Transcripts For CSPAN3 Alliance For Health Reform Examines F

CSPAN3 Alliance For Health Reform Examines Future Of Medicaid April 6, 2017

Good afternoon. Welcome. Im sarah dash. Im president and coceo of the aligns for health reform. Those of you not familiar with us the aligns is a nonpartisan not for profit attention organization within been around 25 years. Our mission is to inform policy make areas eras and help policy leaders on the most pressing policy issues 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 that is the medicate program. Medicaid covers over 70 Million People as we will hear. And it is responsible for taking care of very, very diverse population was an enormous range of medical needs from healthy knew born babies to children with special Health Care Needs to low income adults, people with serious illness and disability and more. 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 wab access to care and Health Outcomes what might be next for medicaid in the states, in congress and in the administration. And id like to thank first our our sponsor for todays even our proton the common welt fund very grateful for support of the briefing. Before i introduce the panel, i just want to take care of a couple of of housekeeping details. First, for those of you who need wifi credentials thaeshd be up on the screen. You can tweet to future dl of dl medicate. When the time comes for questions. Of you know the drill. But wrat your question on a green question card or come to one of the mics on either side of the aisle. Or tweet your question to future of medicate without further a ado, im going to introduce our panelists. One panelists will be joining us shortly. So. To my left is Sarah Collins from the commonwealth. Gale wa lynn ski will join us, shes an economist and fellow who directed the medicare and Medicaid Programs from 1990 to 1929 under jorchl h. W. Bush. Sarah rosenbaum is the founding chair of the dwept of Health Policy at the George Washington university Milken Institute cool of public health. So without further ado im going to surgeon it over to Sarah Collins and well get started. Thanks. Thank you, sara. And good afternoon to everybody. Thank you to the alliance and also the palace for joining us today. As sarah mentioned a major focus of the American Health care act was the Medicaid Program, both the expansion and also the traditional Medicaid Program. The bill likely would have ended the Medicaid Expansion overtime. 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 fangs, refreshing your memories about where the states stand on their expanding on the program and looking at the latest research on the expense of the expansion 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 an agreement in alternative approaches such as enrolling medicaid plans and imposing greater financial responsibilities on bishies, including higher premiums and cost sharing. There are four states that are actually discussing expansion, the Kansas Legislature has passed a bill to examine medicaid, although the governor has vetoed that bill, the legislature is attempting to override it. Governor deal of georgia has expressed good. In maine Medicaid Expansion is a proposition on the November Ballot this year. General mcall i have has introduced legislation to be considered 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 the latest scorecard which was 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 count country. Rates have fallen but they have fallen the furthest in states that have expanded medicaid. There are nine states that saw declines in their unkshd rates of 10 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. The differences between expansion and nonexpansion states have been most evident. These fell by 13 percentage appoints over 2013 to 2015 compared to nine Percentage Points in nonexpansion states. Coverage gains since the passage of the Affordable Care act have been associated with gains in access to health care. These gains have been greater in states that have expanded medicaid. If you look at the middle bars in this chart, the share of adults that report they skipped health care because of costs in states that expanded medicaid, compared to decline, about half that in states that hadnt expanded their programs. Likewise, few adults across the country indicate that they dont have a regular doctor, but these declines have been the greatest in states that have expanded their programs lets consider kentucky and tennessee. These are border states in the south with somewhat similar demographic profiles but which took polar option approaches. Kentucky expanded the Medicaid Program and ran its own market population 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 insurance rate in kentucky fell by 25 Percentage Points. It fell by only nine Percentage Points in tennessee. Kentucky also experienced the largest decline in the country and cost related problems getting care. The share of low income adults who said they have gone without health care because of cost fell from 2013 and 2015. Tennessee experienced no significant improvement on this measure. Likewise, many adults reported that they didnt have a regular source of compared compared to care compared to 2013. A survey has been conducted 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 in selfreported Health Care Status in arkansas and kentucky relative to texas. For example, compared to adults in texas, other adults had significant increases in getting checkups and significant decreases in visits to the emergency room. One of the policy rationalings for repealing the Medicaid Expansion weve heard about is the contention that medicaid provides inferior coverage compared to private insurance and that having medicaid is almost like being uninsured. Research hasnt supported this claim. For example, this study that the Commonwealth Fund did using the biennial Health Care Measure nund adults that on most measures was most comparable or better than that provided by private insurance and better than being uninsured. Cbo estimates 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. 