Transcripts For CSPAN Senate Finance Committee Considers Graham-Cassidy Health Care Bill 20170926

Ok. [inaudible] will come to order. I would like to welcome everyone, and i do mean everyone. Shouting] ble senator hatch if you want a hearing, you better shut up. [shouting continues] [banging gavel] senator hatch all right. Can i observe today . You sure can. That would be great. [shouting continues] [shouting increases in volume] [banging gavel] senator hatch the committee will be in recess until we get our [shouting continues] [indistinct shouting continues] [chanting continues] no cuts to medicaid. Save our liberty. No cuts to medicaid. Save our liberty. No cuts to medicaid. Save our liberty. No cuts to medicaid, save our liberty. No cuts the medicaid. Save our liberty. No cuts to medicaid. Save our liberty. No cuts to medicaid. Save our liberty. No cuts to medicaid. Save our liberty. No cuts to medicaid. Save our liberty. No cuts to medicaid. Save our liberty. Lets have order and show some respect here. A lot of us are on your side. Lets have some order. If you cannot be in order, then get the heck out of here. The committee will come to order. I would like to welcome everyone to this afternoons hearing where we will discuss and examined the grahamcassidyjohnsonheller health care proposal. Given the relatively unique circumstance we are facing with regard to health care generally particular, a hearing has been asked for on this proposal so we can all get a better sense of how it is intended to work. Toward that end, we had two distinguished panels of witnesses before us today. The first panel will feature ourements from two of Senate Colleagues. If the police would please remove that person, we would appreciate it. And keep the door shut. Ok, the second panel will feature another of our colleagues who is also a member of this committee. We will hear from a run and former Senate Colleagues on the second panel as well. Joining them at the table will be experts and stakeholders who are here to share their views on the proposal from senators graham, cassidy, heller, and johnson. The purpose of a hearing is to respectfully discuss ideas and become better informed on particular issues. The purpose of the hearing, as i said, is to respectfully discuss ideas and become better informed on particular issues. It does not mean everyone shares the same views and opinions. I expect that quite a few disagreements will be expressed today, and thats ok with me. Ive been in the senate for four decades now, and in that time, i have been part of some very difficult and contentious debates. Over the years, i have participated in some of the most Heated Supreme Court hearings in our nations history. I was here to take part in passing, debating, and the americans with disabilities act, one of my proudest accomplishments. I was around when the debate over the war in iraq became extremely combative, and of course, i was here when we before itamacare passed, and i have been here for every debate we have had about it since that time, so i have been through an awful lot of this, and its nothing new to me. So i understand there are some strong opinions about this issue. I understandtly, why opinions are so strong. When we talk about health care policy, we are not just talking orut a theoretical concept legislation that impact a single , isolated industry. This topic has a significant on the lives of every person in this country in ways that can make or break both their health and their livelihoods. Isnkly, because this issue so personal, everyone has strong feelings on all sides of these issues. If we could shut that door and keep it shut, i would appreciate it. Two members of the committee, members of the audience, to anyone who may watch more read about todays hearing at some point in the richer, let me say this i respect your opinions on these issues. While i wish that expressions of goodwill could on their own fix our nations problems, that is just not the case. We have to do the work. On these issues, the work is particularly hard. Today, we are here to discuss the most recent proposal drafted by some of our colleagues, and i commend them for their efforts and willingness to put forward ideas to address these very difficult problems. My hope is that we can spend our time today questioning our witnesses about substance and policy, not on scoring political points, particularly when we have distinguished colleagues and a former colleague at this table. I know that for both sides of this debate, passionate demonstrations and righteous indignation, particularly when there are cameras in the room, make good fodder for twitter and especially when the subject is health care. Our committee is generally regarded as being above such shenanigans, the we have not been entirely immune to these types of theatrics in the past. Today, let me just say this if the hearing is going to or ave into a sideshow forum sibley for putting partisan points on the board, there is absolutely no reason for us to be here. I will not hesitate to adjourn the hearing if it gets to that point. It has not gotten there yet, but its close. Im saying this to the benefit of my colleagues on the committee and everyone in the audience lets have a civil discussion. I have very deep feelings about these issues, and i think most here on this committee have deep feelings as well. End ouris that in the efforts will generate more light. Nd less heat than we have seen if we cannot have that, we should all be spending our time on something more productive. Remarks, ithose few turn to our Ranking Member, senator wyden, for his remarks. I have an Opening Statement and at the conclusion of that would like to bring up several points about the process, and i understand we have agreed to that. Senator hatch that would be fine. Senator wanted colleagues, nobody has to buy a letter just because it is the last car on the lot. This Trumpcare Bill is a health care lemon, a disaster in the making. The last the fact that it is the last republican repeal bill standing does not make it ok. Its going to be a nightmare for tens of millions of americans, and it makes a mockery of the president s promise of better insurance for everybody at lower cost. The bill sponsors are not even waiting for the official facts and figures from the independent scores keepers. Version after version of this bill floating around, and the pork parade is up and running. The process that has brought the bill to the drink of passage would be laughable if the wellbeing of tens of millions of americans was not in the balance. Blow the whistle on a few key points at the outset. First off, the American People do not want this bill. In the last few days, the committee has received more than 25,000 comments from people who want it stopped. Ofwith every other version frontcare, this proposal is about as popular as prolonged root canal work. Thee is one group cheering bill on the rightwing republican donor class, the big donors want the entire Affordable Care act thrown in the trash, and they wanted it from the beginning, but it did not work. Toturns out its that policy take Health Coverage away from tens of millions of americans and raise costs for virtually everybody else. Be new strategy is essentially repealed by a thousand cuts. Be national repeal, and it would be statebystate repeal. The heart of this bill is the scene that punishes states that work hard to build strong, private markets and make health care more affordable. It rewards space where lawmakers have sat on their hands, where they spent years loudly rejecting the opportunity to improve the lives of millions of the people they serve. Instead, the committee today will hear a lot of hocuspocus about the word flexibility. The story goes that is flexible controlthe states, more and somehow everybody will be better off, but lets be upfront about what it means in practice. The real flexibility created by the bill is the option for so thato do worse america is forced to pay more for less. Governor and new legislators build new Health Insurance systems, and they will basically have to make hunger games choices, deciding which of all get care and which dont. The ironclad, loopholefree richard protection for those with preexisting conditions will be gone. Bill sponsors will tell you otherwise, but, colleagues, the facts are the facts. Guaranteed protection that no one will began out by a catastrophic disease like cancer will be gone because the door just because the bill opens the guaranteed benefits. Prescription drug coverage on the chopping block, Maternity Care on the chopping block, Mental Health and Substance Abuse treatment on the chopping block, and a whole lot more. The guarantee that nobody could be charged higher premiums because their Health Status or their jobs also gone. Bottom line this bill is an allout assault on final consumer protection. The healthto make care many people need unaffordable. No, it does not adequately protect people with preexisting conditions. The bill does include are a few toothless lines about afford ability and access. That is supposed to be protection, real protection for people with preexisting conditions, but there is no enforcement mechanism, standards , and the watereddown get ation space then can rubberstamp from team trump. An attack, there is on womens health. Hundreds of thousands of women are going to lose the right to see the doctor of their choice. That is what you get when you defund planned parenthood. An aging baby boomer who suffered a stroke might not get the help they need. The guarantee of nursing home care will not be there. The communitybased program that offers care to people at home where they are most comfortable could disappear. Special Education Programs funded by medicaid for vulnerable kids could be put in jeopardy. A few closing points, mr. Chairman the process that has led to this moment has been an abomination, and we had just seen, colleagues, some of the frustration that our people had at closedoor government that locks on americans out of the democratic process. This just is not serious. Offer assurances that this bill got a fair examination and went through the regular order. Its not true. Notte republicans have gotten answers to the most basic questions about the real world effect of the bill. How many people are going to lose coverage . By how much will premiums increase . Will the Health Care Market survive next year . Independent scorekeepers say it will be several weeks before they can put forward estimates of coverage and cost, and their job gets tougher because this bill just changes by the hour as the majority throws around in the scramble their votes. Why the rush job . Its because the coach turns back into a pumpkin at the end of the month. To pass the partisanrack bill expired. We want to be clear. On the side we think we ought to be working on i partisan priorities. We got a good bill for kids, want to be clear. On the side we think we ought to childrens Health Insurance plan, 9 million kids. Funding runs out in a few days at the end of the month. We would like to be working on that in a bipartisan way and we to work on stabilizing the private Insurance Market. I heard about that this weekend, atchildrens a town hall meetinn central oregon. That is what we want to work on, we want to do it in a bipartisan way with our Sister Senate committee. Instead what is on offer is this bill that will trigger a health care disaster, a death spiral in the Insurance Market tax credits and Healthy People costs going to the stratosphere. Democrats on the side of the day is want to do everything to stop this dreadful opposable from becoming law and two, to get down to the serious, heavy lifting of passing Bipartisan Legislation for kids, number one, and for adults and the individual Insurance Market. Wouldhat, mr. Chairman, i like to reppo with a few quick points about procedure for this hearing. Up with a fewp quick points about procedure for this hearing. We are disappointed in the response to hold this hearing in a larger room that could accommodate more members of the public. Im asking that with consent a letter outlining this request be included in the record. Chair thi without objection. Affecting morell than 320 million americans and won six of our economy. As we just saw, there is enormous public interest. We have seen hundreds of people today, many in wheelchairs lined up in the hall hoping to get into the hearing. Account of the committee members, staff, witnesses, and members of the press room we are in only has space for about 30 members of the public. Import. Ng of this normally when Congress Holds a norms that attracts is, we have our hearings and large hearing rooms, the largest hearing rooms to accommodate hundreds of audience members. My understanding is the rooms are available today. The question i have is why not move the hearing there . And more people can attend. Otherwise, it sends one more wants that the majority to keep the bill under wraps this year rather than opening up the process to the American People. Finally, i understand senator cassidy wants to participate in this hearing as a witness providing testimony asking questions of the same Witness Panel he is part of. I expect we will hear a lot today from senator cassidy about flex ability. Flexibility i gather he is a big fan of taxability. He wants to apply it to himself. Dashing back and forth between the witness table and the deus not proper decorum for hearing. I would like to make clear as with respect to the rule, i have to leave it at that. I think it is more appropriate thati think it is more approprie that senator cassidy wears one had during this hearing rather than two. Chair i will make sure he does not ask questions of himself. Maybe i had better withdraw that. Appreciate your kind and good remarks. Interest ande high hearing,tance of this an overflow room has been secured, not to mention it will be televised on cspan and available for Live Streaming on the Senate Finance committee website. To my colleagues complaints about the process for setting up this hearing i will just say that many senators have expressed a desire to examine details of the proposal we are discussing today. Todays hearing is being held to allow members on both sides to delve deeper into the policy and gain a better understanding of what our colleagues proposal expects to achieve. I do not expect this hearing to go on forever. Welcome each of our witnesses to our hearing today. To start off on the first panel we will hear from our good friends and fellow senators, the senior senator from South Carolina, Lindsey Graham who is the coauthor. And opening remarks. We are grateful to have such passionate and wonderful senators join us today to share their views. Senator graham, would you please share with us your remarks and we will go to senator her run a harona. Here becausei am obamacare is a disaster in my state. It is not your job to take care of our stay, it is mine. Maybe we will find a common way forward but i will not be deterred. Chair i intend to help. Weregraham there [inaudible] with another decrease announced friday. In my state it is a disaster. Health care does affect federal finances. By 2042 the entire revenue stream will be consumed by medicare and medicaid spending on the somebody does something about it. There will be no money for the military, the department of education, nih, or anything else. I deal with two problems. Nationally, obamacare premiums in theng up 13 individual market. 40 5 of the counties in america are down to one choice and 45 counties in this country have no choice under the plan you designed. The bottom line is, i do not doubt your intention to help people. I do question whether or not it is working as intended. You can question my motives and quite frankly, i do not care because i know why i am here. Chair you are saying who designed it . Graham if someone does not fix obamacare soon the majority of counties will be down to one provider. It is collapsing as i speak. Medicaid is on an unsustainable path area by 2027, we are going to be spending more on medicaid than the military. By 2042, medicare and medicaid money thatke all the will be sent to washington. We give flexibility control to the states like they have not had before but the population in question. We begin to slow the growth down to make it more sustainable but the flexibility we give will allow us to get better outcomes. Medicaid spending and outcomes are not matched up where anyone should want them to be. When it comes to obamacare, if you do not find a way to stop the bleeding, it is going to basically collapsed before our eyes and here is what we do. I am getting a lot of pushback from our republican colleagues because they leave the taxes in place. The bill. E idea of we repeal the individual mandate but you can reimpose it in your state. If you want to go to singlepayer after you can do it but you will not drag me with you. Asleave the taxes in place 1. 2 trillion and block grant it out to the states and a formula i think is fair. Under obamacare between 20 and 26, four states get 35. 4 of the money, maryland, massachusetts, new york, and california and they are 22 of the population. Good deal for them, not to much for the rest of us. Under this block grant they get 29 , not 35. Still more than the population. Hawaii is expensive place for medicare. It is an expensive place to live. Alaska has 750,000 people, 2. 