Next, a look at the future of medicaid and how it could be impacted by proposed Health Care Policy changes hosted by the alliance for health reform. All right, were ready. Good afternoon. Welcome. Im sarah dash, im president and coceo for the alliance for health reform, and for those of you not familiar with us, the alliance is a nonpartisan, not for profit organization. Weve been around for 25 years, and our mission is to inform policy makers and help policy leaders on the most pressing Health Policy issues and get you guys the foundations of Health Policy, the evidence, and the practice, and today we are here to talk about one of the most pressing Health Policy issues that has been making a lot of headlines recently, and that is the Medicaid Program. Medicaid covers over 70 Million People, as we will hear, and it is responsible for taking care of very, very diverse populations with an enormous range of medical needs, from healthy newborn babies, to children with very special health care needs, to low income adults, people with serious illness and disability, and more. And as we all know, recent legislation proposed the American Health care act would have made major changes to the Medicaid Program, and certainly the discussion about the program is not over, so todays briefing is going to examine the relationship between medicaid coverage, access to care and Health Outcomes, as well as what might be next for medicaid in the states, in congress, and in the administration. And id like to thank, first, our sponsor for todays event, our partner, the Commonwealth Fund. Were very grateful for their support of this briefing, and before i introduce our panel, i just want to take care of a couple of housekeeping details. First, for those of you who need wifi credentials, they should be up on the screen. You can tweet t to futureofmedicaid, and when the time comes for questions, many of you know the drill, but write your question on a green question card or come to one of the mikes on either side of the aisle, or tweet your question to futureofmedicaid. So, without further adieu, im going to go ahead and introduce our panelists. We are still waiting on one panelist, but she will be joining us shortly. So, our panel to my left is Sarah Collins. She is Vice President for Health Care Coverage and access at the Commonwealth Fund. Gael walensky will join us. Shes an economyist and senior fellow at project hope. She directed the medicare and Medicaid Programs under george h. W. Bush, and all the way to the left there is Sarah Rosenbaum, the harold and james hirsh director of health and policy and the founding chair of Health Policy at George WashingtonUniversity School of public health. So without further adieu, im going to turn it over to Sarah Collins and well go ahead and get started. Thanks. Thank you, sarah. Good afternoon to everybody, and thank you to the alliance and also the panelists for joining us today. As sarah mentioned, a major focus of the American Health care act was the Medicaid Program. Both the Medicaid Expansion and also the traditional Medicaid Program. The bill likely would have ended the Medicaid Expansion over time, and it would have placed a federal funding cap on the traditional Medicaid Program. In the wake of the failure of that bill, the question before us now on the panel and for all of you is whats next for medicaid . To set us up for this discussion, im going to focus on the Medicaid Expansion, refreshing our memories about where the states stand on their decisions to expand the program and taking a look at the latest research on the effects of the expansion on coverage, as well as other key indicators. As of today, 31 states and the district of columbia, have expanded eligibility for medicaid. Of those, six have used 1115 demonstration waivers granted by hhs. These six states have struggled to reach political consensus on expansion and found agreement in alternative approaches such as enrolling medicaid beneficiaries in marketplace plans, in the case of arkansas, and imposing greater financial responsibilities on beneficiaries, including higher premiums and cost sharing. There are currently four states that are actively discussing expansion, the Kansas Legislature has passed a bill to expand medicaid, although the governor has vetoed that bill. The legislature is attempting to override it. Governor diehl of georgia has expressed interest in expanding medicaid. In maine, Medicaid Expansion is on the ballot this year and a bill to the legislature would expand medicaid with the republican controlled legislature, considering it this week. Other states where expansion has previously been under discussion might be states to watch this year, they include idaho, south dakota, tennessee, utah, wyoming, and other and a few other states. Based on Commonwealth Funds latest score card, which we released in march, and numerous other federal and private surveys, its pretty evident by now with three full years of experience in the Medicaid Expansion that its made a significant difference in coverage in states across the country. Uninsured rates have fallen in every state since the major coverage expansions of the Affordable Care act went into effect, but fallen the furthest in the states that expanded medicaid. Nine states saw