Transcripts For CSPAN3 Hearing Examines The Medicaid Program

But the congress and the government created a situation where the states are rewarded for cutting traditional medicare which deals mostly with children and people who are in greater need and that because of that disincentive or incentive to spend it on the new folks, the newly found undermedicaid, under the new categories, we create the situation where states have to make a decision as to whether they quicken the shortage on the waivers, get rid of the waivers as fast as they can or spend money somewhere else. Is my understanding correct . Yes, theres both direct and indirect outcomes as related to expansion and my point is that we are not fulfilling the promises to the most vulnerable in our society, wait list or not, but we are making new promises to an ablebodied population that does not qualify for longterm Welfare Benefits and states in a situation where they have to make very tough decisions and making cuts in reimbursement rates that directly impact those with development, disabilities, nursing homes. The access will only get worse for the truly needy. So what youre saying is we need to Pay Attention to that and make sure we have incentives that encourage people to take care of the truly needy and the young and maybe the new group needs to figure that formula out. Absolutely. I think its part of the repeal and replace discussion as we talk about changing medicaid going forward. It must be on the table and we would strongly recommend looking at freezing new enrollment and not allowing other states to expand so you can address this underlying issue of refocusing program on the truly needy. We have a habit of doing that. 20 bill versus 2. We have a situation where even in traditional medicaid, we have awarded states that play games like virginia to not have a sick tax. Thats what it was called with a proposal a couple of decades ago to start taxing the beds of the sick so they could create that money and then put it into medicaid and get matching money from the proffederal governmentn though it would have given us 2 from the sick people but what theyre really doing is creating a tsick tax scheme and should w put a stop to that . Not saying, but should we try to get rid of that so people know what theyre getting and not having to charge sick people to get more money for medicaid . The federal government has capped that states are able to use but its a significant amount of money. 25 billion. Many states use these provider tax taxes. While its legal, theres ethical questions about that, isnt there . I agree with you. Absolutely. I want to move on to something else. Someone said obamacare wasnt collapsing and that was a myth. All kinds of number. 25 increase and a third have only one insurer, a trillion dollars in new taxes and 4. 7 million had to change because they got kicked off the plan they liked. All kinds of problems but whats anecdotal . Happened to me yesterday twice after church group of us go to lunch, i try to stay out of politics at lunch and a discussion broke out the end of the table i was not involved in where they were talking about, what do we do as we go forward and one said, as a christian, i dont mind paying some more money, but when my insurance rates go from 450 to 1250 a year and getting less insurance, its hurting my family and thats a problem. Later that evening in a Small Group Gathering of different people, there was a big discussion about whether or not they could, a family could afford to justify spending money for their daughter who had the flu, several families had been ravaged by flu the last couple of weeks because in order to afford Health Insurance, they had a high deductible costing them to get tamiflu and debating whether or not they should do that and what they should do as they go forward. These are real life examples of how obamacare is in fact failing the american people. I yield back. Thank you, mr. Chairman. Thank goodness for medicaid in america, especially back home in florida. 3. 6 million floridians rely on medicare for their health services. A lot of my neighbors in Skilled Nursing, alzheimers patients, medicaid is the lifeline for these families. Not to mention 50 of children in florida rely on medicaid to go see the pediatrician and get their checkups. The 3. 6 million number, Community Based care or children and based upon what they tell me, medicaid works for them. Medicaid spending growth is lower than private Health Insurance and lower than medicare. Because sometimes they get by on the cheap. Thats one place to improve access, if wed pay our providers more and do better there. Medicaid is flexible. Ive watched in florida as theyve moved to a manage care system. I have questions about that, but that was a decision of the state. They had all that flexibility under medicaid. Theyve also began a change towards more home and Community Based services to get older folks out of Skilled Nursing which can be very expensive. But then, we have to remain mindful about the fiscal cost and fiscal responsibility. Thats why in the Affordable Care act, we passed a lot of new Program Integrity provisions to strengthen medicaid. One involved a shift from the pay and chase model to a preventative approach like keeping fraudulent suppliers out of the program before they can commit fraud. All programs must be screened upon enrollment and revalidated every 5 years. Think about that as you move towards repeal of the Affordable Care act. Why would we want to repeal these important Program Integrity provisions relating to medicaid . I dont think thats the path we want to go down. What this is though, i think the real fear is that this whole terminology of grants and per capita is a stalking horse for less care in florida and all americans, every alzheimers patient, for every child that needs to go see the pediatrician, i want folks to be aware of what block grants and per capita caps means. But what that means is devastation and sabotage to the Medicaid Program. Mr. Westmoreland. Describe impact on americans if this approach is taken, block grants and per capita caps. As i understand, the basic point is to limit federal participation and the state cost of running the Medicaid Program. As Health Care Costs grow over time, the states will be left holding the bag for those increased state costs. For medicaid costs. And as changes occur in the population, as the baby boomer demographic enters into the population, as more and more services are provided for people with disabilities, as Prescription Drug costs go up, the increased cost over time will not be matched by the federal government. States will be left holding the bag. Isnt it interesting that some republican governors believe this approach will have disastrous consequences for their ability to care for their older neighbors and neighbors with disabilities and children, for example, governor, republican governor from massachusetts in a letter to congressman Kevin Mccarthy stated were concerned that a shift to block grants and per capita caps for medicaid would reduce flexibility from states as the result of reduced federal funding. Would most likely make decisions based on fiscal reasons rather than Health Care Needs of vulnerable populations and stability of the insurance market. Could you elaborate more on what this would mean . You would have, i think in my state, may not raise taxes. Thats the choice though, isnt it . Raise taxes to support neighbors or cut . It would be limited in these fashions but the only way to respond to the concerns about deficit reduction. Its limited in that fashion. Then the states have a choice either of reducing the number of people they serve, cutting back and rationing the services to those people and raise local and state tax. Thank you. Id like to ask unanimous consent to enter into the record if anyone is swresed interested learning more, experts have a lunch provided forum tomorrow, or excuse me, thursday february 2nd, 12 30 to 1 30 in the sam johnson room to learn why medicaid matters to kids and i encourage you all to attend. Recognize dr. Burgess for five minutes. Thank you, chairman. Thank you to our panel for being here. Great discussion. Timely discussion. Let me ask you, chairman murphy was, i think, directing some of his questions about improper eligibility determinations and one of the things that has concerned me for some time is the issue of Third Party Liability. Medicaid patient who has other insurance but also has medicaid and my understanding is what happens is sometimes its hard to collect from the party of the first part of the commercial insurer, medicaid is more straightforward. So you end up in a situation where the pen who should be responsible for the bill, the Insurance Company who has been contracted to provide care for that patient, actually is inadvertently led out of the equation just because it becomes easier to chase dollars in the medicaid system. Is that a real phenomenon . Yes, we did work at Third Party Liability at some of the issues that the Medicaid Program encountered. Some is about Information Systems and being aware of the coverage, but then even within that, its about the interaction between the state and Medicaid Programs and the Insurance Companies and being able to assert the fact they should be paying first. So to what extent are the states able to address the underpayments by commercial insurers, overpayments by medicaid . We make some recommendations and ask to provide Additional Support and data on these issues. I would need to check to see whether or not they had been implemented and a little bit more about the specifics. So. Im given to understand that this is not a trivial problem. There are significant number of dollars involved. Is that correct . Yes. And safe to say, it varies from state to state . Some states do better than others. So if i recall correctly back in mid 2000s, 2005, 2006, 2007, you had created a list of states where the percentages of dollars. There were significant differences. I think it was the middle. Iowa did well. Some other states did poorly. Do i recall that correctly . I believe thats right and i think some of it is the more health plans it involves. Some had a Smaller Group of insurers to work with were able to establish better relationships. That was a report years ago. Is this problem worth fixing . I think there have been some fixes done, but im not sure i remember well enough to tell you more than that right now. Let the subcommittee know theres insightful legislation coming on this subject and i hope people will join me on that. Miss maxwell, let me ask you just staying on the Third Party Liability issue. Discussed medicaid overpayments in regard to not reconciling credit balances with the state. Is that correct . Thats correct. It stands to reason states are not active in Third Party Liability claims but aware of beneficiaries with overlapping coverage that might receive services unintentionally paid for both by third parties and the state medicaid plan. Is that a reason assumption . Correct. Is it possible to take advantage of inhouse data to approach practices that might not have reconciled the credit balances . Thats the recommendation focus on. The ability of states to identify those overpayments and then recover them. Were looking at, the report was 25 million in which credit balances had not been reconciled and states had not been able. State that number again . 