5 times the size of texas. Under this will we look at you rather than some bureaucrat in washington who has all the money in the power, we are going to turn it back to you, your state legislature under governor and i ask the following question, how many of you know your state house member . Almost all ofhawaii you raised r hand. I asked the question how many know who is in charge of obamacare in South Carolina . Nobody raised their hand. That is the problem. We will send it back to the states. Have flexibility and accountability for you and someone will listen to you. If you do not like the health care you have got you can complain to somebody you vote for. This the opposition to bill, to the Ranking Member, every Major Insurance Company opposes our bill, why . Because we take hundreds of billions of dollars away from goingnd if that were to them and give it to the states. They do not like that. If i were a Major Insurance Company i would hate my bill. Ould give it to the states states. Everybody opposing this bill is a big winner and my goal is to get the money and power out of washington closer to where people live so they will have a voice about the most important thing in their life. I do not need a lecture about health care but what you have created is not working. It is time to try something new. If we took the money and power out of washington, we have a closer to the patient and put it in the hands of someone you would have a relationship with and you could vote for it if you do not like the product. We are going to get a better outcome and this is the best chance and to my friends to the left, i will do everything i can to stop and put a stake in the heart ofchance singlepayer heah care. You do not like obamacare, you do not think it is Big Government enough, i am here to stop you. Beyond obamacare will ruin health care. This is a debate worth having. Thank you very much. God bless you all. Your we will proceed with statement. Senator hirona thank you for inviting me to testified. Testify. My diagnosis came as a total incidental to a physical checkup that involved a incidental to a physical checkup that involved a different or seizure that i was facing. This is how a lot of people learn about a serious illness or condition. Blue, blue, bang, you cannot plan for it. I received letters, cards, and notes when people found out. I was touched by the hands reaching out, the show of compassion, including from so many of my colleagues. Members of this committee on both sides of the aisle. Every day people come to me at airports, grocery stores, that thets to tell me two are cancer survivors. There is a connection. It is never a good time to have cancer. But what i am experiencing through my cancer is the care and concern expressed by total strangers. This is compassion. It helps me a lot. But what we do as leaders affecting everyones lives should affect compassion. Sadly, that is not in this bill. In the greatest, richest country in the that world compassion shd not be so elusive or indeed, missing. After all the compassion and care i received for my colleagues after i disclose my diagnosis, the grahamcassidy proposal reflects neither care nor compassion for millions across the country. Health care is a right. It is a right. It is not a privilege to be reserved for those who can afford it. Treats Health Care Like a commodity that can be bought and sold. This is fundamentally wrong. Nellie olive us will face a serious illness during our lifetimes. It is a most impossible to budget and plan for the costs associated with treating it and once you are diagnosed you cannot put off will face a serious illness during our lifetimes. It is a most impossible to treatment because you cannot afford it. Health care costs were the biggest driver of bankruptcy in the country. Since the law went into effect you are saying a huge reduction in personal bankruptcies. There is a causal relationship. If you dig into the details and numbers, it is clear this till is much worse than the bill we defeated in july. Under the thin for near of states rights and local control, the bill imposes a radical of the american economy. According to the brookings institution, 32 Million People will lose their Health Coverage under it. There are so much wrong with this bill it is difficult to confine my remarks to only the short time i have been allowed to testify. And contrary to pharmacist gave, it undermines protections for to 600,000 people in hawaii and 134 Million People across the Country Living with preexisting conditions. This will seriously undermined Consumer Protections that require coverage for preexisting conditions and prohibits Insurance Companies from charging more for care which is what they will do if this bill passes. It requires a pro forma explanation of how the state expenses but it is a check off box. Federal government can deny a states waiver application but the people who would be making this decision are longtime opponents of the Affordable Care act. Sadly, the American People cannot trust this administration to do the right thing regarding their health care. We do not have to look back far to see what the result would be of a waiver. They could use age, Health Status, and other factors to determine what premiums to charge. They could set annual and lifetime them on care and refuse treatment about because of how much they cost. I have accompanied it illness and i would reach lifetime limits in practically a nano second. I intend to live a lot longer before that day comes. Under this bill coverage might beavailable but it would prohibitively expensive and able to be taken away in a moment of greatest need. This ill meant dismantles medicaid. It converts medicaid into a block crack a block grant. Medicaid. It converts medicaid into a blockit punishes states like hai that expanded medicaid by cutting federal funding and redistribute it to states that did not expand medicaid and therefore hundreds of thousands of people in those states do not have the kind of coverage that hawaii provided. Were looking at 4 billion in cuts and 91,000 fewer residents having health care because of this bill. Because states would receive some much less money, they will no longer be able to provide quality, adequate care for as many people as possible. They will face the Impossible Task of choosing who should lose insurance and which services to cut. Even then, the most vulnerable members of our society, the , childrend disabled would not receive the care and services they need. We are all one diagnosis away from a major illness. I suddenly found that out. With so much uncertainty, childn would not receive the care and services they need. We are all one diagnosis away now, the one thing that people should be able to count on in the richest country in the world is getting the care they need when they need it. Health care is a right, not a privilege for those who can afford it. Health care is personal to every single one of us. I would like to conclude with a call to action. This bill would be devastating for millions across the country facing dire health consequences. Millions of lives are at stake. Lets return to the bipartisan negotiations to stabilize the Health Insurance marketplace. This is something they are doing bipartisan way. This is exactly how we should approach health care in our country. Focus on the people who are elected to serve. Focus on the people who are elected to serve. Show them the compassion they are expecting from their leaders. They expect us to come together and come up with a bill we can get behind. Thank you. Chair thank you, we appreciate your remarks and thanks to both of you for sharing your remarks to the committee today. I think i speak for my colleagues when i say we are hopeful and praying for your quick and total recovery from cancer. We do appreciate both of you for taking the time to be with us today area today. You are both welcome to stay for as long as you wish. We will turn the panel to two. I will introduce witnesses briefly and each of you provide testimony in the oil order you are introduced. Prior to his coming into the provided care for uninsured and underinsured patients were nearly 30 years. He is a cofounder of the Greater Baton Rouge Community clinic, created a Public Private partnership to vaccinate children against hepatitis b and in the wake of Hurricane Katrina , he led a group of Health Care Volunteers to convert an abandoned kmart building into an Emergency Health care facility. Taught atssidy has the lsu medical school and is a former member of the Louisiana State senate and the u. S. House of representatives. Attended the you Louisiana State university for his undergraduate and medical degrees. We will hear from our good former colleague senator rick santorum. He served in the u. S. Senate from 1995 to 2007 prior to which he served in the u. S. House of 1991 totatives from 1995. Senator santorum and his wife karen are coauthors of the bestselling book bellas gift. How one little girl transformed our 1991 family and inspired a nation. Senator santorum received his matchless degree from penn state university, his mba from the university of pittsburgh, and his law degree from Dickinson School of law. We will hear from mr. Dennis smith, the Senior Adviser for medicaid and Health Care Reform at the Arkansas Department of Human Services and a visiting professor at the university of Arkansas Medical Sciences college of Public Health. Mr. Smith has spent most of his career in public service. The executivein and legislative branches including 10 years on capitol hill and 10 more years at the u. S. Department of health and Human Services. Mr. Smith headed the Medicaid Agency for nearly seven years, the longest tenure of any medicaid director at the federal level. Mr. Smith worked in both the u. S. Senate and the u. S. House torepresentatives from 1989 1998. Mysteryth witness is some miller, the acting secretary of the commonwealth of pennsylvania is department of health and Human Services. Theiously she served as pennsylvania insurance commissioner from january 2015 to june 2017. Additionally, she chairs the Senior Issues Task force and its longterm Care Innovation subgroup at the National Association of Insurance Commissioners. Prior to her work in pennsylvania, ms. Miller served as acting director of the state exchanges group, the oversight group, and the Insurance Programs group and the senate for medicare and medicaid services. She also served as the administrator of the oregon. Nsurance division she received her jd from Willamette University college of law and her ba from pacific lutheran university. Ms. We will hear from cindy mann. And driftedfounder for the center for children and families. She previously worked as a Senior Adviser at the kaiser and theon on medicaid uninsured. Menmann is a partner with at minatt health. Dick woodruff, senior ice president of federal advocacy for the American Cancer Society cancer network. He has more than 35 years of experience in congress, the executive branch, and the notforprofit world including serving as the chief of staff thelegislative director for u. S. House of representatives as well as the director of Congressional Affairs at the National Endowment for the arts. Mr. Woodruff is a graduate of Miami University in oxford, ohio. I want to thank each and every one of you again for taking time out of your busy schedules and coming here today. I look forward to hearing everyone of your remarks. Senator cassidy, will you please get us started . I cannot telly you how honored imt testify before my colleagues. I respect you so much, you are knowledgeable and passionate about health care and about our country. I hope you except i have also studied health care and am passionate about care for the uninsured. I worked for Public Health bills in california and louisiana and spent caring for those who have less. I am sorry about this process. I would have preferred hearings, a market, a democratic cosponsor. For three years have gone around to democratic colleagues and have met with you and asked the we please Work Together . Susan collins and i can with legislation which was so bipartisan in which a state like oregon could keep obama care if they wanted. In myfine but my state the individual market is collapsing. Allow us to do Something Different. It was praised by the left and the right that this was a bipartisan attempt, sincere. All 10 said they could not help. After the Health Care Vote failed in august, i was assured cooperationsan would begin. The individual market in my state is collapsing. If you cannot get a subsidy you could not afford your coverage. Year foring 39,000 a his premiums. People asked us how do you ensure affordability . Is 39,000 dollars a year affordable . That is not including the deductible. When i ask people will you help me, three years i have been doing this and i was tried told nice try. Do i say these people would not help me so i quit helping these folks . That is not why i was sent here. I was sent here to work for them and if this is the only means by which i can do so then i shall. Cassidy, caring for the uninsured and medicare did medicare patients. Havetients did terrible had terrible diseases. The aca promised Affordable Health care coverage, freedom to keep your doctor and to Keep Health Care costs down. On the exchange middleclass families have skyrocketing premiums, mandates they hate, 6,000 deductibles, with costs inflated and doubling into short time frames. If there is one thing we can agree on on a bipartisan basis, obamacare is feeling. 15 senators to clear such while endorsing a singlepayer system. The problems of obamacare require a path forward. On a positive note, i was presiding the other day when senator wyden was praising the chip program. We agree. A flexible block grant was pastor the chip program keeping the protections and requirements of the chip program. The expansion dollars and Obamacare Tax credits [inaudible] the means. Uted it is a mandatory appropriation and the chip Program Requires reauthorization. This will, too but it does not mean the money goes away automatically in 10 years as some have absurdly stated. Let me address the inevitable comment. We do not affect 6 of the economy. That is a misstatement. We are not touching tricare. None of that is such. We are in the individual market and the Medicaid Expansion and traditional medicaid. This is not 16 of the economy. 16 of the economy. We are taking the dollars and continue the expansion program. They have the flexibility to help states, many of which are not able to meet their expansion match. The expansion match is waived. The flexible block grant functions are combined in the waiver. We preserve protections and prohibit charging women more, no lifetime caps. States applying for waivers must prove that the americans with preexisting conditions have access to affordable, adequate canrage, the end and you define affordable as able to afford. This rate is an issue. Many on the left have threatened that we give states the power obamacare usurped. Corrupt governors schemed to deprive the citizens of their state of protections and get told what to do. This amendment rejects that narrative. Partisan virginia gets 4 billion more dollars. Florida, 15 billion more dollars. Missouri, 5 billion more dollars. Increasing access to Cancer Screening and Cancer Treatment for folks in those states get to currently do not have. I wonder if those opposed to the amendment care about those in that state. Right now, those in virginia will have more for these tests. We have to pass the bill and return power to patients, states while suspending spending access to coverage for millions. It is an honor to be here before my former committee. I am father. Ause i am a a father of a child who, like many outside this room, is in a wheelchair because she cannot walk. She cannot talk, either. I am trying to speak for her. And for others like her. I see the hysteria that has been developed around this bill and me. S disturbing to that what is a clearly responsible proposal that as many me. On the right have criticized keeps 90 of the taxes and 90 of the spending is going to cause everybody who was ever covered by obamacare to be without insurance. That just does not make any sense. It is irrational. It is not supported by any facts or any of the evidence. It just shows the frustration that Many Americans have as outside of washington and seeing something put together by not two of the most conservative members of the caucus, Lindsey Graham and bill cassidy whose who sponsored a plan to get a partisan support. These are the sponsors, people on the far and of the Republican Party yet. It is being treated as this draconian slashing. I had the privilege of managing the ill to reform wealth or welfare. People complained that people would be sitting on grades and we would be cutting off services that they had needed. The reality is that we are doing the same thing in this bill as we did in 1996. That is the idea when i talked to lindsay and bill and others about this idea that was based on the success of the 1996 welfare law. A bill that got bipartisan support. There was a recognition that this program was not doing as well as it could be and there were innovations at the state level that could be replicated and done better. To care for people better, to get people off of welfare. That we should not measure the success of welfare as to how but howple were on it we transitioned people and get to work and lower poverty rates. I am on the obamacare exchange. And i pay around 30,000 year for our policy. I do not know how families do that. That it is idea affordable is ridiculous. It is not affordable. It came forward based on the information i had, experience in what working on welfare that suggests we can do the same. I did when i was on the , i had nined before people in my office that i hired who were former welfare recipients. The primary purpose here is to make sure we have a system that works well for america and the hysteria that is being developed here on a bill that, candidly, is modest in its reductions in spending, modest in its reductions in taxes and modest in the flexibility we give to the states outside of the aca to be able to provide care for those who are in need in our society who fall through the cracks. Racks. Ough the chra the medicaid cap was proposed by president clinton. It ties the greatest rate of growth for medicaid and around the level of medical inflation. Have advocates who have said we need Government Run Health Care for everybody. When we put a cap on health care on medicaid at a rate of inflation for health care, we are told that this Government Program will collapse. How can you have it both ways . Government health care is the most efficient but if you put it at the rate of medical inflation which includes these inefficient private plans, youre going to collapse . You cannot make that argument. You cannot keep up with inflation. On the second block grant, it is simple. You give states and enormous amount of money. People say this would be going back to the old system. Have oneystem didnt point 2 trillion to be spent by the states to be able to make the system work. I look forward to the opportunity of getting to the details of how we designed this to make sure that states who have expanded medicaid are not disadvantaged over the longterm, that we ramp down the formula, we do a lot of things to make sure this is a fair people get help so we can have a affordable and stable Insurance Market. Chair that is very interesting. Lets turn to mr. Smith and take your testimony at this time. Smith thank you. It is a privilege to be with all of you here today and i am here to discuss the amendment and i am pleased to convey governor governorpport hutchisons support for the bill. In 2017, cbo estimates that on the medicated bat expansion the premium subsidies, tax credits, costsharing, will spend about 