projects and that they are supposed to pursue the objectives of the program. You know, i think its really interesting that sometimes waivers proceed legislation, and that certainly is the case with the Affordable Care act expansion. Because prior to that, 11 states had come in for waivers saying cant we please cover some of these adults without dependent children . Many of them have a lot of disabilities, but they dont yet meet the disability threshold for coverage. And so it was really a series of demonstrations that led to the argument that maybe extending coverage through the legislation would be possible. And i think that is generally one of the purposes of the waivers both to see if states can test new meds, but to methods, but to see if those new methods ought to be made available through legislative change or at least through broader adoption by the states. And the Family Planning waivers are, i think, a really good example of that, where states were allowed to provide Family Planning services to adults that werent otherwise eligible for the program, and that was shown to prevent pregnancies that were not desired at the time and also that was in the statute. So thats the kind of approach of and, you know, that requires rigorous evaluation. Perhaps i could offer a slightly different perspective here on waivers. In our experience regardless of the political stripes of a state, you can find a blue state medicaid director that will gripe, at least privately, about the whole waiver process for a variety of reasons. And it is important to realize that there are a couple of different ways states can get flexibility whether its a state plan amendment which is usually a shorter process and kind of rules around that or the 1115 waiver process which usually is the bigger medicaid waivers. But what is not told about the flexibility is usually it takes well the average is well over a year for approval for those sorts of waivers. So if im a medicaid directer and im at the state level and i have to balance my budget every year unlike congress, i know [laughter] but at the state level, i have to balance my budget, and it takes me a year to get a yes or a no on whether i can do something dramatically different . Thats not flexibility. From their standpoint. The other thing is i have to go to d. C. To is ask if i can do something, yes or no. When im funding at least partially funding the program. But not fully. Well it fends on the state. But, again, this is a statefederal partnership. So im just i want to reflect that theres a lot of frustration at the state level with how this process has played out over the years and the fact that they simply have to come. And you have states and why probably more republican governors are interested in the block grant conversation, for instance, is to say, look, let me wash my hands of this process. Let me determine how i want to do it. If it means i have to put more state dollars on the table, ill consider it because at least i can cover the populations that i want to cover. So i know theres a big federalism discussion here thats happening, and were bouncing around a funding piece of this because that largely drives this conversation, but i do want it to be heard that a lot of people at the state level dont think its actually that flexible of a process. Even though they can ask for a lot, it just takes a long time. Well, the waiver process is different from the process for asking for for not even having to ask, for indicating which options you want to adopt in the Medicaid Program. And theres multiple options in terms of the benefits that are provided, like what kinds of how you want to design your Delivery Systems. When were talking about these waivers that take time and have to be requested, its because youre asking to change the law, essentially. Youre asking for permission to do something that is different than what the law allows. And it would be pretty untoward if we were going to say that, you know, states could just to that and not have to come to washington or write to washington and just do it. We want to protect the people that are the intended beneficiaries of these programs. And these are really important protections around premiums, cost sharing, continuous coverage, all of that. Whos covered, how long theyre covered. And i dont think anyone should apologize for the fact that permission needs to be requested. So lets talk, lets take a half step back now and talk about flexibility and how much flexibility already exists, what can states do currently. Well, lets start there. How flexible is the program to begin with as a baseline . Well, one of the most flexible areas of the program is really what can be done for home and communitybased is services and for a lot of the services to the elderly and the disabled. There you can get special sometimes its a waiver to be to able to cover children with special needs for whom private insurance is not sufficient to help cover those children. A lot of states have liked to use waivers in that case because they can limit the population, they can have slots for home and communitybased services and not have to open it statewide. So thats, i think, an area thats very important. The really only requirements for the you would orally and the dis the elderly and the disabled are more nursing home care and states have broadly used their authority for Optional Services and waivers to expand what they can do around keeping people in the community and rebalancing Longterm Services. Give us an idea of how widely waivers are currently used. If im not mistaken, every state has them. Every state has multiple waivers. Clearly for the home and communitybased, multiple waivers targeted at different populations. And the reason theres waivers is because, basically, as diane staid, nursing home said, nursing home care is a required service in medicaid. Providing services in the home which is more advantageous, more desired by people and now is more than half of Longterm Services and support is basically optional. And what the waivers do is allow states to design packages of services that are specifically targeted to the population. So they may have, you know, waivers for people with intellectual disabilities, seniors, children with special needs, different packages of services, some of the things that are not normally covered by medicaid such as respite care. Theres a lot of flexibility there. Theres a lot of flexibility in how you provide services, whether you use managed care, different forms of managed care. Were now seeing things like Accountable Care organizations similar to what medicares doing. So all of those things and a tremendous amount of innovation that has taken place over the last years, and a lot of that has been, you know, facilitated by states being able to get some upfront frame dollars to federal dollars to allow them to improve their Delivery System, set up better means of coordinating across providers, integration of behavioral and Mental Health services, all of that, improving delivery for people with Substance Abuse disorders. Thats whats going on. And that is what would be at risk if the federal matching system is changed to a capped funding stream. Then wed be down to just paying for doctors and hospitals. So, josh, what is it that some republican governors are looking for to do with waivers moving forward now . Yeah. So i think thi