15 million of them through the Affordable Care acts Medicaid Expansion, this quick overview i just went through suggests the value of this coverage in helping people get the health care they need, particularly large numbers of people of 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 a concern of policy makers to ensure its strength and viability over time. In terms of what we 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 granted greater flexibility for states through the 1115 waiver process and what will be the implications of that for enroll ease, will congress return to poilgs that would place state caps on medicaid and, if so, what are the potential implications for enroll ease. And ill stop there and turn this over to sara. Thank you. Can you explain the difference between bloc grants and per capita grants . Ill let you both chime in. Thanks. So a bloc grant is a model of federal funneleding in which the federal government basic comes up with an aggregate cap and the federal contribution to state 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 has 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 pop liegs growth. A p population growth. A per capita cap would presumably tie to the number of people actually insured. So as the number of people goetz goes up or 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 appalachipo its not the case that it would grow in terms of changes in service intensity, changes in the price of nshance or the price of health care and other changes that would affect spending on a per person basis. Thank you. Were going to give gale a moment to get settled. Were thrilled to have gail with us. She ran the medicare and med indicates under president George Hw Bush and has many accomplishments besides that as do the other panelistings. I hope youll check out their bios in the pamphlet. Ill turn it over to gail wa lynn ski. Thanks, gail. For those of you who dont know, the metro is closed and we have the opening of the ballpark, so there are a gazillion people trying to drive around. Im delighted to have been able to join you. Fortunately, i had seen sara collins power pl collins powerpoint. I have a couple of observations i wanted to share with you. But first the first is that it is important to be acknowledge that medicaid has been the acas Success Story and i dont think we can ignore what weve been able to see. 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 exchang exchanges, but on the skma negative side, the spending is running higher on a perperson level than was predicted. The second year, as expected, tends to be Lower Per Capita spending than the first yearsomebody is on. Even so, its way above the expectations. Thats one observation point. The second and this is something not actually related to the aca other than 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 poorlow income population. It started, as you all know, as 100 . Its in the process of walking itself down to the 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 sense to have different match race, but this seems to have it backwards. You would think the federal government ought to pay a larger share for the poorest of the poor and that 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 apply for the entire Medicaid Program the third knish 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 voluntary donations. It was the easiest explain and understand. For those of you who dont recall this activity, it started in west virginia. Basically what happened was the hospitals would put up the states share of the matching rate 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 new money in the system was that came from the federal government there are various other strategies that was sufficiently egregious that it was shut down. Tax gets put on a group of the either physicians or hospitals. That money is part of what is used for the match. The match comes in. The matched money and the base money goes back to the source either in its entirety or in large part. There have been more sophisticated ways which make it harder sometimes to shut down involving intergovernmental revenue sharing, since that is a legitimate activity between the state and the counties or the state and the city. Thats harder to get rid of. Also not having an upper payment limit that bears any relationship to costs has allowed states to do this. The up shot and this has been true as late as an oig report that came out in 2016 for 2014 right before the match started is that what weve assumed was the major constraint, that is, the states share of the match isnt really doing the job in the structure that it was intended to do. One could question if the match was as small as 25 , whether it would have, anyway, for the poorest of the states, but it is just not a structure that continues to make sense. As an economist, a Public Finance economist, i was always taught matching grants are a good structure to follow because it gets contributions from the person receiving the money as and is a way to try to have a maintenance of effort. Good in theory. This has proven not so good in actual practice. Which is why i would like people not to be so dismissive of the notion of a per capita bloc grant. It fundamentally depends on the baseline you use as a starting points, which at the moment a bit awkward in the sense that 31 states, mostly blue states have expanded the other states have not. Mostly red states. Kansas is trying. Governor vitoed it. North carolina and georgia are thinking about it. We need to find what is a rational starting point and then we need to have a reasonable index to use, something maybe not quite as high as ppim, the medical doesnt but didntly higher than the regular cpi. If we were going to do that, we could have a very rational program. If you look at a medicaid bloc grant as a way of supplying large savings, what ive said really doesnt hold. Ill turn it over to Sarah Rosenbaum. Thank you very much. Weve heard a couple of things now. One is from sara collins, has medicaid worked and does it work and the answer is yes. I mean, whether you measure it in terms of coverage and of course gail echoes the same point in terms of access to care, medicaid appears to do just what we want insurance to do. And the second point which is the one that gails raising is what should the Financial Partnership in medicaid look like, what are ways to allow the program to do what its supposed to do while maintaining some sort of control over program size and growth, and the third is which sort of flows from the second point is if the Financial Partnership is going to change, how do we change or do we change some of the structural aspects of the Medicaid Program . I think it is absolutely imperative that we find answers to these questions. I first encountered the Medicaid Program as a 24yearold Legal Services lawyer in 1957 or thereabouts in Rural Ver

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