111 billion. , it willr the proposal be 190 billion. That is a 70 increase in the amount of federal spending available to provide coverage. Estimates, the congressional budget act office, when it modeled the for whate care act, the coverage would look like in 2017 in this year so they modeled this seven years ago, what they predicted then was had inate and that cbo its baseline by 2017, they would be 35 million nonelderly individuals on the Medicaid Program under the current law baseline. Act, the Affordable Care 15 million would be added to that number. If you will recall, that is when Medicaid Expansion was mandated under the legislation which is turned out not to be true. We have 69 million nonelderly individuals on medicare and chip, of which 13 have been made eligible by the aca. The individuals that cbo predicted would be receiving subsidies over in the marketplace are in medicaid instead. This legislation puts those two populations together. Now we reform a pool of 22 million lives of which are relatively young and healthy and that would be the new pool again. Everyone keeps talking about how do we stabilize the premiums for this population . We keep trying to throw more money at it. Put more people into it. That is what will truly stabilize the pool. My remarks on the chip program, i was privileged to be 20 years ago with chairman hatch and senator grassley to help create the chip program. I believe it is a great vehicle to use for that purpose to build upon that. As the benefits of having the structure already in place, chip program, people know what it is but it is a capital to the states. It is flexibility. It is deferring to the state on many of the decisions that have been made and i would suggest chip has been wildly popular on a bipartisan base for 20 years basis for 20 years. Talkhird point i wanted to briefly about was per capita caps in medicaid. We already have per capita caps in medicaid. States we are living under a per capita cap. If we exceed that we are at risk for every dollar above that cap. Manage the programs to those caps. The caps, by the way, of the office of the actuary reduces an annual report on medicaid spending. Actuaries made their projections out through the year 2024 for what medicaid was going to be spending. Theirear, they reduced projected spending for medicaid by 140 billion. Nobody is arguing that there is somehow 140 billion has been lost. You revise the baseline. The baseline changed. The baseline is changing, it is doering because the states not have their share of the funds to be able to continue to accelerate medicaid spending at the rate it is. Medical price, the Consumer Price index of medical inflation plus one for the disabled and elderly populations that the bill provides for, that the proposal provides for, when you look at the actuaries report, that is a higher growth rate thatwhat cbo is estimating the beneficiary will grow by. Is slowing on spending on a per beneficiary basis is lower than what the bill is providing for. The last point on the work requirements which is a feature of the bill, again, we have hutchisonsgovernor leadership, past requirements that receive overwhelming i partisan support in arkansas. That stateshicle will be able to readily adapt to, will be ready to put into place, and will continue the tradition of this committee and extending coverage to the most vulnerable americans. Chair thank you. Good afternoon. I sit here today honored to have this opportunity but also very concerned about the potential for this legislation to become law and what that will mean for the millions of americans who rely on the Affordable Care act for quality, affordable Health Insurance. Since passage of the aca, pennsylvania is experiencing an alltime low uninsured rate. We announced we have gone from over 10 uninsured before aca 25 or 6 today. We face in Opioid Epidemic that is devastating our communities. 175,000 people have been able to access treatment. I could go on and on about all the benefits people in pennsylvania and around the country have realized because of the aca. It is important to point out that the aca is not perfect. I had the opportunity to testify a few weeks before the senate welth committee about ways could Work Together to stabilize markets which is the limited area that needs attention. A group of Insurance Commissioners from red and blue states talked about targeted reforms a could be put in place to stabilize markets to ensure the aca works everyone going forward. I was optimistic after that hearing because the first time in this debate, it appeared that senators from both sides of the aisle were genuinely interested in focusing on the problem. The need to stabilize the individual market and finding a solution to that problem, rather than using the problems in the individual market as an excuse to repeal the aca entirely and as the National Associate of medicaid directors put it, make it them the largest intergovernmental transfer of responsibility from the government to states and history. I find myself talking about a proposal that would make cuts to medicaid and force governors across the country to make the most gutwrenching decisions they could possibly face. According to an analysis, pennsylvania with lose 15 billion in federal funding in the next decade. Kaiser Family Foundation put the number at 22. 7 million dollars. Our own analysis estimates we assuminge 30 billion average cost growth. This forces governors to make it possible decisions. Who should receive health care, child born with a disability, or young adults struggling with an opioid addiction, a mom fighting breast cancer, a senior who has worked hard all his life and needs access to Quality Health care to age with dignity . A state insurance regular in two different states and having spent time as a federal regulator, i believe states are in a better position to make decisions impacting our residents. We know our markets better. We are more and ample and able to issues impacting our consumers. When we hear you want to go is more flexibility, you do peak or interest. I gave the Health Committee some ideas for ways the federal government could streamline the 1332 waiver process to make it easier for states to get these waivers but cutting billions from medicaid and getting states reduced funding in the form of block grants, finding that goes away after seven years, is not the kind of flexibility we are looking for. I have been thinking over the past few days about what we would do in pennsylvania if this bill becomes law. Honestly, i am struggling to figure out how we would respond. We would have two years to completely revamp our Health Care System, work with stakeholders to figure out what the new system could look like, develop whatever infrastructure would be needed, make system changes required, pass legislation, getting necessary federal waivers, and a host of other activities. This would need to happen without federal funding to support these essential planning activities. States for years and a lot of funding to support their work. After seven years the funding disappears and the state would be left holding the bag to find whatever system we put in place. That alone makes it highly unlikely we would get anything in place in pennsylvania by 2020. In my experience, state legislatures, they do not want to put a system in place with federal dollars if we do not have a way to ensure sustainability after we lose federal dollars. Viding information implementation funding or extending funding and definitely would not fix the insurmountable flaw in this bill, the staggering cut in federal funding. Pennsylvania is facing a 2 billion structural deficit and our budget now. We do not have a balanced budget for this fiscal year three months into it and we do not have the ability to cover the loss of anywhere from 15 dollars billion to other cuts during the next decade. We have two weeks to analyze the bill. It would have a devastating effect on pennsylvanians with coverage through medicaid and the federal exchange. Do not paper over these spending cuts which will increase the number of uninsured under the guise of state flexibility. On behalf of pennsylvanians, children, seniors, individuals with disabilities, i8 i am poor you to return to the bipartisan process the senate was engaged in an craft a compromise bill to stabilize the market and improve our Current System. Thank you. Chair thank you. You. Ann thank this nation has made enormous progress, increasing the number of people who have Health Insurance, and moving health care to a system that provides greater value with lower total cost. But we still have a long way to go. Every Major Health Care provider and Health Care Plan association and Consumer Group from the ama, sue the it to the American Cancer Society and the American Academy of pediatricians have voiced opposition to the proposal. None of these groups would say that there is not a need for ongoing reforms and improvements in our Health Care System. The amendment would pick up backwards in a reckless and dangerous manner and create chaos and uncertainty. Higher premiums and outofpocket costs for many and an increased instability throughout our system. It would also and most significantly take away the Financial Resources and the certainty about those resources that are critical for states to maintain coverage and continue moving forward. As the group of 10 governors republicans and democrats wrote earlier this month, Graham Cassidy is not the answer. We need bipartisan efforts to make health care more affordable for all people including taxpayers. My remarks look at the implications of this proposal and the 73 Million People covered, focusing on three points. It is important to keep in mind that the Graham Cassidy proposal builds on the better care and reconciliation act, the bill that was voted down in july. It imposed deep cuts to the program. E medicare it would have cut medicaid by 700 sieve 756 billion dollars. The cap gets tighter in the out years. From changes to the medicare expansion funding and to the cap on the federal funding for the program. The proposal maintains and deepens the cuts to Medicaid Expansion that were in the bill. Not only would states no longer get the enhanced funding that was provided, that is provided under the aca but under the proposal, states would not get funding at regular match rates to be able to cover low income adults. Imposecassidy would arbitrary caps for virtually every population covered under traditional medicaid. The government would and its commitment to share the full cost of providing coverage for pregnant women, children, out of three children are covered by medicaid and for the disabled and elderly. Six out of 10 is spent for people over 65 and people with disabilities. If congress adopts the proposal it is cutting and capping funding for the very beneficiaries who are supporters of the legislation. 2 as those medicare ought to protect. My second focus is on the block grant that is created in place of the expansion dollars. Lets start with basics. It is a block grant which means the dollars do not grow based on actual cost of care or enrollment. Overall, looking at the version of the bill that was released on september 13, the block grant billion between 2020 and 2026. , the gapare higher between actual need and funding widens. The second basic fact is the funding has been pointed out is timelimited. It reshuffles the deck, allocating dollars not based on need or cost but to the point where everybody gets, every state gets the same level of funding per poor person. You could see it creates a onesizefitsall funding formula. The problem is, onesizefitsall makes little sense. Our analysis in the report attached my testimony is similar to other analyses. 29 states would receive less federal funding than they would under current law with an average reduction of 19 . In 2026, 18 states plus the district of columbia would lose or more of their funding, including six states represented on this committee, delaware, colorado, michigan, new jersey, oregon, and washington. States would see their funding cut by half or more. There would be adjustments but if they remain, how the adjustments would be made to would be left to the secretarys discretion. Adjustments, those have to be budget neutral. Upward adjustments for one state means a downward adjustment for another. The block grant does provide states with rod flexibility. Broad flexibility. Rely onf a state can planned parenthood to provide women with health care services. How many believe that a state that loses one fourth to one half of their funding will be able to replace the lost coverage and to improve in thety and costs marketplace . That kind of flexibility means states will be able to decide which groups of people will not get coverage, which services will not be covered, and how many people will see their premiums and costs go up rather than down. I want to touch briefly on the issue of implementation. Simply stated, it would create chaos in our Health Care System with frightening implications. 23 Million People are projected to receive coverage through the marketplace and the Medicaid Expansion in 2019. I generally 1, 2020, by the terms of this proposal, that coverage and those subsidies will and. It is impossible for states to make plans and have new programs in place by then. Even without considering they will not know how much money they have from yeartoyear or whether they will have any money in 20 in 2027. Let me quote, with respect to justlimitation, it is not impossible, it is delusional. There are no winners in this bill but there are many who will lose and others who will be at grave risk. It is instructive to consider the array of special fixes in this bill. There are many. And they are growing with every version. Softening the blow for one state or another. Whatever else you might think about these special deals for certain states, they do have help us appreciate how flawed the underlying structure of this bill is. Thank you for your time. Chair mr. Woodruff, we will take your testimony. Woodruff thank you. I appreciate the opportunity to speak about the needs of Cancer Patients and their their patients with serious and chronic illness. I would want to say, this committee has a long tradition of bipartisan achievement and workmanlike effort and passing the chip build many years ago, tax was ae tobacco twofer for cancer. I am honored to be here with you be today. One and two men and one in three women are rightmost with cancer in their lifetime. My mother was diagnosed at the age of 48 with breast cancer. Standard treatment was radical mastectomy and massive radiation. She survived and live to be 93 which was a wonderful thing. But she was lucky. For 45 years thereafter, she lived with a preexisting condition. My dad had a good job with insurance that kept her covered until she reached medicare. She was lucky again. My point is until 2010, Cancer Patients and survivors had to be lucky to get coverage and access to care. Those who had to buy on the individual market were priced out of it. Others faced annual lifetime limits on their benefits and many families with cancer faced medical bankruptcy. That all changed with passage of the Affordable Care act. Patients had certainty and stability. They could buy insurance that covered care in a matter their Health Status. Very low income working single men and women for the first time had access to coverage through the medicare expansion. The Current System has flaws. Premiums are too high for some families. 19 states declined to expand medicaid which is left has left over 4 million low income citizens uncovered. That patchwork has revealed what could happen if the Graham Cassidy deal is passed creating a new patchwork of standards in 50 states and Medicare Medicaid and the individual market. The bill would restructure the individual markets and medicaid as others have said. How that would come out and each state is not known. What is known is the proposed cuts to medicare delivered through the brock block grants and per capita caps would and coverage for millions. The mandatory patient protections in current law that explicitly prohibit pricing based on Health Status and the ban on lifetime and annual caps that are tied to the benefits, all of those would become discretionary. Depending on what state you live in, and now, some states could decide not to cover even Preventive Services like Cancer Screenings, routine mammography or colonoscopy. Prevention is the key to cancer, treating cancer, and it is a way to have health care much more expensive if we encourage prevention. I was struck by the comments and statements that were made by mike leavitt during his testimony before the Health Committee. When he was asked about the appropriate balance between federal and state involvement in health care, he said we need to and statenal solutions because without a National Standard that insures adequate and affordable coverage, how do we really make sure that people get the treatment they need when they get sick . As others have said, the billine written into the it is not realistic and not likely feasible. In the words of the state medicaid directors, states will need to develop overall strategies, invest in infrastructure, and systems contracting,tiate etc. This is not a group with a reputation for hyperbole. Worried that the Cancer Society at the Cancer Society for millions if they lose their insurance. Hundreds of billions will be taken out of health care if this bill passes. If the ehb goes away, so will the protection against annual and lifetime caps because caps on tied to the benefits. Insurers could allow plans that dont cover treatment or all the services canter patients Cancer Patients need. The plan may be too expensive for them to afford. Then, they go without coverage and this is what happens. The cancers are discovered later, they are more expensive to treat, they have a lower chance of survival, their medical costs force them into debt, they for girl Preventive Care and Cancer Screenings, and we are right back to where we were seven years ago, with health care. People want stability uncertainty. Our goal is to relieve patients of their fear. Cancer is scary enough but what is frightening is not being able to afford to fight it. The American Cancer Society Cancer Action Network and our affiliate are nonpartisan and we believe the only way to resolve this impasse over Health Care Coverage is a bipartisan solution. We would like to work with the finance Committee Going forward to help you find solutions that improve the current healthcare law, ones that make premiums affordable for all americans who need health care. Thank you again for the opportunity. Thank you, sir. We areteful coming grateful, this is been a great panel. Theyou walk us through changes made to the text posted on your website this morning so we have a clear understanding of the current language . What we found as we introduced the first bill is that the rate of inflation was far higher for the individual market and medicaid market than we anticipated. The rate of inflation did cause a transfer of dollars from those patients, expanded to those who did not. We want equity so no matter where an american lives, they can get the care they need. We didnt want an abrupt change. We did a couple things. We prolonged the glide path to in , so now, equity anchors in 10 years. We capped the amount of money a state could see as an increase to 25 . Mississippi, if it ends up going up dramatically because they are so low now, is capped at 25 per your. They do really well. The folks in mississippi will have more resources to screen and treat for cancer than they do now. Nonetheless, it prevents a dramatic shift for other states. We went, we want around and we look at some states that were just outliers for whatever reason. Hawaii and alaska have federal Poverty Levels that are 1. 