25 million. Eight states, i believe . Not an inconsequential number. Its a number where they have our attention even though we deal with big numbers up here. Talked about trillions of dollars and bedazzled everybody with that but even focusing on these amounts is important, is it not . Absolutely. I mean, from the generals perspective, every dollar counts and every dollar thats overpaid is a dollar less to provide services. Mr. Chair, i want to point out ten days ago, the day before inauguration, we had round tables with the governors, both on the senate side and the house side and it was one of the most impactful days i have seen up here. There is so much energy and enthusiasm on the part of the governors who want reforms in their system. They want this to be right. They want to deliver the care to their citizens. Theres not unanimity of opinion. A lot of discussion about the moving parts, but ill just tell you, i was very encouraged at the level of involvement of our governors in this issue. Thank you, i yield back. Thank you, and i recognize the gentleman from new york. Thank you, mr. Chair and welcome to our panelists. M you address the waiting lists and the corresponding decline of services or inability of services and that our ranking representative asked you a bit about this or the panel about it and i just want to dig a little deeper into a claim that you did make where you insinuate that expanding medicaid will lead to the 600,000 individuals on medicaid waiting lists less likely to receive services. First of all, can you explain what you mean by medicaid waiting list . I assume youre referring to the waiting list that some states maintain to receive home and Community Based waiver services, is that correct . Correct. Do you know which state has the longest waiting list for home and Community Based services . Its usually related to population. You have more people usually eligible for the program, but thats not a straight correlation that way. Well, my information tells me that texas is the list with the longest waiting list. Some 163,000 plus people in 2014. And of that 163,000 that has been affected by the expansion of medicaid . The data is usually a year or two delayed, so its hard to draw a direct correlation. I would just point out that if were fulfilling the promises to the most vulnerable, i think getting lost in this discussion is that medicaid is crowding out spending of all kinds, whether its education, whether its Public Safety or infrastructure or the waiting list. I dont want to i would suggest it depends on what states do with the Medicaid Program but texas has not expanded. Its medicaid. That was the answer that i would share with you. Its very interesting now we look at some of the data. Do you know which state has the second longest waiting list for home and Community Based services . Again, it depends on the population and no correlation between expansion or not. The concern is even states that have expanded also have waiting lists. So for me, its about priorities and for state lawmakers, they are being put in a very tough position where theyre not able to help families like skylers and thats deeply concerning to me. Florida is the second in the list of the medicaid numbers and they have not expanded with their medicaid issue and i think we can sense a pattern here. So we need to cut to the chase. 61 of those individuals on a waiting list for home and Community Based Services Live in the 19 states that have not expanded medicaid. My home state of new york, one of the most populous in the country and one which has enthusiastically expanded medicaid has a waiting list of zero individuals and a track record that has begun to be very favorable about per capita costs for medicaid. So its difficult for me to see the real world correlation that is addressed in testimony like yours where expanding medicaid and waiting lists for home where theres a contrast or a choice that has to be made between expanding medicaid or waiting lists that grow for home and Community Based services. Do you have any actual evidence at all that speaks to that expansion and any correlation with hcbs . The point is that when you talk to governors and state policy makers, they are put in a position where in arkansas, they have been trying for years to address issues like families like skyler. Now theyre having to yes or no. Is there any correlation that you can cite . Ill remind you. Youre under oath. Any correlation you can cite . What i will say is there is no correlation. Its not a yes or no answer. What we see is alternative facts designed to obscure the simple truth. Medicaid expansion is working. It has provided Health Insurance to 12 Million People and my colleagues on the other side of the aisle are engaged in a cynical attempt i believe to pick good vs. Good to Rip Health Care away from millions of americans and i find it unacceptable, i find it shameful and i dont think we should sit quietly while peoples right to health care is being threatened. With that, i just yield back the balance of my time. Recognize miss brooks for 5 minutes. Thank you, mr. Chairman. I dont think that trying to explore waiting list questions and waiting list issues is an attempt to gut medicaid. In my view, its an attempt to strengthen the services and the ability to provide people with Developmental Disabilities traumatic brain injuries, Mental Illnesses and make sure people on the significant wait lists receive care. And id like to go back to you mr. Archaumbauld. I think its more complicated than that. What have you found in respect to the waiting lists, with respect to the people on the waiting list, with respect to what the states want to do . Ill let you use most of my time. Thank you, congresswoman. I just would say to focus on a waiting list is a vacuum. Some states have what do you mean its a vacuum . Some states delivered care. The phrase, youve seen one state Welfare Benefits<\/a> and states in a situation where they have to make very tough decisions and making cuts in reimbursement rates that directly impact those with development, disabilities, nursing homes. The access will only get worse for the truly needy. So what youre saying is we need to Pay Attention<\/a> to that and make sure we have incentives that encourage people to take care of the truly needy and the young and maybe the new group needs to figure that formula out. Absolutely. I think its part of the repeal and replace discussion as we talk about changing medicaid going forward. It must be on the table and we would strongly recommend looking at freezing new enrollment and not allowing other states to expand so you can address this underlying issue of refocusing program on the truly needy. We have a habit of doing that. 20 bill versus 2. We have a situation where even in traditional medicaid, we have awarded states that play games like virginia to not have a sick tax. Thats what it was called with a proposal a couple of decades ago to start taxing the beds of the sick so they could create that money and then put it into medicaid and get matching money from the proffederal governmentn though it would have given us 2 from the sick people but what theyre really doing is creating a tsick tax scheme and should w put a stop to that . Not saying, but should we try to get rid of that so people know what theyre getting and not having to charge sick people to get more money for medicaid . The federal government has capped that states are able to use but its a significant amount of money. 25 billion. Many states use these provider tax taxes. While its legal, theres ethical questions about that, isnt there . I agree with you. Absolutely. I want to move on to something else. Someone said obamacare wasnt collapsing and that was a myth. All kinds of number. 25 increase and a third have only one insurer, a trillion dollars in new taxes and 4. 7 million had to change because they got kicked off the plan they liked. All kinds of problems but whats anecdotal . Happened to me yesterday twice after church group of us go to lunch, i try to stay out of politics at lunch and a discussion broke out the end of the table i was not involved in where they were talking about, what do we do as we go forward and one said, as a christian, i dont mind paying some more money, but when my insurance rates go from 450 to 1250 a year and getting less insurance, its hurting my family and thats a problem. Later that evening in a Small Group Gathering<\/a> of different people, there was a big discussion about whether or not they could, a family could afford to justify spending money for their daughter who had the flu, several families had been ravaged by flu the last couple of weeks because in order to afford Health Insurance<\/a>, they had a high deductible costing them to get tamiflu and debating whether or not they should do that and what they should do as they go forward. These are real life examples of how obamacare is in fact failing the american people. I yield back. Thank you, mr. Chairman. Thank goodness for medicaid in america, especially back home in florida. 3. 6 million floridians rely on medicare for their health services. A lot of my neighbors in Skilled Nursing<\/a>, alzheimers patients, medicaid is the lifeline for these families. Not to mention 50 of children in florida rely on medicaid to go see the pediatrician and get their checkups. The 3. 