With the failure to pass the bill in congress, some states are looking to expand medicaid, some additional states. Menstruates are talking to cms about what might be possible in the way theyre talking about waivers, what can be done. And so today well talk about our our goal for this panel is to both talk about where we are going into this next year, so where we are, what the aca did, where we are with medicaid, what is under discussion, and well talk about the considerations and possible implications moving forward. So, we are lucky to have with us today three exceptional panelists. Theres one empty estate and that belongs to trish riley, but because of the crazy weather in trish wont be able to get into town and so she will not be with us but fear not, our three other panelists here watch what is happening in the states closely and will be able to give us a full puck picture. First we have Diann Rowland from the Kaiser Family foundation. Diane was also the inaugural chair of macpack, which at advise congress on medicaid poll sir. Then josh from the foundation for government account abilityity. And josh works former gov mitt romney. And the end of the panel we have judith solomon, Vice President for Health Policy the center on budget and policy priorities. I you have their full bios biosn your packet. Id like to start off by ask dianne if you would please happen everybody in the room to understand what is our starting point here . What happened with that was created by the aca and just where are we . What is our starting point . What we have spent much of the last few years talking about medicaid in a very narrow way. We have been talking primarily because of the Affordable Health care act about medicaids role as an Expansion Program to cover additional adults who are very low income but didnt previously qualify for the program. And i think to remind you, that goes back really to the history of medicaid and after the 1965 as the program that was intended to provide coverage to the welfare pop someplace a has expanded tremendously. In that era the deserving poor were considered the aged, blind and disabled, children and adult width dependent cheng children and we have expanded the role of medicaid to be more of an insurer for many children and longterm support for the elderly and disabled and children with special needs but states were unable to obtain the federal matching funds to afford coverage to adult is without dependent children because they were not a category of medicaid. What the Affordable Care act did was say that eligibility should no longer be based on whether or not you fit a category but based on whether or not you can truly low income, and define that as 138 of federal Poverty Level or 23,000 for a family of three. The big change in the Affordable Care act was to reframe medicaid as a program for lowincome individuals that would provide Health Insurance and health care and they intended to build on the map debt under place in the medicate of covering up a children up to 100 of poverty and be by 138 by stepping that to adults which would rates eligibility for the parents of many children who were will below the Poverty Level in terms of state coverage and also to try and provide for a National Standard of how low income people be covered. Obviously when the Supreme Court weighed in it said that should be for adult coverage, a state option, rather than a requirement, even though initially the federal funding was 100 . And so i think much of the discussions that the states are going to expand, and states escaped, what whats impact, what did it cover, what kind of individuals were covered with this expansion, andow that in the 32 states that expanded, some 11 million individuals became newly eligible for coverage. When we look at where this debate is going today its not justining what to do about the expansion population but instead in the g. O. P. House bill that we just saw brought to the committees and then possibly some day 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 healthyearance program that takes care of some 74 million americans, including many of the 20 who are medicare byissues who need medicaid to help supplement medicare and provide for long, Term Services and support. It takes care of many of the Mental Health and other challenges one of the frontline programs today on the opioid addiction problem and has been structured over time to provide states federal matching funs 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 coverages. So the propose sal so end that openended federal financing to some sort of per capita cap has been reduced over time. The federal government says 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 g. O. P. Proposal. So we have two issues here. What happens to the expansion and the expansion population, and then wants to the broader Medicaid Program its role another our States Health safety net. Lets take that one at a time. One is the broader conversation of do we move to a per capita cap or a block grant . What do we do in the longterm, if anything . The first let talk about me 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 theyll 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 . Start with josh on that one and then others can weigh in. Sure. So, thank you for having me this morning. First, would say with a new administration, it is from a state perspective 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 officers theyre thinking differently what theyre going to ask for, for flexibility from the federal government. We can unpack that as we go but theres a big discussion about plan designs and what kind of how you set up these programs out of the financing. The second question on medicaid expansion, we have seen already a couple states look at expanding, kansas being most recent one. That it is a multiyear campaign by hospitals and insurers in the state to find candidates who are more sympathetic to that so that should not be viewed in isolation. Colts down if the house bill moves. If the house bill moves as currently structured and the senate makes tweaks but largely stays the same, the first managers amendment restricted new states from expanding toso that would end that conversation if it became law. Then we moved to that bigger question about financing, so, the expansion debate is active in a couple of of states at the moment, not as active in others pause theyre still just waiting to see will this house bill actually move as its currently conceived and by how much witness that change. Sure. Thank you for having me. Let step back on waivers. We go full speed into that conversation without 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 waiver. It is a very Flexible Program and waivers are on top to give some additional things states can do but what they really are is we have a medicaid statute 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 to provide health care to lowincome and Vulnerable People in the country, then well let you try that for a limited period of time and look at and it test it. So if we start there, i think its a good framework for thinking about 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 requirements and we can get into the detail why we believe these are bad idea for medicaid and the rejection of them in the past has been right. Theres really no evidence base. Even things like premiums where the medicaid statute says we have a low income people were covering here that cant afford to pay premiums songs so you shouldnt charge them them premiums. So giving them waiver and we in the we have tried that and have seen that waivers can keep people from participating in the program. So if you go back to 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 low income people, put particularly working people in jobs that didnt provide health care, and to say, now were going to do something that we know will increase participation i think is not really consistent with the purposes of the waivers, and i think its just always important to think about these as demonstration projects and that hare supposed to pursue the objectives of the program. I think its really interesting that sometimes waivers precede legislation and thats the case with the expansion. 