5 times that of the other 48. They only get paid by medicaid as if they were the same as the other 48. So for those two states, we corrected the amount they get from medicaid so hawaiians and alaskans will have a more appropriate reimbursement for the cost in their state. We did other things like that in trying to minimize whether it was a blue state or red state, any problem they may have with the new formula. This, mr. Ask you smith. How can the federal government work with states to promote revenue market coverage for lowincome individuals while produced preserving medicaid for the most vulnerable . I think mr. Chairman, states are already experimenting with those strategies now, including arkansas in which elected to have the Medicaid Expansion under the previous administration. We have continued to refine that and develop it, but the reality is, the publicprivate partnerships that we have been finding and medicaid and medicaid for the last 20 years, in which private sector managedcare companies are now delivering a great deal of the services to the medicaid population. In arkansas, the private qualified health plans marketed thehe exchange, 80 of subsidies, the amount of subsidies, are for a medicaid eligible population. Are ini think where we these privatepublic partnerships, they have been underway for 20 years. There is a platform to build them on. Thank you very much. Mr. Chairman, first of all, when this hearing was announced, we set up on our website so we could hear from the American People. Almost 27,000 citizens commented. I want to ask that all emails sent to our site be entered into the record. Thank you. First of all, before i get into my questions come i want to make two points that i think my colleagues are going to act go. Stronglyall, we feel on our side, we ought to be working on a bipartisan basis today. There are two clear opportunities for the senate to do that. The first is the bipartisanship bill, where funding will run out at the end of the week area of the second is working to stabilize the private Insurance Market. That is what we are for on this side of the aisle. We think this process has just been an abomination. We are talking about something that is going to affect millions of americans. We dont have any objective information about what is going to mean to peoples premiums. We dont know what it is going to mean with respect to coverage. We dont know whether the Health Markets will survive in the next year. We ought to have that information. That is what you get if you take the time and the regular order. Senator, let me start with you. You managed to bring together people and organizations in the Health Care Field who rarely agree. I guess, congratulations are in order because they all think what you are talking about is a disaster. They particularly agree that americas Healthcare System is going back into the business of charging folks with preexisting more for Health Insurance. Now, i would like a yes or no answer to this question. The question is, do you continue to believe that the thousands of doctors and hospitals and patient groups who are writing us, saying that you are wrong on preexisting conditions, are you continue to believe as of today, they are wrong . That is a yes or no question. Senat that is begging the answer. If you are in an orange states that didnt expand medicaid, so the patience and hospitals in your state dont get benefits, or missourin maine or florida i asked you for a yes or no answer. I think it is more important to have the right answer. I dont mean to be disrespectful but the tennessee governor says this is a gold mine, a godsend or Something Like that, for tennessee. If you are a doctor or hospital in tennessee or maine, you are so pleased. Mr. Chairman, let the record show that our colleague does not want to answer the question and it appears to me that the revised bill, the one we got this morning, indicates that a state could allow insurers to set higher premiums based on a persons Health Status. Now, what i would like that is not true. Youru are entitled to opinion. Let me just interrupt. I will give you the extra time. I want our colleagues treated with right respect. It is not easy to him to testify on this come although it is because he is a doctor and he understands this probably better than anybody in this room. I was a medical Liability Defense lawyer, so i am not some neophyte here. I have probably passed more Health Care Bills than anybody certainly in the senate. Respect forome senator cassidy. This is not easy for him. The fact that you disagree with him, that is fine. He ought to be able to disagree with you, also. Go ahead. Great of our past chairman, patent when a ham, send anybody is entitled to his own opinion but not his own facts. Hearar about the from the American Cancer Society about the facts. They know about preexisting conditions. What do you think, with respect to this bill and what it will do to people with a cancer fight on their hands . It doesnt protect them. It basically makes the patient protections enacted in the Affordable Care act discretionary on the part of each state. Decide to keep those patient protections are not or not. What is important is, the act created the definition, and National Standard for what is adequate in insurance and what theffordable. With essential Health Benefits, we actually have an assurance that when you buy insurance, it will cover the services you need when you are sick. When you have cancer or any other disease, the essential Health Benefits are there to protect you. Thank you. I want the American People to understand the consequence of that statement. The Cancer Society knows something about what it means for patients to get clobbered by an extraordinary illness. What they have said is, this opens the door to charging those people more. Let me ask one other question if i might, senator cassidy. We are trying to make sense out of all the bills that have been released. Here is the first bill, posted on your website on september 13. Was is the second bill that on senator grahams website. That was on september 13. We got a third version last night, at 7 30. We got a fourth version last night at 7 50. Then, we got a fifth version at 9 23 in the morning. Now, is this bill the one that the United States senate is going to actually be voting on . Because i think the American People would like to know. We are on the cusp, we are on on thisof voting extraordinary piece of legislation. We are trying to sort out what it is people are even going to vote on, little of the fact that we dont know what is going to happen to their premiums. We dont know what is going to happen to their coverage or to individual markets. Is this what we will actually be voting on . A couple things. That is a yes or no question, colleague. Can i Say Something please . I apologize if i was rude. I did not intend to be. The last version was correcting drafting evers. 99. 9 the same, just correcting drafting evers. Drafting errors. The American People should be able to read this and cover had it. Is this the last version . I believe so. There may be a drafting error. I hope that doesnt constitute another version. T is just a drafting error. I would like to highlight, colleagues, we have one of our colleagues, and i want to treat every member of the senate with the opportunity to be heard. We got this at 9 20. I dont think when you are talking about the bill of this magnitude, and our colleague is saying he believed this is the final version, that that is good enough when we are talking about putting at risk millions of americans. Thank you, mr. Chairman. Thank you, senator. Senator grassley. First of all, for the people that introduced this bill, i want to thank you for your leadership, truly improving the Health Care System. The point has been made. I think senator wyden made a part a point about the stakeholders involved in this. They have concerns about it. Those of us in washington know that when all the strong forces speak up, it is to protect the status quo or protect our interests. It isnt about providing Adequate Health care for americans. What i care about is what happens to iowans. Obamacare has failed in iowa. There is only one Company Planning to offer insurance in 2018 in iowa, and that companies premiums are well over 50 increased. People in iowa town me there copays and deductibles on obamacare make it too expensive to use. These are issues that must be addressed today, despite our aioli ideological differences. We are able to discuss a path forward. Dr. Kennedy, if i could have your attention. Does this bill spent more dollars in 2026 in iowa than it does today in medicaid . It does. Obviously, it is not a cut then. Isnt this slowing the rate of growth . It does slow the rate of growth across the country, it does. Does everyone agreed that we need to slow the rate of growth in Health Care Spending . X apparently not everyone, but i would. Way, i would also say i have lawrence from senator wyden, when he previously introduced a medicare bill in which he said at cap on growth serves as a backstop. And the best way to hold down Health Care Cost is to give americans the ability to hire and fire their Insurance Company. The caps on growth have had bipartisan support in the past. Rightstates have the incentives under the current Medicaid Program, matching funds to control costs by coordinating care and fighting fraud . You can empirically say they do not. That is the cost plus program. The more the state spends, the more they get. The only limit is on the ability of the state to support the match. For the American Hospital association, the american middle association, the the american medical association, and aarp endorsed obamacare. Can you say they have a financial interest that does not take into account individuals in iowa . If you look at the stock prices of insurance and pharmaceutical Companies Since obamacare passed, they have done extremely well. Premiums have risen for those who do not get subsidies, and tax outlays have risen for the american citizen. There is a direction a direct relationship between the two. They have done very well under the Affordable Care act. I hope i can have short answers. I want to ask mr. Smith, is medicaid sustainable as current inflation rate . Whether you look at Government Accountability office or the National Association of state budget officers, the answer would be no. Medicaidann. Is sustainable at its current inflation rate . States are working very hard right now and have been to be able to improve their programs, andetter delivery of care, different payment mechanisms that reward value rather than volume. Taking away the foundation of coverage will only make costs grow because people only come in when care is needed, and more expensive. So we need to control the rate of growth, senator, but we need to do that in a way that improves care, rather than takes care away. The same question to miss miller. Is medicaid sustainable at current inflation rates . Dashwood t go ms. At the end of the day, insurance is a reflection of the cost of health care. If we dont have a debate in this country and discussion about how we get at the underlying cost of care, we have a major problem. That is really the debate we should be having of the discussion we should be having. Ok. Thank you very much, mr. Chairman. Where to begin, and i wanted to talk about specific provisions. Thank you for being here. I feel like i need to talk numbers, although this has to be about people, not numbers. Let me just the truth of the matter is, when we cut down the number of people walking into Emergency Rooms that dont have insurance, which is what has happened in michigan, 50 fewer people walking into Emergency Rooms that cant pay, the state of michigan saves money. Our republican governor, working with democrats and republicans in the legislature, did the right thing, made sure that minimumwagee workers could receive health care and take their children to the doctor. What has happened is, we have saved 435 million in taxpayer money because people can go to the doctor instead of using the most expensive way to get health care, which is the emergency room. It camelso say that across, the news that Standard Poors says this bill would cost 2027, 580,000n jobs. That is something we certainly want to look into. I think, i want to take just a moment ago through this whole this,on of whether or not as senator santorum says, is a , or as a modest change ms. Miller said, a staggering cut, because that is a big difference. Sen. Cassidy indicated that, well, it is a block grant. Anator cassidy says it is block grant. Here is the reality. In 10 years, in order to continue the block grant, it for thest 190 billion next year at level funding. The entire health and Human Services budget is, for our billion. 164 if we stop doing Everything Else and education and health and Human Services, you couldnt pay for extending that block grant. It is not believable. It is just not credible. I want to show one other thing. These are the staggering numbers for me in michigan, because the cuts to michigan, when this is only implemented according to sources, is 140 billion. Our governor just signed next years budget. 56 billion. There is no way. There is no way that we will not see Peoples Health care, nursing home care, Childrens Health care, cut as a result of this bill. Let me get into specifics. Let me talk about something near and dear to my heart, and that is under essential benefits, we have said that Maternity Care would be covered. As a result of that, and i do have to say, Maternity Care was a major debate in this committee, as one of the 10 essential Health Benefits, trying to make sure just being a woman wouldnt be a preexisting condition or somehow, women having to pay for more more for a writer if they want to have a child. My staff tells me it was eight years ago today in this committee when a former colleague from arizona and i had a debate backandforth about whether or not we should cover Maternity Care. He said he didnt need it, shouldnt be covered. I reminded him that his mom probably did. Putting it in. Now, here we are. Wehave a situation where could very easily be going back prehealth reform days, when in michigan, only 4 of the plans that a young couple could get on the individual market would cover eternity care. Maternity care. We know from studies that young couples get married and may not be planning on having a child ,or a long time, and whoops more than half the time, there is an unplanned pregnancy. Then, she has a preexisting condition. Prior to the Affordable Care act, she couldnt find any care. We also know that, to get an average covered coverage writer at that time was over 17,000. If you couldnt find coverage, you would be paying from 30,000 50,000 outofpocket. Ms. Miller, i am wondering if you might respond to the issue , and yourty Care Experience as an insurance commissioner. Can you talk about what the individual market looks like for women a few years ago, before maternity coverage was a basic benefit . Senator. U, i think my experience is similar to what you indicated. I think women, before the aca, if they had coverage in the individual market, often they didnt have an option to purchase coverage that included maternity as a benefit. We have a lot of discussions about what should be in the essential Health Benefits package, and this bill obviously gives states a lot of latitude to waive those essential Health Benefits. Where i struggle is, when you start to look at the essential Health Benefits, i dont know which one is not truly essential. Maternity coverage is certainly one of those benefits that, in my mind, is truly essential. I worry that if we go back to the world that we had before the aca, where women couldnt cover Maternity Care, they are left paying out of pocket. Tens of thousands of dollars, if they have a baby. Then, we return to a world where we see people going bankrupt because they simply cant pay for the medical bills that they have. Thank you very much. Thank you, mr. Chairman. The acting presiding chairman recognizes senator roberts. Thank you, mr. Chairman. Fact. The affordable i object. Just kidding, that was a joke. [laughter] thank you, mr. Chairman. With the timer please not count the gentleman from colorados untimely insertion of his remarks . Is about much more than trying to fulfill Campaign Promises, i think. Simply put, the Affordable Care act affordable. It is failing the people some of the very people it promised to help. Insurers have continued to pull out. They are requesting omatic premium increases for next year. Nd kansas premiums have doubled since the law has been effect. If we assume all of the plans that have filed rates and the states sign, the final contract in the next few days, all kansans will have two options of carriers on the exchange. One is on a teacher totter. They mayr totter face premium increases of 29 . When i was back home in the state fair of couple weeks ago, there was nothing but concern and frustration and yes, anger, my constituents over the laws failures and questions and demand as to why we in the senate have not successfully passed reform. I believe we reached bipartisan agreement that the law is not working over in the Health Committee. It has been pointed out, we have held numerous hearings over the past several weeks to review proposals to address premiums and stability in the individual market next year. Unfortunately, many colleagues simply wanted more money to patch the problem, not proposals fatalress the laws flaws. There is another alternative out there, a longtime champion of singlepayer, senator bernie sanders, recommended medicare for all, Government Run Health Care. His proposalced with 16 senators across the aisle endorsing that idea. I am continuing to review the proposal before us from senator ,raham and cassidy and others getting feedback from actuaries in the congressional budget office, and more importantly, kansans. I am positive this proposal before us certainly is better than socialized medicine. Senatory has introducedss many proposals. I think it needs to be repetitive. Switching from an openended entitlement to know what is known as per capita caps. Would you constitute such a reform proposal where Spending Continues to increase every year, every year, as slashing the program . No. Tothe debate has led many believe this is a republicanonly idea. It is not. It was actually something proposed by former president clinton, embraced by former chairman baucas, and senator patty murray and joe biden. Kansans say they estimate medicaid spending in the state to increase 3 per year over the next few years. Senator, what is the growth rate in your proposal . Sen. Cassidy in the traditional block grant, you will go to kansans, kansans will have money for Cancer Screening. In Kansas Committee will go from receiving 2. 