6 million number, Community Based<\/a> care or children and based upon what they tell me, medicaid works for them. Medicaid spending growth is lower than private Health Insurance<\/a> and lower than medicare. Because sometimes they get by on the cheap. Thats one place to improve access, if wed pay our providers more and do better there. Medicaid is flexible. Ive watched in florida as theyve moved to a manage care system. I have questions about that, but that was a decision of the state. They had all that flexibility under medicaid. Theyve also began a change towards more home and Community Based<\/a> services to get older folks out of Skilled Nursing<\/a> which can be very expensive. But then, we have to remain mindful about the fiscal cost and fiscal responsibility. Thats why in the Affordable Care<\/a> act, we passed a lot of new Program Integrity<\/a> provisions to strengthen medicaid. One involved a shift from the pay and chase model to a preventative approach like keeping fraudulent suppliers out of the program before they can commit fraud. All programs must be screened upon enrollment and revalidated every 5 years. Think about that as you move towards repeal of the Affordable Care<\/a> act. Why would we want to repeal these important Program Integrity<\/a> provisions relating to medicaid . I dont think thats the path we want to go down. What this is though, i think the real fear is that this whole terminology of grants and per capita is a stalking horse for less care in florida and all americans, every alzheimers patient, for every child that needs to go see the pediatrician, i want folks to be aware of what block grants and per capita caps means. But what that means is devastation and sabotage to the Medicaid Program<\/a>. Mr. Westmoreland. Describe impact on americans if this approach is taken, block grants and per capita caps. As i understand, the basic point is to limit federal participation and the state cost of running the Medicaid Program<\/a>. As Health Care Costs<\/a> grow over time, the states will be left holding the bag for those increased state costs. For medicaid costs. And as changes occur in the population, as the baby boomer demographic enters into the population, as more and more services are provided for people with disabilities, as Prescription Drug<\/a> costs go up, the increased cost over time will not be matched by the federal government. States will be left holding the bag. Isnt it interesting that some republican governors believe this approach will have disastrous consequences for their ability to care for their older neighbors and neighbors with disabilities and children, for example, governor, republican governor from massachusetts in a letter to congressman Kevin Mccarthy<\/a> stated were concerned that a shift to block grants and per capita caps for medicaid would reduce flexibility from states as the result of reduced federal funding. Would most likely make decisions based on fiscal reasons rather than Health Care Needs<\/a> of vulnerable populations and stability of the insurance market. Could you elaborate more on what this would mean . You would have, i think in my state, may not raise taxes. Thats the choice though, isnt it . Raise taxes to support neighbors or cut . It would be limited in these fashions but the only way to respond to the concerns about deficit reduction. Its limited in that fashion. Then the states have a choice either of reducing the number of people they serve, cutting back and rationing the services to those people and raise local and state tax. Thank you. Id like to ask unanimous consent to enter into the record if anyone is swresed interested learning more, experts have a lunch provided forum tomorrow, or excuse me, thursday february 2nd, 12 30 to 1 30 in the sam johnson room to learn why medicaid matters to kids and i encourage you all to attend. Recognize dr. Burgess for five minutes. Thank you, chairman. Thank you to our panel for being here. Great discussion. Timely discussion. Let me ask you, chairman murphy was, i think, directing some of his questions about improper eligibility determinations and one of the things that has concerned me for some time is the issue of Third Party Liability<\/a>. Medicaid patient who has other insurance but also has medicaid and my understanding is what happens is sometimes its hard to collect from the party of the first part of the commercial insurer, medicaid is more straightforward. So you end up in a situation where the pen who should be responsible for the bill, the Insurance Company<\/a> who has been contracted to provide care for that patient, actually is inadvertently led out of the equation just because it becomes easier to chase dollars in the medicaid system. Is that a real phenomenon . Yes, we did work at Third Party Liability<\/a> at some of the issues that the Medicaid Program<\/a> encountered. Some is about Information Systems<\/a> and being aware of the coverage, but then even within that, its about the interaction between the state and Medicaid Program<\/a>s and the Insurance Companies<\/a> and being able to assert the fact they should be paying first. So to what extent are the states able to address the underpayments by commercial insurers, overpayments by medicaid . We make some recommendations and ask to provide Additional Support<\/a> and data on these issues. I would need to check to see whether or not they had been implemented and a little bit more about the specifics. So. Im given to understand that this is not a trivial problem. There are significant number of dollars involved. Is that correct . Yes. And safe to say, it varies from state to state . Some states do better than others. So if i recall correctly back in mid 2000s, 2005, 2006, 2007, you had created a list of states where the percentages of dollars. There were significant differences. I think it was the middle. Iowa did well. Some other states did poorly. Do i recall that correctly . I believe thats right and i think some of it is the more health plans it involves. Some had a Smaller Group<\/a> of insurers to work with were able to establish better relationships. That was a report years ago. Is this problem worth fixing . I think there have been some fixes done, but im not sure i remember well enough to tell you more than that right now. Let the subcommittee know theres insightful legislation coming on this subject and i hope people will join me on that. Miss maxwell, let me ask you just staying on the Third Party Liability<\/a> issue. Discussed medicaid overpayments in regard to not reconciling credit balances with the state. Is that correct . Thats correct. It stands to reason states are not active in Third Party Liability<\/a> claims but aware of beneficiaries with overlapping coverage that might receive services unintentionally paid for both by third parties and the state medicaid plan. Is that a reason assumption . Correct. Is it possible to take advantage of inhouse data to approach practices that might not have reconciled the credit balances . Thats the recommendation focus on. The ability of states to identify those overpayments and then recover them. Were looking at, the report was 25 million in which credit balances had not been reconciled and states had not been able. State that number again . 25 million. Eight states, i believe . Not an inconsequential number. Its a number where they have our attention even though we deal with big numbers up here. Talked about trillions of dollars and bedazzled everybody with that but even focusing on these amounts is important, is it not . Absolutely. I mean, from the generals perspective, every dollar counts and every dollar thats overpaid is a dollar less to provide services. Mr. Chair, i want to point out ten days ago, the day before inauguration, we had round tables with the governors, both on the senate side and the house side and it was one of the most impactful days i have seen up here. There is so much energy and enthusiasm on the part of the governors who want reforms in their system. They want this to be right. They want to deliver the care to their citizens. Theres not unanimity of opinion. A lot of discussion about the moving parts, but ill just tell you, i was very encouraged at the level of involvement of our governors in this issue. Thank you, i yield back. Thank you, and i recognize the gentleman from new york. Thank you, mr. Chair and welcome to our panelists. M you address the waiting lists and the corresponding decline of services or inability of services and that our ranking representative asked you a bit about this or the panel about it and i just want to dig a little deeper into a claim that you did make where you insinuate that expanding medicaid will lead to the 600,000 individuals on medicaid waiting lists less likely to receive services. First of all, can you explain what you mean by medicaid waiting list . I assume youre referring to the waiting list that some states maintain to receive home and Community Based<\/a> waiver services, is that correct . Correct. Do you know which state has the longest waiting list for home and Community Based<\/a> services . Its usually related to population. You have more people usually eligible for the program, but thats not a straight correlation that way. Well, my information tells me that texas is the list with the longest waiting list. Some 163,000 plus people in 2014. And of that 163,000 that has been affected by the expansion of medicaid . The data is usually a year or two delayed, so its hard to draw a direct correlation. I would just point out that if were fulfilling the promises to the most vulnerable, i think getting lost in this discussion is that medicaid is crowding out spending of all kinds, whether its education, whether its Public Safety<\/a> or infrastructure or the waiting list. I dont want to i would suggest it depends on what states do with the Medicaid Program<\/a> but texas has not expanded. Its medicaid. That was the answer that i would share with you. Its very interesting now we look at some of the data. Do you know which state has the second longest waiting list for home and Community Based<\/a> services . Again, it depends on the population and no correlation between expansion or not. The concern is even states that have expanded also have waiting lists. So for me, its about priorities and for state lawmakers, they are being put in a very tough position where theyre not able to help families like skylers and thats deeply concerning to me. Florida is the second in the list of the medicaid numbers and they have not expanded with their medicaid issue and i think we can sense a pattern here. So we need to cut to the chase. 