That is the discussion we need to be having. Is it fair to say most of the people who are in the waiting list who are develop mentally disabled traumatic brain injured people and those with serious Mental Illness are on medicaid, a different type of population and what has been your findings with the governors with respect to how most of them would like to take care of this population if there are consensus among governors, what is the governor, the legislature to deal with respect to the population. I will say there are exceptions to that rule. How did they do it. And they are focused on those that are the most needy and made that a priority in their state and their waitlist. We need to explore the states that found ways with little or no wait lists. And the application to cms for medicaid waiver to continue suyears. And outstanding program, it is a way to save and help, it can be replicated. It is an incredible model that can work, we have a waiting list in indiana. I hope the new nominee to lead cms, we could get all of medicaid stronger and better programs with controls in place, i worked with the units, we need to do more to support them, and they are protected and i yield back. Now recognizing miss clark. Thank you, mister chairman and ranking member. I want to respond to Mister Howard. And the impression left by characterization of the empire state. New york states Medicaid Redesign Team is a National Leader in controlling costs and improving quality for medicaid members. Selfdescribed as fiscally conservative think tank and government watchdog. In december 2016 medicaid spending per recipient dropped from 10,684 to 8781 or 18 from 2010 to 2014. Nearly twice the national average. According to the control office, and the medicaid spending growth, only 1. 7 annually during the period of fiscal year 201013. This is a significant reduction over the trend to the previous ten years of 5. 3 . During the same period medicaid reenrollment grew by half 1 Million People. Spending has been cut. Fiscal year 1415, a total of 15. 4 billion was saved next to the m rt initiative. This track record led to the Controllers Office to declare mrt represents the most comprehensive restructuring of medicaid systems since the Program Began in 1956 and we have no waiting list. I turned to Mister Westmoreland. In Mister Archambaults written testimony he cited concerns about Medicaid Expansion. He ignores the fact there was a positive impact on the quality of life and help, he ignored the fact of cost savings from preventative medical examining, Early Detection of disease and future cost savings to the state and government. Im a strong supporter of Medicaid Expansion, significant value of the program. Im interested in improving the program. Miss archambault claims Medicaid Expansion funding threatens the truly vulnerable. Can you clarify why this is not the case. I begin with first challenging the discussion as i did in the testimony of who is truly vulnerable. Not all people with disabilities, any of those discussions that have been ongoing, and in receipt of ss i and many people who we consider disabled, and the Medicaid Program until enactment of the aca. Lets start with those people. Secondly, there have been macroeconomic studies by Business Schools, economists showing states have significant budgets and revenue gains. And Medicaid Expansion in their state so it is clear states benefit on a financial basis, and the financial basis in ways i outlined in my testimony. Mister archambault and Mister Howard claim Medicaid Expansions have an unsustainable burden. Can you clarify why this is not the case . Why have most states that expanded medicaid experienced budgetary savings. And fewer uncompensated care costs. And a reverberating multiplier. And able to provide as you suggested preventive and Early Intervention services that might not have been available to uninsured adults by ongoing healthcare costs. My understanding numerous studies have disproven the myth that Medicaid Expansion i yield back the balance of my time, mister chairman. We recognize a new member, gentleman from michigan, mister tim walberg. I appreciate the safety net, we want to have safety nets, we dont want to have safety nets forever. And working at us steel, going out and being responsible to take the plug out of a heat of molten steel. And have a fall protection strap on me. I appreciate that. I dont want that strap. I wanted to move on, the goal to find ways, the people who truly need the safety net have it. We make sure we dont waste it on others who dont and encourage and move on in a positive way. And ms. Maxwell, would like to comment after Esther Archambault your testimony references waste and fraud issues, individuals that passed away two decades ago using high risk for stolen Social Security numbers, tens of thousands moved out of state and medicaid. There are a number of things we would recommend, the first is a a change that states could only redetermine eligibility once a year in case they were given a reason to recheck eligibility, to access data internally in State Government and thirdparty vendors. On a quarterly or monthly basis they are finding individuals have life changes like all of us, they move or die or get a significant raise we need to make sure we