9 billion from 2026 under current law. Under our proposal, you would 2026 4. 7 billion from 2020 to provide Cancer Screening and treatment for lower income kansans. Is it fair to say the kansas cap is higher than what they currently spend . Waxy yes, yes. You have the flexibility to do that, as well. Lets go to the yes or no questions. You can cheat on that a little bit. Our dependence up to our dependence up to 26 still allowed to remain on parents plans . Yes. Lets say at state redefines the essential Health Benefits that have been a to ms miller and ms. Mann. Would mandated benefits be in effect or are we looking at the wild west . There is a supposition the governors are not going to take terra people in the state, which underlies all of these questions by some who oppose the bill. I disagree. I think governors want to take care of people in their state. If they apply for a waiver, the statute says the governor must establish that those with preexisting conditions have access to adequate and affordable coverage. If they fail that, there is a provision in which the secretary of hhs can pull dollars back, deny and pull dollars back if they miss the fund by not providing access to adequate, affordable coverage. Senator . Oliver witnesses. Thank you so much for your testimony and your presence today. I have a friend i would like for us to go back to a time we spent in this room debating the Affordable Care act. We did not have one day of your news. We had 97 hearings, around tables, and walkthroughs. 97. The Senate Finance committee did eight days of markup on the legislation. 130 amendments work considered. The folks who run cbl here at whattable told us about the effects would be on our budget of the Affordable Care act word. It and we were told under their score, which they the debtto produce, would be reduced by 130 billion and the second 10 years by one trillion dollars. During the course of the debate, the top labor education committee, some 300 amendments were offered. 160 republican amendments adopted. 25 consecutivet days in session on Health Care Reform. The second longest in the history of our country. We were here for one day of a hearing. One day. Yes my friend how he is doing he says compared to what . How about compared to what. Theparticipated in this last week before the pension committee. They did not just have one meeting. They had four days of hearings. Insurance commissioners, providers, health. Nsurance companies from all over the country. Four days. Those were preceded the each day by roundtables. Bipartisan roundtables were People Like Us who do not serve on the committee can meet with and question the witnesses, including you. That is what we do. This is an unprecedented effort. One of the things i take my had a for and i think our new republican colleagues, one here and when i used to work with on bipartisan welfare reform effort, we i look for a panel of witnesses to be able to unite us. I would say this proposal from 400riends have united some organizations, health care organizations, and groups. Ive never seen a coalition like this in my life. Maybe they are all wrong. Maybe darrell run. They stretch from coasttocoast. Every note and cranny. They say, please do not do this. Slow down. If the pause button. Do what was suggested over and over again which our john mccain asleague also suggested recently as last week. One of the things missing harris obamacare. Where did it come from . It came from really initially from the heritage foundation. They were asked to develop a marketbased alternative to hillary care. Did. Hey it was introduced in the United States senate as legislation by john chafee, republican from rhode island. Cosponsored by two of our colleagues here. The two Senior Republicans on this buddy. Rrin hatch it is called obamacare. Barack obama had nothing to do with its creation. This is a republican invention and frankly, as one democrat, i thought it was a pretty good invention. It is kind of like dr. Frankenstein operating on his patient and trying to fill it. Why dont we ask it . And i say during these the base you participated in, what were some of the good ideas to fix it, that which the republicans created. What are some of the cures . Thank you senator. I think what we heard from commissioners from red and blue states was the president the problem with obamacare are really in the individual market and most of the people in the market of axes to Financial Assistance so the law is working well for the. The people not getting Financial Assistance that it is not working well for. What you for it from all both red or blue is continuing to pay costsharing reductions. Making sure we have an effective mandate. Making sure we get young, Healthy People in the poll and trying to figure out how we can get at the underlying cost of care in china reduces. Those are things i think we can all get behind. There is a path to a bipartisan solution to fix the individual market, which is really where the problems are. Of we all come together we can get there. I think we outlined that in the Health Committee. I was in boston last friday. I spoke to a number of people about romney care, which is based on heritage ideas. I said, how are you doing with basic, 98 of people are covered. The increase in premiums over the last year, 4 . One reason is because they had a healthy mix of people to be insured and a lot of competition in the exchanges. That is what we need to do. We have to fix this. The legislation before us today is not stabilizing the exchanges. It is a big mistake. Thank you. Back to the distinguished senator from ohio. Thank you mr. Chairman. And to my colleague mr. Carper, nobody is more focused on a bipartisan solution then you are. I get that. I will say the experiment in massachusetts is what they wanted to do and with a lot of flexibility they were able to put together a plan that works for them. Their Health Care Costs are also very high. Probably some of the highest in the country but that is how they chose to do it and i think what has been missing a little but in this debate is what this is all about. It is a very different proposal van the proposal we have been looking at previously. This is one reason senator graham and senator cassidy have received tea from conservatives. The cousin takes the funding in the Affordable Care act and it sends it back to the states. It gives the states the flexibility to be able to do it they think its right for their citizens and to be able to more effectively cover low income citizens in those states. Ms. Tally agree with what miller and ms. Mann, democratic witnesses is morning have said in terms of the cost of health care. I would just suggest that one way to get that is to give states flexibility to get at it. We seem to be talking past each that isttle bit but fundamentally what this is about. Yes, there is a change of traditional medicaid as well and we could argue about that. A senator graham said if you do somethingme about medicare and medicaid it takes up the entire budget within 30 years. We have to figure out an entirely different way to get revenue the country if not. Even there, again, there has been some criticism from the right saying this is essentially andng the existing cost continuing them. ,f you look at the per capita that means it increases by population. Annual adjustment by inflation and it is medical inflation and medical inflation plus one. O projects for instance in the blind and disabled category and medicaid is actually slightly less than what these guys are proposing for their per Capita Program in the annual increase in medicaid in that category because it is m and m 1. So it has been mischaracterized. Lets talk about why were here. You all hear it. You have individuals in your are small businesses, families. I got an email from a guy who lost his job and 2009. He finally found a plan that worked for him. The Affordable Care act came in, he lost his plan. He is now paying, according to him, twice as much for a plan for him less benefits and higher deductible. Mike from westlake tells me recently his health care rates to 580om 98 a month up a month. Health care cost was obviously a huge topic in ohio for them. No wonder. , shee from dublin says doesnt have health care at all because under the Affordable Care act her deductible went up to 11,000 for a family. They will never reach the deductible. She says, i dont have health care. Here are the numbers from ohio. We just published the numbers for 2018. 34 increase. The can afford that . These small businesses, what is their answer . Working. S quo is not either way, grew up with their carper said about the csr. Costsaving reforms but a place to put stabilization. If we do that in ohio, Insurance Companies it will be a 23 increase. It helps but it is still totally unacceptable. I guess to you, mr. Smith, because you are one of these experts dealing with this every day, can you explain how this block grant model will help someone i talked about like mike . Or joan . Or other folks in ohio seeing their cost skyrocket under the Affordable Care act . Yes. Thank you, senator. Again, i think that giving the flexibility back to the states, i think we ought to judge what states will do on what they have actually done. Chip, would point out being a very good expression of that where they had tremendous flexibility in defining what the benefit package was. Defining cost sharing, etc. And states put their efforts into competition in good, comprehensive health care and also trying to be as efficient as possible at this. As i pointedk that cbo got the insurance full so vastly wrong because the subsidized old turned out to be somewhat smaller and the medicaid pool turns out to be so much larger. This put those two pulls together and ringing those healthy lives into a larger pool is what will help stabilize. I look forward to a second round of westerns. I will talk more about the formula. We talked about the theory. I continue to have concerns about the formula, dr. Kassie. As you know. Thank you mr. Chairman. Thank you senator. Thank you. Thank you mr. Chairman. I want to thank all the witnesses for being here. I ask consent and i put into the record mr. Chairman letters i received from people in maryland in opposition to this. Without objection, so ordered. I want to point out that the process being used here today, i want to make it clear. We are eight months past the Time Congress Senate Passed the budget that we are now reconciling to with this amendment. We are finished of the debate time on the floor of the United States senate. Weve had no committee markups, no chance for amendments. Ondo not have a cbo score senator cassidys proposal. We know tens of millions of people lose coverage. Premiums will go up. Quality of coverage will go to down. We do know that. I want to concentrate on, set of been made here. Senator cassidy i think correctly identified the problem. We have a problem in the individual marketplace with individuals who are not receiving subsidies. That is all the examples senator portman just gave which fell into that category. My state, believe that is about 1 of the population. That is a significant number. Im not trying to underestimate the problem. Confirmd you just whether the numbers i am talking about are correct . Igs, senator. And when you we estimate that population is between 1 2 of the population. Very small. Very important because they are my coverage on their own, but very small. But the proposal being brought forward will affect tens of brains of people because tens of money the people will lose their coverage. Many will lose the quality of their coverage. We will see a significant Cost Shifting for those who do not have Health Care Coverage. Correctlyi think analyzed, with the states, what you have to do. They will manage to the cap. That is accurate. States have budgets. They have to comply with budget. States that have already shown Great Initiative in Delivery System models to try to bring down costs and make the system ,s costeffective as possible what is left to manage to the factors. Wo major reducing eligibility, cutting people off the medicaid rolls and then, since they no longer have the mandate on the central Health Benefits, it is going to eliminate certain benefits that are currently covered. Are there other options available i do not see . Mrs. Miller . Ok. Legs when you are trying to cut the dollars out of a program are tryingwhen you to get the dollars out of a program like we are doing you only have three levels. Cut the number of people out, reduce services, or reduce payments to providers. Those are really your options. So that a site you managed to the cap. One of the individuals in maryland i was with today, peggy, was talking about her daughter. Epilepsy. She is very concerned. You gave some genetic examples of families that have children disabilities. And how they are going to be at risk because in managing to the cap, they have to limit the amount of services they provide to these high cost individuals. Jerseyad today a new citizen, ellison, who identifies philosophically with prolife. Whose child was born with a rare birth defect. There was not a dry eye in the room as she explained what she is going through. But she said she do at least this nation would take care for child. She would not have to go through bankruptcy. She had a protection that was out there. Notwe in danger are we in danger of losing that protection that we see every person, every child is entitled to make sure benefits are available . Isnt that lost under this proposal . I believe it is. Three through those suffering from opioid addiction. Before Affordable Care act, the state did not cover that. That is certainly at risk as the state manages to the cap. Is that right . That is right. I think was brought up mental parity stays in place but that does not guarantee access to coverage. It requires parity if you have the coverage to begin with but it is not currently going forward. As sen. Carper to doubt, this does not deal with that 1 public. There is nothing to deal with the specific problems that those that are trying to repeal the Affordable Care act continue to monitor. These are relishes whiffed a deal with. Dealing with costsharing, reinsurance, dealing with the mandates. Dealing with the actual problem common not this bill. What we put at risk, well talk about our compassion for those who suffer from cancer. But we know that some of the treatments are pretty expensive. Managing to the cap put a limit on the opportunities of those who are young women with breast cancer. The type of treatments available to them. I think that is what mr. Woodruff is saying it is at risk. Senator. If you have not finished, the head. Absolutely. Ok. Senator scott. Senator scott thank you mr. Chairman. Thank you to the witnesses for being here today to discuss this very important issue. I heard a lot today about stability and certainty in the marketplace. In South Carolina it is a very important issue. In 2014 we had nine and sharers and individual markets. In 2018, we will only have two left in the market and only one in the exchange. On top of the lack of choice in the marketplace, the individual market is saying and individual 27 rate increase in 2017. That does not sound affordable to me. A 27 rate increase and 2017. On top of that, were looking at in 2018. E increase these rate increases are coming right out of the paychecks of the average person incident and South Carolina. Furthermore, the instability in the marketplace is a severe that those who signed up and 2017, out of 100 folks who sign up and 2017, only 69 are still injured. In other words, the stability and the certainty we had hoped for in the aca is missing. It is not missing in the future. It is missing right now. 31 of south carolinians who signed up at the beginning of simply cannot afford to continue the coverage. That is just the exchange relation. But beyond the exchange population, families i spoke with one in somerville whose pace 31,000 whose family pays 31,000 for their insurance. The a in the aca stands for affordable. That is not affordable at all. On top of that, we still have 136,000 South Carolina in trapped in the coverage gap. They are in eligible for any insurance. So when my friends on the other side demonize any effort to take a look at anything other than the aca, lets fix it. They miss the obvious point that for so many people today, the aca is not an option. And yet, my friends celebrate romney care. We are saying, why not pass those decisions to every state to make decisions . If you look at all of the polling information one thing is clear, residents and citizens throughout the entire country say that there local and state politicians have their confidence more thing in their federal politicians. This seems like a nobrain are. To give the money to the states. To provide the very important strong,ity to carve out reliable, Affordable Health care options for their citizens that they see at the walmart, grocery stores, every single night. Based on your experience and expertise, please delve into the issue of state flexibility and how this could create lower premiums and allow more south carolinians to stay on their plan. Two id very much, senator. Again, think