61 of those individuals on a waiting list for home and Community Based<\/a> Services Live<\/a> in the 19 states that have not expanded medicaid. My home state of new york, one of the most populous in the country and one which has enthusiastically expanded medicaid has a waiting list of zero individuals and a track record that has begun to be very favorable about per capita costs for medicaid. So its difficult for me to see the real world correlation that is addressed in testimony like yours where expanding medicaid and waiting lists for home where theres a contrast or a choice that has to be made between expanding medicaid or waiting lists that grow for home and Community Based<\/a> services. Do you have any actual evidence at all that speaks to that expansion and any correlation with hcbs . The point is that when you talk to governors and state policy makers, they are put in a position where in arkansas, they have been trying for years to address issues like families like skyler. Now theyre having to yes or no. Is there any correlation that you can cite . Ill remind you. Youre under oath. Any correlation you can cite . What i will say is there is no correlation. Its not a yes or no answer. What we see is alternative facts designed to obscure the simple truth. Medicaid expansion is working. It has provided Health Insurance<\/a> to 12 Million People<\/a> and my colleagues on the other side of the aisle are engaged in a cynical attempt i believe to pick good vs. Good to Rip Health Care<\/a> away from millions of americans and i find it unacceptable, i find it shameful and i dont think we should sit quietly while peoples right to health care is being threatened. With that, i just yield back the balance of my time. Recognize miss brooks for 5 minutes. Thank you, mr. Chairman. I dont think that trying to explore waiting list questions and waiting list issues is an attempt to gut medicaid. In my view, its an attempt to strengthen the services and the ability to provide people with Developmental Disabilities<\/a> traumatic brain injuries, Mental Illnesses<\/a> and make sure people on the significant wait lists receive care. And id like to go back to you mr. Archaumbauld. I think its more complicated than that. What have you found in respect to the waiting lists, with respect to the people on the waiting list, with respect to what the states want to do . Ill let you use most of my time. Thank you, congresswoman. I just would say to focus on a waiting list is a vacuum. Some states have what do you mean its a vacuum . Some states delivered care. The phrase, youve seen one state Medicaid Program<\/a>, youve seen one. Some states have decided to take the people that would qualify for a waiting list and include it into an 1115 waiver request and deliver services in a different way. My point is that the principles we used to have as a country for our safety net is that we make sure a safety net accomplishes a few things. One, is it argumenttargeted to y nee needy . Are we making promises before we make new promises . Is it fair to say those on waiting lists in the states are the truly needy . Is there any dispute about that . I think there would not be. And i would be happy to explore it, but im not sure how intellectually disabilities or Mental Illness<\/a> would be seen as ones we wouldnt want to try. People who cannot take care of themselves. People are often not working. Is that correct . People who truly are incapable of taking care of themselves, physically or mentally. Yes. And that was the traditional, the age, the disabled, pregnant children, and pregnant women that we were trying to fulfill that promise to. The aca changed that discussion. How did the aca change that discussion . A vast majority, 82 childless, ablebodied adults. These are individuals that dont qualify for tanif or longterm food stamps. Not traditionally been the population and whats important for us to remember here is our goal is not to get people to stay on medicaid. Ultimately, we want to make sure they have Better Health<\/a> outcomes and most would agree if theyre able to work, out in the workforce and on private insurance and thats ultimately, i think, where we want to be as a country and thats the discussion that we need to be having. D is it fair to say most of the people on the waiting list, the developmentally disabled traumatic brain injured people will always be on medicaid . Yes. Its a different type of population. Correct. What has been your discussion and 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 governors and the legislatures view with regard to this population . I think theres ongoing discussion with governors that theyre not able to support these. But i will say theres exceptions to the rule. If you look at kansas and maine, the governors have been able to buy down their wait lists. Maine from 1700 individuals down to 200 individuals. How did they do it . Well, they got some budget sanity. They did not expand medicaid and focus on eligibility, to make sure the programs are truly focused on those that are the most needy. The age, the blind, the disabled and made that a priority in the state and has success in vying down the wait list. I think we need to explore the states that have found ways to have little to no wait list. I certainly hope today our governor, governor holcomb, with a medicaid waiver healthy indiana plan for additional 3 years. Its an Outstanding Program<\/a> i hope both sides of the aisle, its a way to save and help those who truly need it. It can be replicated. I believe its an incredible model that can work. Unfortunately, we still have a waiting list in indiana. We dont want a waiting list but i hope with the new nominee to lead cms, we can make all of medicaid a far better and Stronger Program<\/a> with the controls in place. As a former u. S. Attorney, i worked with the units. We need to support them and need more to support all of these to make sure those who are truly vulnerable are protected. With that, i yield back. Okay. Recognize miss clarke for five minutes. Thank you mr. Chairman and our ranking member. Before i get into my actual question here, i want to respond to mr. Howard because as a proud new yorker, i must correct the impression left by your characterization of the empire state. Are you aware the new York State Medicaid Redesign Team<\/a> has been a National Leader<\/a> in controlling costs and improving quality for medicaid members . The Empire Center<\/a> for public policy, selfdescribed as a fiscally conservative think tank and government watchdog released an analysis that new york medicaid spending per recipient dropped from 10,684 to 8,731 or 18 between 2010 and 2014 . At nearly twice the National Average<\/a>. According to independent new york state Comptrollers Office<\/a>, retained spending growth to 1. 7 annually during the period of fiscal year 2010 to 2013. This marks a significant reduction over the trend for the previous ten years of 5. 3 . During the same three year period, medicaid reenrollment grew by more than half a Million People<\/a>. Billions of dollars have been saved and per recipient spending has been slashed. In fiscal year 1415 alone, saved thanks to the mrt initiative. This track record let the Comptrollers Office<\/a> to clear. Its the most restructuring since the system began in 1966. And we have no waiting list. I id like to now turn to mr. Westmoreland. In mr. Archbaults testimony, he cited Medicaid Expansion<\/a> but ignored the fact its had a positive impact on the quality of life and health for millions of americans. He also ignores the fact that many of the positive impacts such as cost savings from preventative medical exams and Early Detection<\/a> and treatment of disease will result in future cost savings to the states and the federal government. I am a strong supporter of Medicaid Expansion<\/a> because i see the significant value of the program. I am interested in improving the program and not destroying it. So mr. Westmoreland, mr. Arshumbald say its to the truly vulnerable. Can you clarify why this is not the case . I began with first challenging the discussion as i did in my testimony of whos truly vulnerable and be clear that not all people with disabilities, cognitive, traumatic brain injury or any discussions ongoing were traditionally eligible for medicaid. Its tied to a 75 poverty and received with ssi and many people whom we would all consider to be disabled have never been eligible for the federal Medicare Program<\/a> until the enactment of the aca. And there have been significant studies, economic and some by business cooschools and economi, significant budget savings and revenue gains by having the expansion in their state. So i think that its clear that sat states benefit on a financial basis and the citizens benefit on the financial basis in the ways that i outlined in my testimony. Both say Medicaid Expansion<\/a> poses an unsustainable burden on state budgets. Can you clarify why this is not the case . Why have most states actually experienced net budgetary savings associated with the expansion . Yes. Lets start with the Health Care Expenses<\/a> as we discussed earlier are fewer uncompensated care costs within the state. In addition, theres an influx of federal funds in the state to pay for Health Care Services<\/a> and federal funds have a reverberating Multiplier Effect<\/a> in the state economy and finally, states are able to provide, as you have suggested, preventative and Early Intervention<\/a> services that might not have been available to uninsured adults before and lowered the ongoing Health Care Costs<\/a> for the people. My understanding that numerous studies have disproven the myth that Medicaid Expansion<\/a> diminishes. Is that correct . Yes. I yield back the balance of my time, mr. Chairman. I now recognize a new member to the subcommittee. Welcome aboard here to the committee. Thank you, mr. Chairman. Mr. Archambul, we want safety nets. We dont want safety nets forever. I remember working at the u. S. Deal south works and third helper of going out and being responsible to swing up a sledge and take the slug out of a heat of molten steel and the fall protection strap on me. I appreciated that, but when the shift ended, i didnt want that strap. I wanted to move on and thats a laudable goal we find ways to make sure people who truly need that safety net have it. We make sure that we dont waste it on others who dont and encourage them to move on in a very positive way. Id like to ask you for further response from your testimony and also, miss maxwell, id like for you to comment after mr. Archambal. Its individuals that have passed away decades ago. Individuals using high risk or stolen Social Security<\/a> numbers and tens and thousands who have moved out of state yet remained on medicaid. How can we come back more effectively . Thank you for the question. The first one is allow states to check eligibility more frequently. Under the aca, there was a change that states could only redetermine eligibility once a year unless they were given a reason to recheck eligibility. We have found that states that are able behind the scenes to access data internally within State Government<\/a> but also through third party. These individual have life changes just like all of us so whether they move or die or get a significant raise, we need to make sure that we find that sooner rather than later. Otherwise, were just wasting money and i believe theres bipartisan agreement on that we need to make sure. The other thing is we need to make sure that the federal databases