declines of ten Percentage Points or more by 2015 and they were all in Medicaid Expansion states. Kentucky had the largest decline, followed by california, new mexico, and West Virginia. Since 2014, coverage gains have been the strongest among adults with lower incomes, and its in this income range where the differences between Medicaid Expansion and nonexpansion states have been the most evident. Uninsured rates in expansion states among adults with incomes under 200 of poverty fell by 14 Percentage Points from 2013 to 2015 compared to nonexpansion states. Coverage gains since the passage of the Affordable Care act have been associated with gains in access to health care, but these gains in access on average have been greatest in states that expanded medicaid. If you look at the middle bars in this chart, the share of low income adults reporting that they had skipped health care because of costs fell by 5 1 2 Percentage Points between 2013 and 2015. In states that expanded medicaid, compared to decline of about half that in states that hnlt expanded their programs. Likewise, fewer adults across the country report they dont have a regular doctor, but again these declines have been the greatest in states that expanded their programs. So lets just consider the case of kentucky and tennessee, and i use this example because these are border states in the south with somewhat similar demographic profiles, but which took polar opposite approaches to their Medicaid Expansions. Kentucky expanded their Medicaid Program and ran their own marketplace for a few years anyway and also conducted an aggressive Outreach Campaign to encourage enrollment. Tennessee did not expand medicaid and did not run their own marketplace. The states had similar uninsured rates prior to the Affordable Care act. The uninsured rate in kentucky among adults with low incomes fell by 25 Percentage Points, fell by only 9 Percentage Points in tennessee. Kentucky also experienced the largest decline in the country in costrelated problems getting care. The share of low income adults who said they had gone without health care because of costs fell from 34 in 2013 to 21 in 2015. In contrast, tennessee experienced no significant improvement on this measure. Likewise, many fewer adults in kentucky reported in 2015 they didnt have a regular source of compare compared to 2013 and tennessee did not see any measurable improvement in this measure. Ben summers has been conducting a survey of low income adults in three states since 2013 to track the effects of Medicaid Expansion. He selected arkansas and kentucky, both of which expanded their programs, and texas, which did not expand. His analyses have found significant improvements on key measures of Health Care Use and self reported Health Status in arkansas and kentucky relative to texas. For example, compared to adults in texas, adults in arkansas and kentucky had significant increases in getting checkups and significant decreases in visits to the emergency room. Ben also found low income adults in arkansas and kentucky experienced marked improvements in affordability, including a drop in out of pocket spending since 2013 compared to adults in texas. One of the policy rationales for repealing the Medicaid Expansion weve heard a lot about is the contention medicaid provides inferior coverage compared to private insurance and having medicaid is almost like being uninsured, but research hasnt really supported this claim. For example, this study that the Commonwealth Fund did using the Commonwealth Fund biannual Health Insurance survey found medicaid provided adults access to health care and financial protection that on most measures was comparable or better than that provided by private insurance and better than being uninsured. Cbo estimates that by 2026 more than 70 Million People will get their Insurance Coverage through medicaid, as sarah said, that many get their coverage now through medicaid, and 15 million of them through the Affordable Care acts Medicaid Expansion. This quick overview that i just went through suggests the value of this coverage in helping people get the health care they need, particularly large numbers of people with low incomes across the country, the program is really a cornerstone at this point in the u. S. Health insurance system, and it really should be the concern of policy makers to ensure its strength and viability over time. In terms of what you might see in the next year in terms of medicaid policy, some of the key questions are, will more states move forward on expansion . Will cms grant greater flexibility for states through the 1115 waiver process, and what will be the implications of that for enrollees . Will congress return to pursuing policies that would place state caps on federal funding of medicaid, such as block grants, and if so, what are the potential implications for enrollees . And ill stop there and turn this over to sarah. Thank you. Thank you, sarah. So, we may be we have a bias towards people named sarah today. Gael walensky is here. While shes getting settled, let me ask, many of you obviously have been following the debate, but for those who maybe need a little refresher, can you just explain the difference between block grants and per capita caps . And ill let Sarah Rosenbaum