that in many respects the states are the ones who understand there are markets. There is no such thing as a national Health Insurance market. Health Insurance Markets are statewide and even below that, they are local. And again, mycms former colleagues who i am the greatest respect for, but to say that they can manage every Single Market across the United States just, again, the examples that you have made show that that is not very well done. We call that hogwash and South Carolina. It to give back the states the flexibility that they have, to be up to make decisions to adopt new tools that are on the surface and in some states, that are trying to lead the way, of helping again to manage to the cap we now have managed Longterm Services and supports models that we did not have previously that we are now partnered with the private sector to be able to manage the highest cost individuals that are out there in the feeforservice world or what we used to call the end for self. Fendhat we used to call for self. Thank you. I am almost out of time here. One must question for my hollies. Two i so much, sir. Sen. Cassidy and to senator cardins point which has to do with opioids. , to senator cardins point, can you talk with us about what to do about those citizens suffering under the weight of opioids . Rag states have the ability to take this money and craft something which is particular for the Opioid Epidemic. Two fit somebody in washington, d. C. , concept of what it looks like but it has to fit into what is needed. Thank you, sir. I wanted to answer the question for senator cardin. On an abandoned. Senator van hollen thank you mr. Chairman. Im not sure where to start. I can tell you this, my republican colleagues will disagree with this. Is bending in his grave at legislation like this. The situation this will create merely to keep it a Campaign Promise of obamacare is a disgrace. The senator was quite incorrect earlier when he said we did not have a partisan process and place. We had the Health Committee. We had a number of hearings but then the Committee Rooms and outside. I think ms. Miller you said there is actually a consensus andeen republicans democrats. As in that correct . That is correct. What we are trying to deal with in a conservative manner was to deal with the individual market, which these folks are talking about having been destabilized. That is to say, they have said it is destabilized. It is in many cases destabilized. That is what were turned to address. Isnt that correct . Is right. Into that 70 of people in and have insurance or less those with subsidies or even far less comments that correct . Is right. I would say all of our politics for the last nine or 10 years about health care been distorted as a result of trying to figure out what the right answer that some percentage, would you agree . Absolutely. Malware at the moment where we have bipartisan consensus on how to do it that 7 and it is snatched away in favor of this partisan effort. Is that request my is right. I will say that. You dont need to agree with that. It is true. Sitting here listening to the comments, the only thing i can come to is that the conclusion that says this is to keep a campaign is to repeal obama care because in the bill we talked about in the Health Committee obamacare would not be repealed. Weit that right . And might have to admit it wasnt actually complete all civic economy takeover. Answer that. E to instead, lebowski dismissed miller, is there anything in this bill were that is responsive to the bipartisan testimony we heard in Health Committee . There is a twoyear Reinsurance Program. I will tell you that is not going to be enough to equalize the market. Is on it in your mind is an expert cumbersome but he who is an insurance commissioner, is there any doubt in your mind that this bill will create massive instability in the private Insurance Market for the 7 of the people that are in that individual market . There is no doubt in my mouth this will create chaos. And you will love that chaos . Because if you do not do it the consensus was with the csr and creating some flexibility and having the mandate or some other idea to have the mandate, you will get instability like you have not seen before. Right . Exit is right. So why are we here, colleagues, making matters worse . It is disgraceful. As all of you said and i will agree there are things in the Affordable Care act that need to be fixed. My view is this on that subject, whether you are for the Affordable Care act or not has a lot to do with whether you supported president obama not. Not exactly because there are people who had preexisting conditions before who are now covered, but it tends to be that way. State isscovered in my whether people support the Affordable Care act or dont, theyre deeply dissatisfied with the way their family intersects with the Health Care System in america. With the way they are small this is his intersect with the Health Care System in america because they know they are having to make choices that nobody else in the industrialized world have to make. Because this congress cannot get a sack together. Right now when we have this issue staring right at us in the notvidual market, we choose to take any of the recommendations that have been made in a partisan way in hearings in the Health Committee and on top of that, we look for an excuse to cut poor people off of medicaid. Do think that about sums it up, mr. Woodruff kretschmer i think it sums it up very well. Ask can i ask you, do work for an Insurance Company . Note. Is the American Cancer Society and insurance complete . Nope. On me and i cannot believe the hypocrisy of people supporting this blog thing theyre fighting against Insurance Companies want what they are doing is stripping hardearned Consumer Protections from the American People. It is a disgrace. We should be going upstairs to the Health Committee continuing the bipartisan work that ms. Miller described and addressing what is a serious problem in South Carolina, and ohio, and and colorado. As somebody who put up for the Affordable Care act, and i still scott or time than mr. Senator cardin, somebody who voted for the Affordable Care act let me say for the record when something comes up and they say to me, michael, because of the bill you voted for i have to buy insurance that is too expensive for my family because i live in a place where there is not enough competition and the prices i. The deductible is too high. That and, when i call and want my insurance for some reason it is never there because they cant have people staying on the phone longer than i can send the phone. You caused the pub. Its a. I say, you know what . Your criticism is exactly right. We should fix it. Now is our opportunity to exit as that of playing politics with the American Peoples Health Care System. Chairman. Thank you. Since mr. Cassidy is on the handle, our tradition is that a panelist cannot question other panelists in the middle of a be mr. So the next will casey. Thank you very much. One of the more compelling pieces of evidence or testimony has been what we offered from folks around the country. Individual states. Sarah has that pile of letters but, we had a series of letters delivered from whichc of pennsylvania over the last couple days, a pretty hefty sum there and then others that went to the finance committee from pennsylvanians and other states. We are grateful for that. I think the processor, even folks who work support of of this republican bill would say that the process is not in any way commensurate with the gravity of the challenge and the scope of this legislation. I would incorporate by reference with senator bennett said his been happening in the Health Committee. Some of the best bipartisan work in health care baby in a decade moving toward a consensus and having for hearings just on those topics. Nowhere near the scope of this bill and yet we had two weeks of hearings, great or partisan work. We should return to that, get that build on and then maybe i issues. E on to other i do not think there is any question when you compare the hearing time either on the finance committee or Health Committee on the Affordable Care act. There is obviously no comparison. Once you get above one hearing of course, you are above where we will be tomorrow in this committee. 11 days of hearings in the finance committee over the course of the consideration of the Affordable Care act. 26 errors on a Health Committee. 147. The healthngs on committee. A stark contrast. Finally, i would say in terms of process we could move in that direction and have a series of hearings on this legislation or any other but i know there is a deadline that some want to meet which i think is not the measure that the bill should be guided by. The september 30 deadline, instead of working over months for a series of hearings. I had a couple of questions that i had just been wondering about. I will throw them out. More statements and questions. What i cannot understand is the accession republicans have on this committee and it seems across the congress against medicaid or the hostility they have to medicaid. I do not understand. It has got me very angry the last couple weeks and months because i care deeply about that program. To the net, protective, strengthen it. It covers more than 27 millions of americans. Kids, seniors getting into Nursing Homes come i dont understand that and i also do not understand what is the big problem with 11 Million People Getting Health Care, and this case through Medicaid Expansion. The balance Getting Health Care through the exchanges. At was that a problem . Why is that wrong . Well out of it when people gain we all benefit when people gain Health Care Coverage. We all benefit and are potentially diminish when they do not. Do we want 11 on people to not have health care . Should that not be considered a do we want 11 million to not have health care . Should that be considered a measure of progress . Senator santorum is here today, i welcome him back to the committee. Does it in our state we have a huge rural population. I spent a lot of time in the month of august going across the state and a lot of those were those rural lts. Counties. Talking to folks there just about the opioid crisis, as commissioner secretary miller and others have said, just that alone is a huge challenge and in several counties they said that god we have Medicaid Expansion. Having the biggest impact on that problem. Not a magic wand, not solving the problem totally but people in pennsylvania getting treatment and services for an opioid addiction problem solely because of Medicaid Expansion. So, i do not understand the obsession with winding down and ultimately getting rid of Medicaid Expansion. So let me get to some questions because i know we have limited time. We will get another route. But i want to start with secretary miller. You testified before the health when you review the work we were doing their and then when you review this legislation, did you find any evidence of the stability proposals we are working on in the Health Committee, did you find any of those in this well, the republican bill we are discussing today . Secretary miller senator, the only provision we discussed i saw this proposal is a Reinsurance Program that lasts for two years but it is not going to be enough to stabilize the market without csr funding. Without repeal of the mandate. Those things are going to seriously destabilize the market in 20 18. Quickly, one to be of seven of time, but secretary miller, pennsylvania expanded medicaid. You understand that better than most. Block grant the medicaid funding in 2018 and eliminated entirely in 2020 some. Can you explain the impact this would have on pennsylvania . Maybe on my second round i will ask miss man who can do that local stamp my. How about a short answer Chris Marquette we do that . People are waiting. That is why i asked for a short answer. I think the effect of these cuts will be devastating to pennsylvanians. The governor has done everything and all of us in the administration have worked very hard to make sure would expand Coverage Access to as many people as we can. Even if you look at the conservative estimates whether were talking about 15 billion or 30 billion was our estimate, any of that range, those cuts are going to have a real impact on people that rely on medicaid for their health care. Thank you. Thinking for indulging. Im for the short time ive been here, we have had an escalation of the amount of time senators are taken. I hope that some of the other people on both sides will reduce their about to make up for the extra time that others have taken. Senator warner. Senator warner probably not. [laughter] senator warner thank you mr. Chairman. Let me make a couple comments and try to get a couple questions and. The sponsors give of this legislation credit for one thing, this is the most ,adical, the most audacious change in our Health Care System i think we have ever addressed. To dotarted as an effort let meth obamacare and add to the voices on the side of the out the will and knowledge there are a lot of things in obamacare that need to be fixed and dealt with. Dramaticed into a program ofion of a medicaid that has existed for more than 60 years. And i am not asking to take some wildid democratic leftleaning liberal group. Let me just take American Enterprise institute, a wellrespected centerright think tank. Their quotation as they go through the analysis, talking to the sponsors and supporters of this legislation, they quote they should be mindful of the Public Perception that the most important piece of Domestic Legislation in many years is being pushed through congress before there is time to fully understand it or raise legitimate questions about it. [indiscernible] Standard Poors, not, again, some wild eyed leftleaning group has come out with an analysis at 3 00 today that their first look at or analysis of the graham nextdy proposal over the swing time would cost our , 240ry 580,000 jobs billion dollars of lost economic activity. Not some wild eyed group. I would say to my colleagues and can i complement those with radical ideas debated. This is a good idea. It would be a good idea three weeks from now after appropriate review. It was a good idea three months ago after we actually got to hear what senator bennett said from the host, not of Insurance Companies but of doctors, hospitals, Disease State advocates. Literally hundreds of people sitting outside this hearing room wanting to add their voices heard. If this is such a great idea, lets take the time to analyze it, review it, and put it through all of the same hoops through. Acare went chances are there might be democratic amendments that would be accepted but no, we are going to this trumped up process to try to get a political scalp before september 30. Someo would say, clearly, of the sponsors, and i have Great Respect for all of them, but none of them have ever been a governor. And i have been governors. We have had responsibility at a state level to try to implement massive programs and changes. Shortgislature meets session. We have a new governor coming up for a fouryear term in virginia unfortunately but we have a new governor come january. Governor, that a new fresh legislature, could redesign a whole health care it, byy model, submit march of 2019 and if this administration could somehow provide a host of waivers isween then and 2020 obviously from somebody who has never run a program or surely never run a state. And again, do not take my word National Association of medicaid director said again, quote, taken together, the per and visionand the block grant would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our countries history. Of quite honestly, if those you for own sponsors of the legislation come i think my state legislatures and governors should weigh in and wife we want to do this kind of process, why would we not invite governors. Lets invite republican governors here to weigh in on this legislation rather than trying to jam it in before some arbitrary deadline and the strattera, will not get to my question because i will try to honor my fiveminute time but after join my colleagues. I believe strongly in a bipartisan process, the guy at the scars to prove it from previous actions where i was willing to take on entitlement reform but this current process is a travesty. Next is senator cantwell followed by senator brown in been senator isakson. Thank you. I was hoping senator hatch would be here. I want to take 30 seconds to say as critical as the stations and i feel it is for a critical, i also view the situation in puerto rico is very critical. I would help our colleagues would work hard to make sure there is a federal fema declaration for all of her ego, every county, and i hope we worked very diligently to encourage the white house to appoint a lead at the white to workerhaps a desire with all federal agencies and coordination. I know sen. Hatch s lot a lot about the Health Care Issue but these are issues that are going to take a long time for us to recover and i hope our colleagues would work to encourage such coordination at the white house level. Thank you. On the subject im having a tough time understanding the overall philosophy of this legislation. I can say that i definitely had town meetings and was encouraged by the fact that senator cassidy wanted flexibility for states. I was encouraged. I think i even mentioned it, that he wanted flexibility. And the reason were not working together now on this legislation is because it is taking the premise of flexibility and turning it on its head as it relates to a program that has been a 52year relationship between the state and federal government. Millionking a 70 population in basically saying, i am going to change the way health care is delivered to you under the ruse that you are trying to address the individual market which is 19 million. 