find that sooner rather than later, otherwise we are wasting money and i believe there is bipartisan agreement on that, need to make sure. The other thing is we need to make sure the federal databases which we havent talked a lot about, the quality of the data is so poor. And complained constantly how late the data is, out of date, making sure states are looking for dual enrollment and the food stamp program, we should be doing it for medicaid. Just to be sure we are not wasting money as a result of individuals. Ms. Maxwell, can you add to that . I would definitely echo the crucial need for better medicaid data. We have to understand programmatic issues for policy decisions and also to find fraud, waste and abuse. In addition to that path of protection, we need to think about fraud happening in the first place. In addition to the data, to work with states, to make sure providers get in and want to pay. An audit in arkansas, 43,000 individuals on medicaid, and 7000 with any record of living there. 20,000 medicaid enrollees in high risk identities. Fake Social Security numbers, etc. Something of interest to me in michigan has identified 7000 lottery winners receiving some public assistance including individuals winning up to 4 million. Those jackpots are something, dont encourage him not to be on medicaid assistance. Do these individuals get approved for and stay enrolled in the Medicaid Program and is it the federal government . Maybe a little bit of both. To answer that question, what is really important is there are policy changes that have happened was the Affordable Care act remove the test for the Medicaid Program. These outlier cases for when and individual wins 4 million and takes a lump sum payment they may not qualify that month but the next month they would qualify for this program. We are not checking for 12 months in most cases. We wouldnt know. We need to make sure gaping holes exists, in a State Government, and the federal government needs, in a regular basis, and Mister Howards point, that is not the incentive that is inherent in the current financing structure. My time is expired. As many of you know, i grew up with farmworkers in the underserved community. I have seen firsthand what it means when a community is medically underserved and when they cannot access care. It is not for medicaid in regions like this across the country that did not have access to healthcare on this day us and families enjoyed. If we repeal Medicaid Expansion people will lose healthcare coverage and stop seeing their doctors because their too high, and 3. 5 that is millions of families losing access to health care. If we repeal Medicaid Expansion uncompensated costs increase straining our nations Healthcare System which will drive up costs for everyone. When people dont have Health Insurance they dont stop getting sick and emergency departments, do not turn someone away, and the hospitals have to make up the cost. In 2014 alone, there was a decrease in uncompensated care by 45 in 2014. All hospitals in my district, in particular a drop in uninsured patients by half. We need to expand medicare even more, make it more efficient and desirable for providers to see more medicaid insured patients. Fraud is bad and political amplification of the problem to wrongfully justify cutting Health Insurance for six patients is bad. Here is the possible common ground. Here is what i think we can both agree on. If we start with the premise that we need to cover more economically struggling families like the middleclass and more vulnerable families then we are on the same page. If we start with the ideological goal, read mistrust and millions of people will be harmed including the middleclass. And sick and injured people getting the care they need. Anything short of this is negligent. To expand coverage to a few struggling, uninsured middleclass families so the question i have if you were to choose one thing you can do to combat fraud, if theres one action you can take that can make the biggest difference in the system what would that be . It is around the providers making sure we have eligible providers in Good Standing and those not in Good Standing should not be providing services. The one thing that will make the biggest difference. I would have to go back to the data. A lack of data across the nation from the managedcare companies. One thing to change to make the biggest difference what would it be . Engaged data transparency, and benchmark to provide performance and engagement. Where does the evidence suggest about how Medicaid Expansion is making health care more affordable. And reducing patient needs to forgo medical care due to costs. Medicaid expansion is associated with a decline in personal bankruptcies and associated with greater Financial Security for those newly eligible. These are middleclass families having Economic Security because of Medicaid Expansion. What does evidence say about how Medicaid Expansion affected Patient Access to primary care and preventative care. People in those beneficiaries insured Medicaid Expansion have higher rates than traditional sources of care, primary care and Preventive Health services. My closing statement, is this leading to expansion for economically struggling families, the ultimate goal is to create