which we havent talked a lot about, the quality of the data main those is quite poor and the leaders will complain constantly how late the data is, and its not flexible enough. So making sure states are able to look for dual enrollment, for example, and the Food Stamp Program<\/a> is moving in this direction and we should be doing it for medicaid. Just to make sure were not wasting money as a result of individuals moving across state lines. Thank you. And miss maxwell . Could you add to that . I would love to. I would definitely echo what we just heard about the crucial need for better medicaid data. It hampers the ability to understand these issues for problematic decisions and also deterred for us to find fraud, waste, and abuse. In addition, we need to think about protecting the program from happening in the first place and in addition to the data, would encourage us to work with states to improve enhanced provider screening to make sure that providers that get in, others we want in want to pay. Thank you. Mr. A. , revealed 4,000 individuals on medicaid who did not live in the state. With nearly 7,000 having no record of living there. Also high risk identity including stolen identities, fake Social Security<\/a> numbers, et cetera. Something of interest to me, michigan has recently identified more than 7,000 lottery winners receiving some kind of public assistance, including individuals winning up to 4 million. Those jackpots are something that ought to encourage them not to be on medicaid assistance. Mr. A. , do these stay enrolled in the Medicaid Program<\/a> and is it the federal government or the state thats dropping the ball . Congressman, it may be a little bit of both to answer that question and i think whats really important here is theres some policy changes that have happened. The Affordable Care<\/a> act removed an asset test for the Medicaid Program<\/a> by and large . Theres some that it still applies to, but as a result, these sorts of outlier cases admittedly but takes a lump sum payment, they may not qualify that month but the very next month could qualify for the program. Let alone, were not checking for 12 months in most cases so we wouldnt know. So the point im making here is to get the gaping hole that exists. We have data across state lines and the federal government needs to incent states to say, if youre doing this on a regular basis, you can take a bit of the savings to pay for those efforts. And this points to mr. Howards point that is not incentive thats inherent in the current financing structure that weve set up. Thank you. My time has expired. Please, five minutes. Thank you, mr. Chairman. As many of you know, i grew up with farm workers in the medically undisturbed community of coachella and seen firsthand what it means when a community is medically underserved and cannot access care and i can tell you this. It was not for medicaid that Coachella Valley<\/a> and regions like mine would not have access to health care, every one of us on this and our family enjoy. We repeal medicaid exanxiopansi they will stop seeing doctors because the cost too high and stop taking lifesaving pri prescriptions because too expensive. Nearly 3. 5 million individuals who enrolled in medicaid under the aca expansion provision could lose their coverage. Thats millions of families losing access to health care and if we repeal Medicaid Expansion<\/a>, uncompensated costs straining the Health Care Systems<\/a> which will drive up costs for everyone. Because you see, when people dont have Health Insurance<\/a>, they dont stop getting sick. And our Emergency Departments<\/a> do not turn someone away because they dont have insurance. Emergency physicians treat the patients like they should. So the hospitals have to make up the costs and in 2014 alone, Health Systems<\/a> of california saw a decrease in uncompensated care in 2014. All hospitals in my district in particular have seen a drop in uninsured patients in the Emergency Department<\/a> by half. So we need to expand medicare even more, make it more efficient and desirable to see more medicaid insured patients. Fraud is bad. And political amplification of the problem to wrongfully justify cutting Health Insurance<\/a> for sick patients is bad. So heres the possible common ground. Heres what i think we can both agree on. If we start with the premise that we want to cover more uninsured economically struggling families like the middle class and more vulnerable families, then were on the same page. But if you start with the ideological goal to cut or end medicaid, then youll breed mistrust and millions of people will be harmed including the middle class. So the real question, and the real question, mr. Howard, is are sick and injured people getting the care they need . Because anything short of this is negligence. Lets tackle fraud so that we can expand coverage to more struggling uninsured middle class families. So the question that i have, if you were to choose one thing that you can do to combat fraud, if theres one action that you can take that we can make the biggest difference in the system, what would that be . I think its around the providers. Making sure that we have eligible providers in Good Standing<\/a> and those who are not providing services are not going across at a tim across states to provide services. What would make the biggest difference as many. The data. We have a lack of data across the nation and all coming in from the managed care companies. Mr. Howard, if you had one thing you could change to make the biggest difference in fraud, what would it be . In fraud in particular . Engaged data transparency as my colleague just said. It should be enclave to benchmark provided performance and engagement. What does the evidence suggest about how Medicaid Expansion<\/a> makes health care more affordable and evidence, for instance, its reducing patients need to forgo medical care due to costs . Your mike. Medicaid expansion is highly associated with the decline in personal bankruptcies and also associated with greater Financial Security<\/a> for families newly eligible. These are middle class families having Economic Security<\/a> because of the Medicaid Expansion<\/a> . What is the body of evidence say about how Medicaid Expansion<\/a> affected patients access to primary care and Preventative Care<\/a> . People in those beneficiaries who are newly insured had much higher rates than traditional sources of care and using Preventative Health<\/a> services. Thank you very much. My closing statement is, you know, if this is leading to increase in expansion for economically struggling middle class families, then, you know, im in. But if the ultimate goal is to create a facade and amplify a problem politically to then justify policies that will hurt the middle class and decrease Health Insurance<\/a> . Then im not in. So lets tackle fraud so we can expand more Health Care Coverage<\/a> to middle class teafamilies. Thank you very much. Now we recognize a new member of our community. State senator mayor congresswoman mimi walters. Recognized for five minutes. Thank you, mr. Chairman. First, the supporters argued that Medicaid Expansion<\/a> would increase jobs. Has this happened . Theres been a number of studies where the consultant predictions have been very off whether its enrollment or jobs and in particular, iowa and tennessee where there were predictions of gains in hospital jobs and Health Care Jobs<\/a> as it related to expansion and the opposite is actually taken place. Theres been a loss in Health Care Jobs<\/a>. Okay, and during the conception of the aca, supporters argue that Medicaid Expansion<\/a> would stop hospital closures. Has this been the case . It certainly has not stopped hospital closures and a number of states, hospitals have still closed and i think its important to realize that the supporters claims that it is a Silver Bullet<\/a> to stop closures has not been true. So list off arizona, massachusetts, a number of these states that have expanded and hospitals still closed. And finally, Medicaid Expansion<\/a> was projected to lower emergency room use. However, you pointed out that the evidence suggests that emergency room use has increased after expansion and that many emergency room visits by medicaid beneficiaries were deemed to be avoidable. Can you explain what might have led to this oakutcome . My experience is not just influenced by the aca. I worked on romneycare and looked at it closely. The traditional population, people are not getting coordinated care because they show up at a higher rate than those who are privately insured or uninsured. We need to ask about the quality of care the individuals are getting and theres been a number of surveys looking at how many of these visits are avoidable and unfortunately, at least in massachusetts, those surveys found 55 of medicaid visits to the e. R. Were unavoidable. Thank you, i believe my time has expired. Recognize commissioner for five minutes. Thank you, mr. Chairman. The Affordable Care<\/a> act has just been a blessing for so many people in our country. 12 million more americans have access to health care. Mr. Westmoreland, governors across the country submitted letters in response to representative mccarthys request to describe the impact of the aca and the expansion of medicaid. Im assuming youve seen some of these letters . For the record . Yes. Some governors appear to have positive things to say about the expansion with medicaid in their state. The letter from my home state of illinois stated that the governors say our medicaid population, quote, now stands at 3 3. 