18 million. So, you are trying to say to people, i am fixing that in the individual market when youre not. Premiums and states that expanded medicaid have 7 lower premiums and the individual market and the notion that we should do this because 10 of was line, the 10life of experiment, which i should bring up, your state is the lowest in the nation and per capita benefits in the sense of people youundred serve the last least benefits. What has driven people out of poverty in america is not the way we structured it, it is the ei tc. The snap program. That is what it has helped. So now to take this block grant experiment and say you are going to somehow magically drive down cost and health care, when in reality you are just kicking millions of americans off with them to af pointing decapitated program and then cutting their benefits. So, to me, it is not a panacea for the future. I would love to see oh, by the way, you take the one creative flexible idea that 1331, that, section has allowed 650,000 people in the state of new york to get cheap, Affordable Health care at 500 a premium and crossed that out. So you took one of the most Creative Ideas that will cost new york millions, probably 3 billion 4 billion because you crusted out. So my point is is to ms. Miller, i am pretty sure there are innovative ways in the Affordable Care act to drive down cost. I am pretty sure your state, pennsylvania, to advantage of them. I think you helped expand a program to get people off of nursing home care and into communitybased care. In our state that saved billions. I am pretty sure that will probably save a lot of money in pennsylvania. What about those ideas and drive down the cost of medicaid . Because my colleagues on the other side i think seem to think the only way can cause down the drive of medicaid is cutting people off and i totally agree disagree. In fact, i think the chart that raises the question on role health care is how many people in hospitals in rural america, the nonexpanded states, have seen the most closure several hospitals in america. Why is that . Why is that . Said the notion that somehow we have in the corner of Graham Cassidy figured this out, i just do not believe. So do we have innovation in the Affordable Care act that is driving down cost in the medicare market in the good way and can we push and faster . Thank you senator. I think you are alluding to our Community Health Choices Program where rolling out. I think we all know that seniors and their served communities and i think our governor has made a real push to get people out of Nursing Homes and let them age in their communities. And we also know terms of costume medicaid, it is mandatory in terms of paying for Nursing Home Services but communitybased services are not mandatory and yet moving people out of institutions and and into the community is how were going to save money. Thank you. Thank you. Senator brown, senator isakson , and sen. Cassidy stop thank you. Literally200 on foot thousands of letters and emails my office has gotten over the recently in opposition to this plan. I would like to enter these into the record mr. Chairman. Ok. Without objection. Thank you. I appreciate what senator bennett said a moment ago about the discussion from the other failure of a obamacare. Has been centered on some percent of the market and not even 7 . More like 1 to were not getting subsidies. So the importance of i think it really did answer you know, oft dishonest kind opposition to the Affordable Care act and what is been happening but Something Else was at a moment ago. One of my colleagues said there was a coverage gap of 30,000 people in his stages simply are thegetting insurance and Affordable Care act is not taking care. The fact is his state did not expand medicaid. That is the reason he has the coverage gap, the coverage trap, whatever terms he tends to use. Governor john kasich did in fact expand medicaid. 700,000 people in my state have Health Insurance because the governor did that. 200,000 people right now in ohio are getting opioid treatment because of medicaid. Because of the expansion of this. Something those of us in the committee should not forget. Mr. Cassidy, you sort of answered this question about opioid treatment. I want a more direct answer. Suggests 45 million specially requested from some of this on the committee for opioid addiction treatment. Is there a provision, needing us or no answer, is there a provision in your bill, a similar provision with dollars specifically targeted for opioid treatment . It is in the lexical block grant states to choose. I presume in your state they want. I guess i would take that as another because i quit put the Columbus Dispatch with says generally a very conservative paper, the states secondlargest, this build is not specifically include money to treat the epidemic of opioid addiction. It goes on to say the Study Suggests lawmakers in columbus would have to find millions of new state tax dollars to maintain current levels of health care for people receiving medicaid. I also listen to what governor kasich says who is the republican governor my home state. More than a people in ohio will likely die today if this is a typical day due to an opioid overdose. We tragically lead the nation of the number of people that died. Yearse laws couple because of opioid overdose. Governor kasich the secretary said make no mistake, losing billions of dollars would be devastating to a high was we work to our states must bondable and drug addicted. The only ones who can support this legislation are those not had time to properly assess the damage it would do. As my colleagues pointed out, you certainly, mr. Chairman, and senator hatch on Republican Leadership of document is the time. As senator kays exec, he and i said on the Health Committee. 150 Health Amendments were excepted. That went on for weeks. Abuse why tempt on. You can say the bill is shorter than the affordable air, ok. And deal. But it has to happen allies, we know that. It dont take my word for it. I am at the talbot house meeting with people about opioid tremble. And father sat there with his 31yearold daughter. He turned me a touch on the shoulder and said, she would not be loved of it were not from etiquette. Or the sheriffs, im at with a group of shares in columbus on a training center. They talked about the importance of opioid treatment and other things that they need to do. A woman in youngstown who said her son is getting treatment today because of medicaid. That. W the importance of we know this Graham Cassidy bill does not at all address the issue of medicaid. Opioid treatment paid for four medicaid. My question, ms. Mann and ms. Miller, will states have the tools in your mind to fight the Opioid Epidemic if we adopt this bill . I will start with you, miss man. They will be loosing the Medicaid Expansion dollars. They will be losing even the ability to cover those individuals with regular medicaid matching dollars. So that is a source of incredible important funding and will dry up. It is easy, that is the danger of a block grant to say, not a problem because in fact you can take some money out of the block grant to adjust the opioid crisis. You can take money out of the block grant, you can provide coverage chevron, you can solve all the problems in the muck of place. In fact is a money is not there to be able to do all of those important goals. This miller, will more people past . Graham cassidy is of opioid addiction . Or Something Else . I am concerned they will because i do not think, i do not with thewill have reduced funding, governors are going to have to make very difficult decisions and some of those decisions may be eliminating essential Health Benefits like Substance Abuse treatment and before the aca i think it is worth noting that often times people cannot access Substance Abuse treatment treatment was often a in the individual market that was not covered. Ive set you see in harrisburg and lansing, too, real quickly, mr. Chairman, you took 20 seconds of my time at the beginning so im taking a back and beat out my. You can see in columbus and eris lobbyists forand Nursing Homes fighting with advocates for childrens hospitals fighting with opioid addiction counselors for those declining dollars, the scarce dollars that now art generally available but will not be in those days. Said is exactly the public. I asked you what. Senator isakson, senator mccaskill, senator toomey. To make a point senator casey, yes or no answer. True that you recently cosponsored with a republican legislation to create priority review vouchers for around childhood diseases which two weeks ago the first drug approved under that program was printed now jerseys and type of cancer four years . Is that not true you did that on a i partisan basis . I did add that senator is a good man. Rights to reason as ive been her the whole time, listen to the accusations. Give me yes or no. You always know it is a low because we estimate we do a lot of things together as republicans or democrats that we dont tell the public about. One pisa good news after having the hearing today. Thank you very much. State has 159, my counties. Next year we will only have one oneier and 96 of those hundred 59 counties. Do you have a similar type of decline and available cares for your citizens under the Affordable Care act . Guides sender, for pennsylvania actually we did lose a few carriers but we still have five Insurance Companies in our market. This year at the beginning of the year we heard from all of those carriers that our individual market was stabilizing. 8. 8 . Te filings averaged they wont be back in one week or so would wind up improving rates because of all of the instability coming on washington, d. C. , but of the world stay the way it is today for next year and all of these discussions went away, and pennsylvania we would see a 20 increases. To what do you attribute that . Up there. T we may do to what do you attribute that . The market is stabilizing. Daca included threeyear programs. Threeyear were programs. I think those developed the aca. When you change the world like you do, you change the rules coming at a new population covered it is going to take a few years to stabilize. I think what we size exactly what those drafters of the aca saw after three years. Our market is stabilizing. Arkansas has three carriers. Statewide we hope to attract more. We hope to do that by building on competition. And inducing new service Delivery Systems. An entirelyoping new service Delivery System on the medicaid side of things. Part of my concern is we have gotten bogged down into false choices about you have to cut this or you have to cut that or you have to cut that. If we started doing things smarter, if we started doing things that inject competition entirelyveloping an new form of organized care. And organize care model in which providers are accepting risk. Are the things that invite us to be able to make medicaid sustainable. For the long run for both states and federal government. Differentlyo things and medicaid. It is a false choice to say all you have to do is cut benefits or eligibility. I believe we are demonstrating more ways to do things better that are better for the individual. The people we have been talking about with developmental disabilities, mental illness. Who are the least capable of being able to maneuver through a fee for service system. We are organizing care around them that will keep them out of hospitals. Theut together in 2005 deficit reduction act that included a provision called money follows the person. That was a republican idea to help get people out of institutions back into communities. There are a lot of ideas. I dont think we really talked about any of the ideas we can do to make the program sustainable. To continue to serve people in a manner they choose to be served. Thank you very much. Senator cassidy. Do you remember the date you introduced cassidycollins. What was that date . I dont remember the exact date and i remember approximately what date was at . Two months ago, eight months ago, i dont remember. If you had listened to a lot of questions you wouldve thought it was introduced last week. In fact, your original concept which was cassidycollins was introduced almost a year ago and has been worked on by that. I am a cosponsor of that legislation about six months into the time is that right . Yes. I thank you for your leadership and the opportunity to ask questions mr. Chairman. A yield back. Thank you. Senator mccaskill followed by senator toomey. Este when are mr. Chairman. Let me briefly go through what the s p said this afternoon at 3 00. On insured levels, lower level of entered. On the macroeconomy. This has already been mentioned. 583 thousand lost jobs. Two engine 40 billion in lost economic activity. Ensuring gdp growth remains stuck in low gear of around 2 at best in the next decade. 2 gdp at best in the next decade. Increased flexibility comes with fewer federal dollars. This is not this is the s p. Not snl. Andting increased fiscal operational burdens of the state. Insurance industry. Increased surety in the short term with lack of clarity around costsharing reduction. Aei. I do not typically real out of aei but i read this because it is interesting. I will read too short portions from the American Enterprise institute which typically i would not be on the side of the side with a room typically. Although an important policy goal for republicans is to lower remains in the individual market, Graham Cassidy, like the kcra, is likely to have the opposite effect. Because Graham Cassidy is so complex and farreaching, we believe more time is needed to understand and debate its merit. Legislation would benefit from a traditional markup and committee were serious amendments could be considered. Moving too fast risks significant unintended consequences and public resentment. Now, moving too fast as an example that when i got on a plane this morning i thought i knew what the bill said. I got off the plane, did not say that anymore. An important change, i have not had a chance to read it all, my staff told me this is one of the changes that was made. I have not had a chance to adjust all of them. Now we have lived in terms of legislative history and litigation that will occur around this legislation, i can plenty, inwill have the legislative history in every version of the bill until now the states applied for a waiver. No more way for now. Now, the states just have to give a description of how the state shall maintain access to adequate affordable Health Insurance coverage and i cannot find, senator cassidy, where i put a hand is defined. Is there a Legal Definition of adequate and affordable. Merriamwebster definition says you cant afford as opposed to the premiums in the essay. Excess number question. Is there a definition of either adequate or affordable the bill . Neither is there a definition and. D amd no waiverere is now for essential Health Benefits. You can just weigh them. I mean, you dont have just for permission anymore. The essential benefits are gone. No waiver necessary. Some Maternity Care, Prescription Drug coverage, addiction coverage. I understand you can say, while the state can use the money we giving them to do that but we are asking them to do more with less. So the question i have for you is when the state calls and says, this is what we are going to be able to do and i guess cinema says that is not good enough on the state says, whipped have to have more money to do what we need to do that is it, right . I mean, there is no more money. It is cap. First, missouri has lots more money because you are a known expansion state and youll be treated as if you were an extension states on your state there will be more money. Of a talk about that. You said earlier inherently would assume the governors want to take care of people in their state. I just. Well, ive been painfully watching in my state when the people in charge in Jefferson City who would be in charge of this program made a decision to turn around the lands and billions of dollars that the citizens of missouri were entitled to poor health care. Acting against their and selfinterest because of politics. This bill is it to the. I understand up a you act as if they are always going to do the right thing for their people. A lot of the state said no, we dont even want the federal money. They dont want people at health care. Were going to turn away the federal money to help him with health care. Now you believe all of a sudden there will be a change of heart and he will be stretching every dollar . Why cant we do waivers now . Hides the problem was states were not sure they could afford the match. Ms. Miller has said there would be a problem in pennsylvania with their state aged and that is driven by the 10 match required by the expansion. We waved thats his day to fear they could not cover the match now that the dollars without the match. They get the best of both worlds. They are cutting medicaid providers in my state right now without expanding medicaid. They are cutting providers right now. I understand the status and eight have position because they have a balanced Budget Amendment where they have so many dollars and they can only do so much so i guess this is my final question. There is a 27yearold man. The mandate is gone. Ive been lectured by personal responsibility by friends across the out throughout micro. A 27yearold man can either afford a Health Insurance premium or a harley. P buys the harley. There is no more mandate. He gets on the pavement, if life lighted hospital in kansas city or st. Louis, given millions of dollars of health care because we dont stop them at the emergency room door and say sorry, you did not buy Health Insurance. He is bankrupt and tenements. Who pays that bill . Likes he could be automatically enrolled in insurance. By the way, missouri gets 20 billion more from 20202020 six to get them everybody is going to get insurance if you dont have insurance . You can automatically enrolled if you wish and have that flex ability. Under your bill, nobody has to buy insurance until they shop at the hospital . No. Just like on medicare when you turn 65 you are automatically enrolled, the state could decide that folks who were eligible work automatically enrolled. They might give them a policy with a high deductible will step he is 27years signal. Is states could say you are in the pool if you dont call is were going to i want to see how this works. People can get insurance of they show up. To be followed by senator heller. To mr. Chairman. The recall none of panelists suggested to send her grassley that medicaids growth rate is now on a sustainable path. That has been the case for a long time and it was observed previously to this afternoon heller, grahamcassidy, johnson bill and previous are not the first attempt to restructure medicaid and a way that would put it on a sustainable path. In 1996 the Clinton Administration proposed and a great cap on all decayed and fishery categories and propose further that as those caps would grow at a rate of per capita gdp but not at the rate of medical inflation. Proposed it would go into effect six months from the date it was first proposed. It was supported by the american committee, the chairman of governors, howard dean who raised the idea of caps. The National Association of public hospitals, now known as americas essential