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 disables but dont yet meet the disability threshold for coverage so it was really a series of demonstrations that led to the argument that extending comp through the legislation is possible. I think thats generally one of the purposes of the waivers, both to see if states can test new methods and to into if those new methods should be made available more broadly, maybe through legislative change or through broader adoption by the state. The family waivers are a got example, provide Family Planning services that were not otherwise eligible for the program that was schoop shown to prevent pregnancies that were not desired a at the time and also so that is the kind of approach of that requires rigorous evaluation. Perhaps i can offer a slightly different perspective here on waivers. In our experience, regardless of the political stripes of a state you can fine a whether you 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 there are couple of different ways states can get flexibility, whether its a state plan amendment which is using a shorter pros and rules, or the 1115 waiver process which is usually the bigger medicaid waivers. What is not told about the flexibility is ugly takes the. A is well over a year for approval for those sorts of award. Ive im a medicaid director the stately and i have to balance my budget every year, unlike congress i know but the state level i have to balance my budget and takes me a year to get a yes or no on whether i can do something dramatically different . Thats not flexibility. And from their standpoint. The other thing is have to go to d. C. To ask if i can do something yes or no. Weep im partially funding the program. But not soley. Depends on the state. This is a state and federal partnership. I want to reflect theres a lot of frustration the state level how this praise out and the fact they simply have to come you have states and probably more republican governors more interested in a block grant situation to say let me wash mishands of the process and let me determine how i want to do it. If it means have to put more state dollars on the table ill consider. It mean is can design my coverage and cover the populations i want to cover. Theres a bigfordism discussion and were bouncing around the funding piece but i do want to be heard that a lot of people the state level dont think its actually that flexibility a process, even though hey can ask for a lot, it just takes a long time. The waiver process is differ from the process for not having to ask for kitting which option you want to adopt. And in the Medicaid Program and theres multiple options in terms of benefits provided, like what kind how you want your desired Delivery System. When we talk about the 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 states could just do 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 the programs and these are really important protections around premiums, cost sharing, continuous coverage, all of that who is covered, hundred, and i dont think sunshine apologize for the fact that permission needs to be requested. So, lets take a half step back now and talk about flexibility and how much flexibility already existed and what can states do currently and well start atlanta. How flexible is the program the base line. One of the most flexibleaires what to do for home and Community Based services and services so the elderly and the disabled. You can get special sometimes a waiver own a limited gain, good coverage, children with special needs for whom private insurance is not sufficient to help cover the children. A lot of states have liked to use waivers nat case because they can limit the population and hat slots for home and Community Based services servict have to open statewide. So thats anaway that is very important. The only requirements for the elderly and disabled for ben fed are more nursing home care and states have broadly used their authority for Optional Services and for waivers to expand what they can do about keeping people in the community and rebalancing longTerm Services and support. Give us an idea how widely waivers are used . Every state has them. Multiple waivers. For the home some Community Based services, multiple waivers targeted at different possible layingses and the reason is basically, has diane said, nursing home care is a required service in medicaid. Providing services in the home, which is in moredred a vong yous and more desired and is half of longTerm Services and support is basically optional and what the waivers do is allow states to design packages of services that are statistically targeted to the population so may have waivers for the people with intellectual disability, seniors, children with special needs, different packages of services, some of the things that are knowing 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 medicare is going. So all of those things and a tremendous amount of innovation taking place over the last years, and a lot of that has been facilitated by states being able to get some upfront federal dollars to allow them to improve their Delivery System, set up better means of coordinating across providers integration and Mental Health service, all of that improving delivery for people with substance disorders and that is what would be at risk if the federal matching system is changed to a capped funding stream. Then well 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. I think this gets at a bigger issue about medicaid. Is it Health Insurance or a Welfare Program . Defending hop how to answer the question is how you think how to design it you have republicar governs wrote look at ick like a welfare entitlement program. So if youre going to follow that logic can things like work requirements, time limits, become things to look at for certain populations on medicaid. So i think theres actually a decent amount of research on other Welfare Programs showing that for certain populations, atrium through helpful. If you view it like Health Insurance you want it to look like Health Insurance so this discussion about plan design, deductibles, premiums, copays that when you slow up to the emergency room and its not emergency you have some financial skin in the game. Then the actual benefits mandated, a lot of state just to give one microexample. Nonemergency medical transport. So, do states have flexibility how to set that up . Could they work with uberor lyft and say you live near bus route, take the bus or the subway, but theres not a lot of flexibility in how States Imagine around those. The authority is quite wide but for the Obama Administration in particular and the bigger problem not trying to knock the Obama Administration its the interpretation at cms at that moment for what you can do and thats the bigger criticism. Think republican governors are seeing a political window their ask for things. Know that cms folks there now have been welcoming them and sent out letters saying wed like to grant additional state flexibilities. Well have to wait and see how flexibility they are or put in