2 million, almost a third of the state population and carefully consider the ramifications of proposed changes, similarly, governor sandoval of nevada stated in his letter to mr. Mccarthy that, quote, i chose to expand the Medicaid Program<\/a> to require managed care for most enrollees and implement a state based Health Insurance<\/a> exchange and these decisions made Health Care Accessible<\/a> to many nevadans who never had Coverage Options<\/a> before. Can you briefly touch on how the residents of states that expanded medicaid under the aca have benefitted such as illinois and nevada . I didnt understand the last part of the question. I cited illinois nevada but can you briefly touch on how the residents of states that did expand medicaid under the aca have benefitted . Lets begin with 11 Million People<\/a> have medicaid coverage who didnt have it before. Many of the people are in serious need. I would point out and agree with you that of the governors who wrote to mrs. Mccarthy, none requested to repeal, i believe. And pass 16 of the states republican governors and ohio, mr. Kasich, one of your former colleagues, i think most passionate in describing not only how it has benefitted the rez kesidents of ohio to have services but believed it was a moral duty to cover these people under medicaid. Thank you for that. And can you briefly touch on how, lets see, i also wanted to mention the other examples. States, as you said, that have had positive outcomes for their residents and providing Health Care Benefits<\/a> to additional 12 Million People<\/a>. How has Medicaid Expansion<\/a> helped states manage their budgets . Ha has it had a positive impact . Theres been studies suggesting those who expanded medicaid have had not only a net increase in federal funds coming into the state but also enjoyed revenue increases because of the reverberating effects providing those funds in hospitals. I would also point out to you that there is a longterm study to be done of how productivity might actually be improved by people having Health Care Services<\/a> who previously were denied those services. Thank you. Some of the letters i was referring to seemed to raise concerns by republican governors with changes that would produce destabilizing cost shifts to the states. For example, governor baker of massachusetts in his letter to mr. Mccarthy said, quote, medicaid is a shared federal partnership and suggests that states may be provided with more flexibility and control. Must not result in substantial and destabilizing costs to states. Is there a valid concern under the republican proposals you are seeing such as proposals to block grant medicaid or pose per capita caps on medicaid or concerned about states should be very concerned. The first question is what level will the initial block grant and its formula be set at. The major question for states to focus on is how the evolution, the increase of funding over the in the future, will evolve as compared with the actual cost of providing Health Care Services<\/a> and the number of people who need them. As i suggested earlier, states will be left holding the bag for both medical inflation and the number of people who have no Health Insurance<\/a>. And what about for those receiving health care through acas Medicaid Expansion<\/a> are they at risk particularly if they block grant the Medicaid Program<\/a> . First, i suggest that my colleagues on this panel would point out that those suggest that those people should be the first to go off of the health care rolls and would return to traditional medicaid populations as they have existed over the last 20 or 30 years. I would suggest the people who are on Medicaid Expansion<\/a> are the people most likely to be on the chopping block to begin with. But secondly, i would say that as every state, expansion or no expansion, experiences the growth in Health Care Costs<\/a> that is almost inevitable looking at cbo or any other projections, if the states are left holding the bag and they do not have a guarantee of federal funds, theyre going to be cutting back on everyone. Thank you, i yield back. Thank you. Another new member of our committee, mr. Costello, of pennsylvania, appreciate you being here. Youre recognized for five minutes. If i could ask a couple of questions on hhs oig. Has the number of criminal investigators increased or decreased over the years . The number of criminal investigators specifically . Yes. I think right now were below our ft ceiling. Were still trying to hire more. How many more do you think you need to hire . Well, were we would hire as many as you let us, but we we need were at 1700 is where were pegged for, the entire oig. True or false, for every 1 expended in the oig, 7. 70 is returned to the Health Care Fraud<\/a> and abuse control program. That is true. Is that a consistent return . As far as i know, been around 7 and same thing for the Medicare Fraud<\/a> units, they have the similar ori. Youve conducted a review of state medicaid agencies presented with allegations of provider fraud. Did you find that state agencies properly suspended medicaid payments to those providers . They did not make full use of those tools. To say they did not suspend all they did not. Though in a number of the cases where they did not suspend, they cleared the provider of wrongdoing. Very good. Since your work on the issue of Program Integrity<\/a>, since your work has found cms oversight of states claiming of matching dollars is inadequate to safeguard federal dollars, what more could cms be doing to ensure the integrity of medicaid matching . There are a number of things along the Program Integrity<\/a> principles that we believe cms could do in conjunction with the states given that cms and states share fiscal risk, we believe they should share accountability. So as i mentioned, prevention, helping states implement the enhanced provider screening, helping them drive down improper payment rates and then, of course, the data to be able to understand the program and to tech fraud and more importantly the data helps us hone in on fraud, waste and abuse and target our oversight so we can get this tricky balance right between trying to have really strong Program Integrity<\/a>, but also not put undue burden on providers. Im going to shift this question to mr. Archambault, but after he answers, anyone else feel free to respond including what you just mentioned about the issue of specifically enhanced data matching technology. It seems to me that if you have technology and you have data, when were talking about the aca change which only requires states to perform one check per year, knowing that we have the data, knowing that were pretty technologically advanced society, it would be, i think, a little bit easier to go about detecting ineligibility or fraud or anything of the sort to cut down on those who are ineligible from being accepted into the Medicaid Program<\/a>. Mr. Archambault, i see in your written testimony in the first ten months of operation pennsylvanias Award Winning<\/a> enterprise Program Integrity<\/a> initiative identified more than 160,000 ineligible individuals receiving benefits including individuals who were in prison. And even millionaire lottery winners resulting in nearly 300 million in taxpayer savings. What can we do in order to pivot to real time identification of something that doesnt seem quite right rather than just relying on that one moment in time annually to beef up Program Integrity<\/a> here. So i think there is a number of things that the federal government can do to enable states to do this. The first one is if theyre investing state dollars in some of the efforts, that if theyre able to find cases that are eligible for them to keep a piece of that savings up front and more than they get to save now, given the funding formula that we have. The other one is let them check more frequently. And then the third one is to make sure that the actual data that the federal government is allowing access to is timely or allows states to go somewhere else to get it from a private vendor if the federal governments data is not timely enough. Yeah, i would agree that the coordination and sharing of data is critical between the federal and State Government<\/a>s. One area we found a real problem is when providers are enrolled, were asked who the owners are, so we know who theyre doing business with. In one case, we found that the state Medicaid Agency<\/a> thought there were 63 owners, medicare thought 14 owners and they told us it was 12. Trying to coordinate the data to all the program know who were doing business with, in addition, we recommend that the medicare data be improved, so that medicaid can share that and reduce the provider burden to enroll in different programs. That gets to the point about the duplicate eligibility issue, correct . Yes, it does. While we are a technologically advanced society, the Medicaid Program<\/a> truly is not. States data systems are pretty antiquated and there is a lot of work to do to get good data systems that are more flexible, more agile. If i could, sir, i would also say that the recently published managed Care Organization<\/a> rule provides for substantial improvement in data systems and i would ask this, and this committee actually accelerated the Effective Date<\/a> of that with the 21st century cures act. I would ask you to keep the mco rule in mind as you move forward with the question of whether regulations will be withdrawn in the early part of this in the early part of this administration. I think it is valuable addition to try to be able to find i agree with all my colleagues, the data systems need to be improved and i think the mco rule does that. Thank you for your comments. Thank you. And now recognize another new member of our committee, the owner of carter pharmacy, a place we might see someone like elie walker and opie serving drinks very much. Small town medicare. Good to have you on board. Mr. Carter. Thank you, mr. Chairman. Thank you for being here. We appreciate your participation. I want to preface my questions by apologizing if i ask you something you werent prepared for. And if you dont know the answer, if youll simply tell me, you know, that you can get me the answer, that will be fine. Miss maxwell, i understand looking at your bio last night you have some expertise on the 340 b program. I do. I dont want to get into that program, however i want to explain to you a situation that exists in my district. I have a hospital in my district that was participating and receiving monies from the 340 b program and because didnt meet the threshold, they they were put out of that program. They got back in it. As i understand there are two Different Levels<\/a> that you can be at as a Sole Community<\/a> provider, and also as a disproportionate share. Both covered amenities. They got back in as a Sole Community<\/a>. But what the ceo is telling me is because they cant get back as a disproportionate share, theyre losing over 300,000 a month, now that is significant for them. Im sure significant for anyone. But for this hospital system, it is very significant. Now, he also is telling me that the formula that is used for that, that medicaid participation, the medicaid rate is also in that formula to determine whether they are a Sole Community<\/a> or whether theyre in the disproportionate share. And what im hearing is that those states that did not expanded my cade, like the state of georgia, that theyre put at a disadvantage and that we arent eligible for that. Is that true . Is that the case . Im going to have to take your offer to get back to you on that. Okay. My expertise really is in the 340 b pricing of the drugs themselves and not as much in this disproportionate. But i know there have been issues and i certainly know there are people in our office that can answer that question and well get back you to as soon as we can. Thats fair enough. My question is twofold, first of all, if thats the case, secondly, if that were the intention, was that the intention to penalize states that didnt expand medicaid so they couldnt receive these dollars or was it an incentive to get those states to expand medicaid . I couldnt speak to the please include that in your answer. I will do. Ill move now to mr. Archambault and ask you, the video you showed there, i spent ten years in the Georgia State<\/a> legislature, on health and human services, i understand about medicaid, and, you know, we did the hospital bed tax in order to draw more dollars down, brought up by one of my fellow members earlier. In fact, theyre looking at reauthorizing that again this year. And you bring up a valid point about how states balance budgets. Because quite honestly, we did it that way. And that was one of the reasons why. But, my question is about the video you showed. Now, i am a strong believer that medicaid should include the a age most of the cost of the Medicaid Program<\/a> can be attributed to the abd. With that be what percentage would that be . 