More now from the alliance for health reform. This next panel takes a look at the challenges facing medicaid. Theres a discussion on healthcare trends. This is an hour and a half. With the failure to pass the bill in congress, some states are looking to expand medicaid. Some additional states. Many states are talking to cms about what might be possible in way of their talking about waivers, what can be done. So today well talk about our goal for this panel is to both talk about where we are going into this next year. 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 crazy weather we had d. C. Trishas not going to be able to get into town. So she will not be with us. Fear not, our three other panelists here watch whats happening in the states very closely and will be able to give us a full picture of whats happening. So first to my left, we have diane roland, executive Vice President of the Kaiser Family foundation. Diane was also the inaugural chair of mac pac which advised congress on medicaid policy. To her left is josh archambault. He spent time here in d. C. With the heritage foundation. Hes up in massachusetts where he also worked for former governor mitt romney. And at the end of the panel, we have judith solomon, judy is Vice President for Health Policy at the center for budget and policy priorities. I wont go into further detail. You have their full bioes in your packet. 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 . We 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 to the history of medicaid, enacted in 1965 as the program that was intended to provide coverage at that time, to the welfare population. Its expanded tremendously. In that era, the deserving poor were considered the aged, blind and disabled, children and adults with dependent children. Initially just single adults with dependent children. And as weve seen over time, weve expanded the role of medicaid to be more of an insurer for many children, help with Long Term Service and supports for the elderly and disabled as well as children with special health needs. 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, about 23,000 for a family of three. 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 healthcare. 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 Poverty Level in terms of their state coverage and also to try and provide for National Standard of how many low income people would be covered. When the Supreme Court weighed in, it weighed in to say that should be for adult coverage, state option, rather than a requirement. Even though initially the federal funding was 100 . So i think much of the discussion has been which states are going to expand, which states did expand. What was the impact. What kind of individuals were covered by this expansion. We know that in the 32 states it expanded, 11 million individuals became newly eligible for coverage. 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 Long Term 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. Its 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 built in Optional Services and optional coverage. So the proposals to change that open ended federal financing to some sort of a percapita cap have been introduced over time. The federal government seems periodically to give the states more flexibility in return for being able to limit the federal governments commitment to the program. That was part of the debate going around the gop house proposals. We have two issues here, really what happens to the expansion in the expansion population and what happens to the broader Medicaid Program and its role as our state Health Safety net. Lets take that one at a time, those two pieces. One is the broader conversation of do we move to a per capita grant, what do we do in the long term, if anything. 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 governor and medicaid offices theyre thinking very differently than they have in the past about what theyre going to ask for for flexibility from the federal a. There is a big discussionbout 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 couple states look at expanding, kansas being the most recent one. Thats a multiyear campaign by hospitals and insurers in the state to fund candidates who are more sympathetic to that. That should not be viewed in isolation. What i think ultimately comes down to is if the house bill moves. If the house bill moves as it is currently structured and the senate makes tweaks but largely stays the same, i actually dont first of all, the first managers amendment restricted new states from expanding. That would end that conversation if it became law. 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. Theyre waiting to see will the house bill move as its currently conceived or how much will that change. Sure. Thanks for having me. So i would love to step back a little bit on waivers i think you know, we go full steam into that conversation without really thinking about what they are and what theyre supposed to do in the Medicaid Program. If we think about medicaid, it has numerous options that dont require waiver. Its a very flexible program. And waivers are really on top of that to give additional things states can do. 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 healthcare 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 based. But things like premiums, where the medicaid statute says we have a low income people were covering here. They cant afford to pay premiums. So you shouldnt charge them premi 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 healthcare. 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 precede legislation. Thats certainly the case with the Affordable Care act expansion. Because prior to that 11 states had come in for waivers saying cant we cover these adults without dependent children, many of them have a lot of disabilities but they dont yet meet the disability threshold. It was 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 methods, but to see if those new methods are things that ought to be made available more broadly maybe through legislative change or at least through broader adoption by the states. Family planning waivers are even a 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 now is in the statute. So thats the kind of approaches 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 different ways states can get flexibility whether its a state plan amendment and rules around that or the 1115 waiver process. 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 director and at the state level and i have to balance my budget every year, unlike congress, i know, but at the state level i have to balance my budget. It 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 otherwise thing i have to go to d. C. To ask if i can do something yes or no. When im partially funding the program. But not fully. It depends on the state. This is a state federal partnership. I want to reflect theres a lot of frustration at the state level with how this process has play immediate out over the years and the fact they simply have to come. Why probably more republican governors are interested, look, let me wash my hands of this whole 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. I can design the program i want to design and cover the populations i want to cover. I know theres a big federalism discussion here happening and were bouncing around funding piece of this. That largely drives this conversation. But i do want it to be heard that a lot of people in the state level dont think its actually that flexible a process. Even though they can ask for a lot. It takes long time. The waiver process is different from the process for asking not even asking for indicating which options you want to adopt in the Medicaid Program. Theres multiple options in terms of the benefits that are provided. What kind of how you want to design your Delivery Systems. When were talking about 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 these programs. And these are really important protections around premiums, cost sharing, continuous coverage. Who is covered, how long theyre covered. I dont think anyone should 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 exists, what can states do currently. Lets start there. How flexible is the program to begin with at the base line . One of the most flexible areas of the program is really what can be done for home and Community Based service and for a lot of the services to the elderly and the disables. There you can get special sometimes its a waiver, its not a 1115 to be 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 Community Based services and not have to open it state wide. So thats i think an area that its very important to really only requirements for the elderly and the disabled for benefits are more nursing home care and states have really broadly used their authority for Optional Service and for some waivers to expand what they can do around keeping people in the community, rebalancing Long Term Services. Give us an idea of how widely waivers are currently used if im not mistaken every state has them. Every state has multiple waiver. Certainly for the home and Community Based services, multiple waivers targeted at different populations, the reason those are waivers is because basically as diane 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 Long Term 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 its managed care, different forms of managed care. Were now seeing things like Accountable Care organizations. Similar to what medicare is doing. So all of those things a tremendous amount of innovation that is taking place over the last years, and a lot of that has been, you know, facilitated by the 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 of behavioral and Mental Health services. All of that including delivery for people with Substance Abuse disorders. Thought is what would be add risk if the federal matching system is changed to a capped funding stream. Wed be down to 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 this gets at a bigger issue about medicaid. Is it Health Insurance or is it a Welfare Program . And depending on how you answer that question is how you think about how you design it. And so you have a lot of republican governors, in particularly, you have some democrats, governor in West Virginia comes to mind,