a facade and emphasize problems to justify policies that hurt the middle class and increase Health Insurance i am nodding expand more Health Coverage for middleclass families. Recognizing a member of the committee. Ucla former state assembly, congresswoman mimi walters of california. My questions are directed to Mister Archambault. Supporters argue Medicaid Expansion would increase jobs. Has this happened . A number of studies where predictions have been off, and in particular, there were predictions of games and hospital jobs related to expansion and the opposite is taking place. During the conception of the aca supporters argue Medicaid Expansion would stop hospital closures. It stopped hospital closures in a number of states hospital still closed. Important to realize supporters claims it was a Silver Bullet to stop closures. And massachusetts and the number of the states that expanded hospitals. Medicaid expansion was projected to emergency room use. The evidence suggests emergency room use increased after expansion and emergency room visits were deemed to be avoidable. I live in massachusetts, worked on romneycare, one thing that is apparent is the expansion population, and getting coordinated care showing up to the er at a higher rate than those privately insured or uninsured, these are questions to ask about the effectiveness of the program and the quality of care individuals are getting a number of surveys looking, as unavoidable. 55 of medicaid visit to the er are unavoidable. The Affordable Care act has been a blessing for so many people in the country. 12 million more americans have access to health care, and governors across the country, with senator mccarthys request, and expansion of medicaid within the states. Im assuming some of these letters. Even some republican governors appear to have positive things to say about the expansion of medicaid. The letter my home state of illinois stated governors say are medicaid population, quote, stands at 2. 2 million, almost a quarter of the state population enters Republican Leaders in congress to carefully consider the ramifications of proposed changes, governor sandoval of nevada stated in his letter to Mister Mccarthy, the Medicaid Program to require managedcare, to implement a statebased Health Insurance exchange, these made healthcare accessible to many nevadans who never had coverage before. Can you briefly touch upon how the residents expanded medicaid under the aca benefited like illinois and nevada. Illinois and nevada, touch on how residents of states that did expand medicaid under the aca. 11 Million People had medicaid coverage, and point out and agree with you, the governors who wrote to Mister Mccarthy none requested appeal and pass 16 of the states governed by republican governors and ohio, one of your former colleagues was most passionate in describing not only how it benefited the residents of ohio to have services and believed it was a oral duty to cover people under medicaid. Can you touch i wanted to mention other examples, that have positive outcomes for their residents and beyond Healthcare Benefits of 12 Million People how is Medicaid Expansion helped states manage their budgets, had a positive impact . I suggested there have been Business School study that economic studies suggesting states expanded medicaid not only had a net increase in federal funds coming into the state but enjoyed revenue increases reverberating effects, providing funds in hospitals. I would also, and productivity improved by people having Healthcare Services that were denied this service. Some of the letters i was referring to seem to raise concerns by republican governors of changes to the Medicaid Program first cost shift. Governor baker of massachusetts in his letter to Mister Mccarthy said, quote, medicaid is a shared federal Partnership Proposal that suggests states are provided with flexibility and control, with substantial and destabilizing costs. Is there a concern with a cost shift under the republican proposal, seeing such a proposal to grant medicaid or per capita spending, should state be concerned about major cost shift . What level will the initial block grant and its formula say that but major the evolution, increase of funding over the future compared to the cost of providing health stock costs to the number of people who need them. States will be left holding the bag to medical inflation and the number of people who have no Health Insurance. What about those receiving healthcare through acas expansion are they at risk to block grant the Medicaid Program . I suggest my colleagues on this panel point out suggest those people should be the first to go. Returning to traditional medicaid populations. Over the last 20 or 30 years. I would suggest people on Medicaid Expansion are the people on the chopping block to begin with. As every state, no expansion experiences the growth in healthcare costs that is almost inevitable looking at cbo or any other projection states the left holding the bag and do not have a guaranty of federal funds. Another new member of the committee, Mister Costello of pennsylvania. You are recognized for five minutes. If i could ask a couple questions, has the number of criminal investigators increased or decreased over the years . The num