70, 80 . Miss yocom. I think it is at least two thirds. At least two thirds . Yeah. Okay. Were all in agreement thats most of it. But my question, mr. Archambault, why didnt this patient why wasnt this patient eligible as a disabled . Would have seemed to me they wouldnt have had to have waited on a waiver. I think it is important to know that we are talking about a couple of Different Things<\/a> here. What were talking about in particular for her, for schuyler and her mother there are services she could have access to under the waiver programs. For schuyler, you cant call a neighbor to baby sit. You need certain skill sets to be able to watch her given her condition, and so this would allow access to those services. It is not that individuals are completely off of medicaid, it is that were talking about are we providing the services that that we have promised to individuals in a holistic manner to be able to take care of the most needy. Okay, well, understand, again, i am one who believes that we that medicaid should be taken karcare of that group. We can have a discussion and debate who is covering and who is not to be covered. I honestly believe, as a Health Care Professional<\/a> that they should be covered. And that and congressman, thats my exact point, we are extending new promises to able bodied, largely childless adults before fulfilling that. Thank you for that. Very quickly, im sorry i dont have much time, mr. Howard, i wanted to ask you hhs projects that newly eligible medicaid patients are going to cost 6,366 per enrollee in 2015 and that this is a 49 increase in what they have projected before. Why is that . Why are they costing more . Congressman, may be because in these new expansion programs states have raised their reimbursement rates to providers to get newly eligible population in the system. Thats my understanding. It would appear to me if the again, i get back to the age, blind and disabled, if they were already included, they are the most expensive. And why are they im sorry, i know im running past my time. Just baffles me why it has gone up that much. Okay. Thank you, mr. Chairman. I yield back. Okay. Thank you. Now recognize mr. Collins for five minute s. Thank you, mr. Chairman. Ill be directing this to you, mr. Howard. Some background. Im western new york, new york, as we all know, is one of the highest state in medicaid per capita spending and total spending. While new york onliey s has 6. 5 the population it accounts for 11 of the National Medicaid<\/a> spending. According to a 2014 report from medicare, and the chip payment and access commission, using data from 2011, new york spent 44 more per medicaid enrollee than the National Average<\/a>. All kinds of complex and fragmented funding streams that make it very difficult to provide adequate accounting controls for the program. So the question is this, in 2012, a report from the hhs office of the Inspector General<\/a> revealed that new york had systematically overbilled federal taxpayers from Medicaid Services<\/a> for the mentally disabled for 20 years. New york state developmental centers, which offered treatment in housing for individuals with severe Developmental Disabilities<\/a> had received 1. 5 million annually per resident in 2009 for a total of 2. 3 billion. They were compensated 10 times higher. So the simple question is, how could these overpayments go unnoticed for 20 years . Congressman, it is because there is simply no financial incentive for the states to go back and police their symptoms in a way that would result in a decrease in federal funding. The state of new yorks settled with hhs i believe for 1. 63 billion for over payments, i think 2009 through 2011. So to smome extent the problem was remedied, the reality is the ratchet only goes one way. Congresswoman clark pointed out earlier, that Governor Cuomo<\/a> has had quite a bit of success which i noted in my testimony in bringing down the payment rate for the growth rate for medicaid. I think if someone who had an r by their name had suggested what is effective for new york state, a cap on growth of the most nondisabled part of the program, held to 30 effectively below the historical payment rate for the program there would have been compromise of poverty, and we would be throwing people out of the program. Miraculously, new york state providers found ways to significantly decrease their spending by hundreds of millions of dollars. I think the belief that significant flexibility or block grants or per cap ita cap s ignores there is significant opportunity for eefficiency in health care and until we give states better programmatic and financial goals to seek out that efficiency, we are not going to be getting the best outcome for every dollar were spending on health. Well, you know, being a new yorker and bringing this up i would have to say, you know, while we they apparently negotiated a significant settlement, it did not reimburse the federal government for 20 years of egregious behavior, which i would say was deliberate. You cant be charging ten times the National Average<\/a> for 20 straight years and try to, you know, prove that this was not intentional. So, you know, we talk about rs and ds, i wonderf there was a d behind the president s name and d behind our governors name if that settlement would have come closer to reimbursing the u. S. Taxpayers. But what i think was grand theft auto. So another question about new york, and by the way, the reason i come at this the way i do is county executive of erie county, largest upstate county, were one of a handful of states where the counties have to pay a share. By the way, on dish and igt for upl, the counties pay 100 of the federal match. The state pays nothing. And in the case of erie county, my county, second, third poorest city in the United States<\/a>, city of buffalo, 110 of our property taxes went to medicaid. We couldnt raise enough property tax to even pay our county share of medicaid because of the way new york state runs this program. We had to supplement it with sales tax revenue. So thats why i get a little emotional when i find out the state has been cheating for 20 years, especially the way they handle the counties. But also, as i understand it, in a 2009 report, new york state ranked last in affordable hospital admissions, last. So our outcomes are so poor, what is going on in new york and we only have 20 seconds, but just quickly, i think there is consensus that the amount of spending we put on health care does not automatically correlate to better outcomes. So if you look at a scatter plot of state spending per enrollee, it is all over the map and outcomes are all over the map because there is an increasing body of research that says Health Behavior<\/a> dictates longterm outcomes. We have to think about health differently. I couldnt agree more there is no correlation between spending and outcome. Thank you very much for your testimony. Now recognize the chairman of the full committee, welcome back, mr. Walden, recognized for thank, mr. Chairman. Thank you for conducting this oversight hearing. I want to thank our Witnesses Today<\/a> for your extraordinary testimony. It is very valuable in the work were engaged in. I want to focus on data and high risk. Especially to both the gao and to the hhs oig. My understanding is for 14 years running, medicaid has been on your high risk list. What is behind that . Is that because cms does not collect the right data to begin with . I think there is a couple of things behind it. One is the nature of the partnership itself that by the time the federal government is reviewing expenditures, the expenditures have occurred so that prevention ability is always challenging. The second piece really is about data, you simply cannot run a program this large when you cant tell where the money is going and where it has been. And we need better data. And so have you made recommendations to cms to collect better data and have they ignored those recommendations or what is the issue there . We have a report coming out in a few days that might answer that question a little more fully. But i think feel free to go ahead and share it today. The ig has been focus ed on this area for quite some time. We have followed evolution of the National Data<\/a> and continue to push cms to create a deadline for when they think that data will be available specifically for Program Integrity<\/a> reasons. So one of the issues that has come up in the press is this issue of wood working. Everybody is trying to count numbers here, and i would like what you said about lets get to the quality outcomes, but off that for a minute. There is this issue of wood working. How many people are eligible before that are being counted now as if theyre new eligibles. My question is, do we know that answer . And, second, are there states that are getting reimbursed at a higher rate as if we were paying for newly eligibles and what would be a 95 rate now, when, in fact, those individuals were actually always eligible and should be the states should be compensated at a lower rate. Do we know any data surrounding that, how many people are actually wood working, have states been reimbursed at a higher rate when they should have been reimbursed at a lower rate . I cant speak to the working numbers specifically, i can tell you that ig has the same question you have and we have work under way to answer that exact question. Are states pulling down reimbursements for beneficiaries as if they were in the newly eligible category when they should have been enrolled in traditional medicare, medicaid. And that work will be forth coming. Do you have a timeline on when you think you may have answers for us on that . We have four states were looking at. The next two states, the next couple of months will be out, and the other two probably later in the year. Can you reveal what the four states are . I can if you give me a minute. Okay. We did have we did issue some work that looked at this question. And we did identify some issues where it appeared that people were not accurately categorized by whether they received the 100 match or state expansion match or that regular f map. We did identify problems there. And one of the recommendations that is still outstanding in this area has to do with the fact that cms adjusted the eligibility differences but then did not circle back and correct the financing that occurred. So we think those two things need to be related. If you identify an eligibility issue, either way, if the matching rate is off, it should be corrected. Cms is starting to look at that, but it could be a big number. We dont know. But it is an important thing to get right. I remember i spent about 4. 