chime in this on that, as well. Thanks. Good morning, everybody. Can you hear me . Yeah, okay. Good morning. So, a block grant is a model of federal funding in which the federal government basically comes up with an aggregate cap on the federal contribution to state Medicaid Programs. Many factors go into that aggregate cap. The Congressional Budget Office has very useful information on some of the factors that go into, or could go into, estimating an aggregate cap. The Commonwealth Fund put out a short piece on how aggregate caps are built, but the point is, its an aggregate cap and it doesnt necessarily relate to and certainly over time probably would not relate to actual population growth. A per capita cap is an approach to federal funding limits that would presumably tie to the number of people actually insured. So as the number of people goes up or goes down, the cap, the amount of funds would change, but as with an aggregate cap, a per capita cap also includes many factors that determine how its going to grow Going Forward. So while a per capita cap might grow in relation to population, its not necessarily the case that it would grow in relation to changes in service intensity, changes in the price of insurance, or the price of health care, and other changes that would affect spending on a perperson basis. Thank you so much. So, im just going to give gail a moment here to get settled. Again, were thrilled to have gail with us. She, again, ran the medicare and Medicaid Programs under president george h. W. Bush and has many accomplishments besides that, as do the other panelists, and i hope youll check out their bios in the packets. With that, we heard from Sarah Collins, and ill turn it over to gail walensky. Thanks, gail. For those of you who dont know it, the metro is shut down between metro center and union station, and we have opening of the ballpark, and so there are a gazillion people trying to drive around, but im delighted to have been able to join you. Fortunately, i had seen Sarah Collins powerpoint, so i know the points that she was making. I have a couple of observations that i wanted to share with you. The first is that it is important to acknowledge that medicaid has been the acas clear success story, and i dont think we can ignore what weve been able to see, that Medicaid Expansion actually accounts for the majority of newly insured. It has been able to do this without experiencing the kind of churn that we have seen in the exchanges, but on the somewhat negative side, the spending is running much higher on a perperson level than was predicted. The second year, as expected, tends to be Lower Per Capita spending than the first year somebody is on, even so, it is way above what the expectations were, so thats one observation point. The second, and this is something that not actually related to the aca other than a very in a very peripheral way, the medicaid current match structure really makes very little sense for anything other than to start a program. What you have with the aca expansion is the highest match rate covering the higher income of the poor lowincome population. It started, as you all know, at 100 . Its in the process of walking itself down to 90 . Even so, that is way beyond the matching rate that exists for the base medicaid population, which as you know is between 50 and 73 . It not only doesnt make any sense to have different match rates for different parts of medicaid, ship, of course, follows into this, as well, but this seems to really have it backwards. You would think the federal government ought to pay a larger share for the poorest of the poor and not for those that are near the cutoff in terms of Medicaid Expansion. We understand why that happened to try to lure as many states in as possible, but once we are on any kind of stable footing, that needs to be resolved. We need to find a match rate, probably somewhere between the base match rate and the new match rate, and have it applied for the entire Medicaid Program. Having these three different match rates for different pieces of medicaidship makes no logical sense whatsoever. The third issue that i want to raise is something that i have been commenting on now probably longer than id like to remember, but at least the last 25 years, which is that the states, we dont usually give them enough credit for creative financing and creative thinking, but the states have shown themselves very able to find various types of financing strategies. The end result of which is their part of the money is less than what is statutorily required. It has gone through various versions. The first started just before i was running medicare and medicaid, around 1989, 1990, with something called voluntary donations. Its in some ways, because it was the most egregious, the easiest to explain and understand, for those of you who didnt recall this activity started in West Virginia and basically what happened was the hospitals would put up a state share of the matching rate by donating money. Thats the voluntary donation part, to the state. The state would then use that money as its match money for the federal government. It would get the federal match and the money would then go back to the hospitals, including their piece, which meant that basically the only n