5, 5 years on a Community Hospital<\/a> board at a time when the federal government decided to go after every hospital on the ledge, billing misbehaviors, going back, i dont know, eight, nine, ten years. And the threat to the hospitals was we will use the rico statute because you have engaged in criminal practice because of multiple cases. And it strikes me that they are willing to do that there, everybody had to settle because nobody wanted to go down that path. We know the government sometimes gets it wrong. But we would never go after the government with rico. What is happening here with the states i guess is a legitimate question when we have people age, blind, disabled, waiting to get on, are we in a limited resource and we dont have the data. Thats what youre telling me, isnt it . Yes, and i have the states so we will have data. On the first states. And theyre kentucky, california, new york and colorado. Kentucky, california, new york, and colorado and your timeline to conclude your analysis . The first couple will be probably the next month or two and then the next the final two will be later this year. All right. Be sure to let you know. If we could do one thing with cms to help you be able to do your job the way you want to do it, what would that be . Miss yocom. I hate to keep saying it, but it has to be the data. We need the data. Miss yocom, the same . I would agree. Okay. If there are specific items related to data please get those to us. Ill be happy to work with the incoming cms administrator and well do our best to get you the data. Because it is important to all of us for our decisionmaking. And we know we have people waiting on lists, cant get access to care. We got to get the waste and the fraud out, got to get them off this risk list. Thank you very much for your testimony, mr. Chairman. Thank you for your leadership. One more question i want to ask mr. Howard. This relates to trying to find some other ways of saving money and providing more effective care within medicaid. It has to do with payment models as a way to reduce cost, that being physicians, providers, hospitals are paid to take care of the patient as opposed to a fee for service, which is every time someone shows up, you know, you bill them, like paying a carpenter by how many nails he put s in the house. Hell put a lot of nails in the house. Where as an alternate payment model, making calls to patient to check up on their medication, to remind them of their appointment, to counsel them to keep them out of the emergency room, im thinking in linking with the medicaid amount, hhs estimated the improper payment for medicaid amounted to 30 billion in 2015 with an aerror rate around 10 . Medicaid coverage does not necessarily result in Better Health<\/a> outcomes as we talked about before. So what do you think about the alternative payment models as a way of saying that the skin of the game is also the physicians and hospitals to make sure that theyre doing all they can to keep the patients healthy. Absolutely. I think that experimenting with this model is critical. You need the data to understand who is the best provider. We talk a lot about waste, fraud and abuse, thats a big problem. Estimates from even people like daniel burr wick are that 20, potentially 30 of upcare is ineffective or wasted. And there are providers that we know are doing terrific jobs at a fraction of the cost. Hospitals across the street from another hospital providing care more efficiently. If we had data transparency, we could encourage more Competition Among<\/a> those across the payment models. Can you get us information how you see those things work out . Absolutely. You have a followup comment . A couple of comments, mr. Chairman. The first thing is that here is something we can agree on in a bipartisan way is getting you folks the data you need. So ill just echo what mr. Walden said, whatever specific suggestions you have, let us know. And also im assuming you need that staffing that thats going to be a problem. I just want to make a couple of comments about the Medicaid Expansion<\/a>, which is first of all, a lot of people i keep hearing people today say that we really want to make sure that people who have chronic and severe diseases like the videotape we saw get services and thats true. And then people on the other side keep talking about able bodied adults. And i would just point out that 80 of the people who are getting the Medicaid Expansion<\/a> are working. So, you know, they might be able bodied adults but they have jobs and they were uninsured before because they either their employers didnt offer insurance or because the insurance that they could get was too expensive. So these people were going without health care, which as mr. Westmoreland and others said, that just increases the costs for everybody because of the cost of uncompensated care. And if there is ways, you know, i was just talking to miss brooks about this, if there is ways that we can find efficiencies in the program, all of us are for more efficiencies and were for delivering health care in a more Cost Effective<\/a> way. Not just within medicaid, but within private insurance too. And this is something, again, i think that we can work in a bipartisan way to make this happen. But just to say, well, we shouldnt give the Medicaid Expansion<\/a> because these people are, quote, able bodied adults is not understanding who is getting it. I want to close with an email that i got from my best friend from South High School<\/a> in denver, colorado, were not Spring Chickens<\/a> anymore. And heres what my friend lori dunkley, she sent this a couple of weeks ago, without solicitation, just sent it to me. I want to add my story to others youre hearing about the Affordable Care<\/a> act. I was laid off during the recession, and lost a lot of my retirement stability. Then at age 54, i looked for a job for three years without success. I had no Health Insurance<\/a>. Finally i fell back on my journalism skills and landed work writing for several neighborhood papers. This has worked out fine, but only because of getting insurance through the aca. I make very modest money and soso i qualify for the expanded Medicaid Program<\/a>. What a god send. Sen sense im not yet medicare age, i dont know what i would do without this help. This is the people that were talking about. So we have to figure out how were going to give health care to the 11 to 12 Million People<\/a> who have gotten health care because of this Medicaid Expansion<\/a>. Thats what were talking about. Thank you, mr. Chairman. This will bring to a conclusion this hearing of the subcommittee of oversight and investigation. I would like to thank the witnesses and all members who participated in todays hearing. I remind members they have ten Business Days<\/a> to submit questions for the record and ask witnesses all agree to respond promptly to the questions. Thank you for being here. With that, the subcommittee is adjourned. To watch any or all of this hearing again, go to cspan. Org, search medicaid. From the Los Angeles Times<\/a> this morning, President Trump<\/a> will take aim at financial regulations today, they report ordering a review of the dodd frank wall street reform law that could lead to major changes and suspending a conflict of interest rule for retirement advisers before it goes into effect this spring, according to a Senior Administration<\/a> official, the times writes that President Trump<\/a> will be targeting major initiatives of the Obama Administration<\/a> that republicans have strongly opposed. At noon, hell sign an executive order directing the treasury secretary to consult with regulators about what needs to be done to fix the dodd frank wall street reform and Consumer Protection<\/a> act and report back within a relatively short period of time according to an official. Read more at l. A. Times. Com. Betsy devos nomination to be education secretary advanced today in the senate with an early vote, a party line vote, 5248, to move the confirmation vote forward to a final vote early next week. Two republican senators Susan Collins<\/a> and Lisa Murkowski<\/a> have announced they will vote against confirmation though both voted today to move ahead with the nomination. Senators continue to talk about the devos nomination. You can follow that live now over on our companion network, cspa cspan2. This weekend on American History<\/a> tv, on cspan3, saturday evening at 6 00 eastern, on the civil war, author and historian Harold Holzer<\/a> on abraham lincolns views you on immigration and his efforts to court the german american vote early in his career. One in ten immigrants, one in ten, joined the Union Military<\/a> as soon as they arrived. By lincolns optimistic calculation, the result with black enlistment factored in and even with the dead, wounded, captured and missing subtracted was a net gain for the military and for the country at large. Then at 8 00, on lectures in history, Rhodes College<\/a> professor Charles Mckinney<\/a> describes civil rights efforts to end segregation during world war ii. The new deal creates spaces for africanamericans and southern africanamericans in particular to start to push for civil and economic rights. Civil and economic rights. It gives them, again, to use Roger Wilkins<\/a> phrase that human space to push for and aspire for that inclusion into the mainstream of american life. Sunday afternoon at 4 00, on reel america, the 1958 United States<\/a> Information Agency<\/a> film communist propaganda. What do the communists have to say concerning our air force . Accidentally dropped some rockets over florida. 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