husband is, the secretary of health and Human Services donna shillelagh and interestingly, in december of that year every single democratic member of the senate sent a letter to president clinton saying, and i quote, expressed strong support for a per capita cap structure and of court. That would include senator murray, lay high, feinstein, as well as every other democrat senator at the time. It is worth noting that unlike , theassidy graham proposal clinton proposal did not face and over eight years. It phased in and six months. The clinton proposal did not include bonus payments for highquality delivery of care. It did not exclude the medically complex children. All features in the Cassidy Graham bell. Some things have changed since the 1990s. What is happened with medicaid . A group tremendously. It was then less than 6 of the federal budget, now it is 10 . Medicaid is now the single largest net federal expenditure from general revenues. Other have large, medicaid has done. Cbo continues to project it will far exceed the growth of the economy. Despite the fact that republicans have adopted a democratic idea and proposed a democratic idea, we have colleagues are suggesting these ideas are cruel, obscene cuts. That it constitutes a war on medicaid. That it is an attempt to decimate the program. Colleagues, i understand changing your mind. I understand abandoning the reform that your party once unanimously embraced at least at the level of the United States senate. I understand deciding youre not interested in entitlement reform anymore. But when you attack the character and the motives of republicans have proposed your proposal, actually eight gentler and more generous version of the proposal that once had unanimous Democratic Senate support, when you malign the character of us for doing that it diminishes the this message that you so much what to Work Together on a bipartisan basis to get this stuff done. Senator cassie, let me ask you a couple questions of i could. Whiff are about the devastating cuts to medicaid. In what year does medicaid spending and get cut . For almost every state, 20 some. Not because the luck grant is not reauthorize. Chip as always we authorize. Some of these studies claiming 20 2 million insurers assume all of the money goes away and 2020 some. No, because i did the tunnel which states actually, their cost actually inflates to the caps. So they will have 10 years to adjust their health care Delivery System so as to respond to the caps. Mr. Smith, if i understood you correctly the elderly category of medicaid recipients, that category, that per beneficiary cap under this legislation, gross at the rate 14 a numberpi plus of years and then at some point, the growth rate switches to medical cpi. Did i understand you to say that cbo is projecting the actual Cost Increases are projected to be less than the growth in the caps under the Cassidy Graham bell . At is correct. Under their most baseline, recent baseline, yes sir. That allows it to grow at a rate that cbo does not even think were going to reach . Is correct is the is greg get that is a cut . Correct but yet that is a cut . I see. Do ive time for one more question . [laughter] i will save it for the next round. Thank you. This to chairman, i just want to interject that comments notwithstanding from the panel, chip expires this saturday so lets not had ourselves on the back until we actually do that if were going to brag about chip. Mr. Chairman i want to thank you and the Ranking Member for holding this hearing today on Graham Cassidy Heller Johnson and i want to thank my colleagues, senator cassidy and graham for their leadership on this particular proposal. When the senators came to me with an idea that would fundamentally change the way our Health Care System works, when they told me that this plan offered nevada more flexibility and more funding to meet the needs of our patients, i said signing up. Our proposal represents what i set out to do from the very beginning of this Summers Health Care debate and that is to do what is best for the state of nevada. The citizens in our state and across this country. Nevada citizens and americans across the country are facing higher cost and fewer choices under obamacare. As a small Government Conservative i believe in a health careour system needs to be rooted in increased flexibility with the goal of enhancing affordability and access to coverage. A onesizefitsall approach is not the answer. So what is the alternative . To remove washington from the decisionmaking process. Allow a 50 state decision where each state is empowered to do what they think is best on behalf of their patients. Two weeks ago i held a telephone town hall meeting where i heard from a nurse in las vegas who is also a patient advocate. Grahamught up the Cassidy Heller johnson plan and said she is glad people in washington, d. C. , finally get it. She agreed it is essential to Bring Health Care decisions down to the state and local levels to improve the quality of care in this country. Our proposal takes obamacare funding and replaces it with a block grant given annually to states to help individuals care theireir pay for health care. It gives flexibility to innovate in create Health Care Systems that will lower premiums, expand coverage, allow states to serve their medicaid population as they see fit. This proposal represents and presents states with many options for coming up with a tailored approach most appropriate for their citizens. For example, states like the matter that have expanded medicaid can continue serving this population with their block dollars. In because the batter will not be on the hunt for the 10 match required under obamacare in 2020, the state will save 1. 16 billion dollars. As someone who recognizes the increased needs within our states as a result of the states decision to expand medicaid, these provisions are critical. Our proposal also allow states to use up to 20 of their block grant dollars on traditional states withoviding additional flexibility to serve individuals who rely on this program. Understanding that nevada is committed to providing affordable quality care to our patients including the most vulnerable, our proposal allows them to advance sees efforts. For example, nevada can enter arrangements with insurers including managed care providers to continue its commitment to vulnerable patients as well as an sure that nevadans who rely on medicaid have access to services they need. Under this proposal, states can also access additional funding to allow them to address Urgent Health care needs at home. These are just a handful of examples of how states can from this proposal through increased flexibility. We believe our plan is the best path forward to address our Nations Health care challenges. I am grateful to the chairman for allowing this opportunity. A quick question to mr. Cassidy, could an expanded state like nevada use the money to replicate their current Medicaid Expansion system . Absolutely sen. Heller folks say they are losing their Medicaid Expansion dollars but you still get them. If you wish to fund Opioid Services you can find Opioid Services. If you wish to do something good hivecrease transmission of you can. Absolutely. You pegged it. It was mentioned earlier that 40 of obamacare dollars are spent on four states. California, maryland, massachusetts, new york. Onlyu think, and they represent 22 of the population. Do you think this speaks to a equity issue inherent in the Current System . And does. A doctor who worked in louisiana for so long trying to bring to services, the idea that you matteret it equity no where you live you could have access to the same level of support from the federal government and your state does not go bankrupt cousin has to come up with them match the mr. Miller tells us we will have a hard time doing because we wait the match we think we get to where we need to be. Legislation give nevada more dollars with more flexibility . Correct. History chairman thank you. Thank you and i am going to. Witch places thank you mr. Chairman. I think we have heard discussions today about there being, this is going to create chaos. I think it kind of depends on what your definition of chaos is. In my state of south dakota with seen premiums increased by 100. 4 since 2013 in the individual marketplace. We once had 17 carriers, we now have to. Almost half of the curious in america are going to have one. One option when it comes to buying in the exchanges in the individual marketplace. That seems like the very definition of chaos. I think what the gentleman from louisiana and his colleagues are trying to do is to try to bring some order to that chaos. I thought the senator from pennsylvania covered very well caps. Story of per capita ive also heard some of my colleagues talk about how radical some of these ideas are. So radical that president bill clinton and congressional in 1996. Oppose this per capita caps. Love grants to greats, something talked about for a long time. Been successful on some level. In terms of complication of this bill, this bill in its current form is one hundred 46 pages long. 146 pages. Obamacare was 2700 pages. I think this is a very good faith effort to try and solve a problem well know has to be solved and that as we have an individual market in freefall. I give great credit to the sponsors of this bill for trying to fix his problem and trying to limited some of the ks that exists in the individual marketplace today and to try to reform a program we all know is unsustainable. So dr. Cassidy, your proposal has been developed based on feedback from openers, correct . Correct. 15 governors have signed a letter of support. 18, sorry. It would be my belief and i cannot imagine it will shared by most of the people on this panel that there are going to be some unique needs and individual states. Everybody has different population. The assumption of obamacare is the onesizefitsall approach is best. Well know that does not work. Our cost, higher taxes, fewer options. That is the legacy of what we have. Why not try Something Different . Something that has been implemented in the past with welfare reform. My question is based on the conversation ship had with some of these governors, how do you expect states to use their block grant dollars and their ability to way certain regulations based on the feedback you are getting from governors . Writes the governors are excited about. They see this as the ability to implement change tailored for their state as opposed to onesizefitsall. Mr. Smith spoke about a couple things. Arkansas has been very innovative but if you have an unstable and fragile market because there are too few people forhe individual market actuarial stability, you can combine that with your Medicaid Expansion population. The bigger pool providing stability for the older and sicker. Premiums could go down by as much as 20 . You can also do it main did care act affordable will them to shut down the socalled invisible high risk for where there is reinsurance. The patient is not even know it exists. They stopped the Care Management from the entrance company but just that itself, according to Susan Collins who it knows insurance so well, lowered premiums by 20 . This miller kept speaking as if there are only three ways to lower cost. She is absolutely wrong. You can put in policies. In maryland, there is such market concentration of hospitals. Theres no competition. Hospitals charge very high rates. If you started to go after market concentration you could lower the Health Care Cost because market has attrition leads to higher cost. I could go on but the governors who are creative can think of all sorts of things. And very quickly, mr. Smith you read past papers about the need for maintaining flexibility. How do you think the proposal under consideration will accomplish that goal in individual marketplace and in medicaid . I think it gives the greatest flexibility of all to answer so many different questions. Sen. Mccaskill up an individual sen. Mccaskill brought up an individual situation. Those hospitals are eating the cost. Under this proposal, a state could use those findings to say, i am going to pay directly for the cost of that care for someone who did not get injured. So the flexibility within this block grant is really what the voters have been looking for for a very long time. The other thing to remember about the Medicaid Expansion and why some states do not take it was because they were required to go all the way to 138 of poverty and stead of a state could say we will expand medicaid to 100 of poverty and because that is the Poverty Level and medicaid is for people in poverty. Some states, if they would have to go all the way to 138, would have taken people who were in the private sector paying for insurance on their own, taking them out of coverage and putting them into medicaid. So the medicaid issue is far we justcated than did not want to expand. States if they wouldve had that ability at the more states would have expanded to 100 . Thank you mr. Chairman. Thank you. Next the senator ramsey. Chairman. Mr. Senator santorum. This has to seem like deja vu to you. You were here when we did the welfare reform act and i am pretty sure that the comments you are hearing here, as i remember, are the same kind of comments we heard about doing that reform. That there is an assault on the poor that leads to rapid poverty. Death of thousands of not millions overtime. How did that work out . Welfare rolls, once they block grant was deployed, welfare rolls dropped 50 . I remind everybody we gave the tanif had broad support that was not helping welfare. Ansition off we went to a different system supported by the Ranking Member. One of the 23 democrats who voted for this bill. The only one said it did not cut enough benefits and spending. We had senator complaints on this bill. Not only did was go down 50 , i say this all the time, that wouldve been a failure if that was a result and that was it like it when up and went up dramatically. Poverty went down, and went down dramatically. States took advantage of this. You will see this of this bill is successful, some states will do a terrific job in developing Innovative Solutions to provide great quality care. Wisconsin dropped their roles by 93 . Still has an Incredible Program of transitioning people from poverty, from welfare to work. But the innovation that has been copied is even in maine recently. Governor lepage. Took him 20 years to do it but it had very strong results. There will be a lag result in some states, maybe some inequity but a craze competition and the opportunity for states to learn from the innovation of other states. Thank you. I will have some written questions for you, too, because you have a wealth of knowledge on this and have actually spent more time on this building and a , notf other people including of course senator cassidy or senator graham and others but you have got some history to back it up so mr. Smith, what kind of delivery intem could a state engaged with this block grant approach . What would they be able to do one impact to the cost the drive up premiums . In wyoming were looking at a 48 increase. Were not an expansion state. The state did not trust federal government to come through their promises said they have stayed conservative and all of these things had been serving people . Ut what could be done thank you senator. All talk about insurance, at the heart of the you are talking about risk. And who you spread the risk across. We have talked about the per capita cap, will the states be willing to accept that risk . They are willing to accept it when they are able to innovate and have greater waves of serving people differently than the way they are doing today. But there was also a risk to the states of a strategy that the federal dollars will always get bigger and bigger and there is no end to the federal governments contribution. That is also a risk and a lot of states were not willing to take that risk because it is unsustainable for the federal government as well as for the states. The innovation that can be done, and i mentioned that we are introducing a new type of organized care for people with the highest cost that we can target to individuals with severe mental illness, to put coordinated care around them, to take them to some extent off the books. So the state manages their care directly. There have been different concepts about, sharing the risks of reinsurance or the old pools, theyols are always putting more money into the Health Care System is off to absorb that risk and there are different ways to share the risk, to help bring down the premiums as well. West thank you. I have reached my time. A final comment, this would not be the last bill to be done on health care, it might be one of the first for encouraging changes, but i have been at those hearings, that are progressive in a bipartisan way and i hope they continue. Senator wyden . Sen. Wyden i think [indiscernible] mr. Chairman, i am sorry to interrupt. Four purposes of the senator, i will wonder if you could tell us what the speaking order is . If i could, and i think the indulgence of acting chairman. After senator nelson a wouldbe chairman hatch, myself, senator grassley, roberts, harper, it, kc cott, then warner andnnett, mccaskill. We do have an agreement with chairman hatch that editors get to ask all of their questions. So, he is going to vote and come back and i will go and vote after that. We will just keep the going. Actually, i think we will take a 15 minute recess that everybody can vote. That is fine on our side. Alright, i will be quick. Most of you know i have been dealing with the aftermath of a hurricane, not only are we facing that down in puerto rico and the Virgin Islands, they are in very tough shape. The Medicaid Program is one that is particularly important to hurricane recovery efforts. As it is currently structured, medicaid can risk on to Public Health emergencies and Natural Disasters. As the needs go up, whether it is because people become eligible or because they have lost their jobs or their homes, or the other Health Care Needs grow, federal funding goes up automatically in response. Us ise bill in front of of great concern. It is problematic that it does not provide states with sufficient funding to respond to Natural Disasters like hurricanes. Provides a fixed amount of funding, and the medicaid per capita ar cap provides a fixed amount per beneficiary. So, you can see what would happen if people need Health Care Coverage and the costs are rising on a per beneficiary basis. And then, what about in the bill, the Public Health exclusion, the expenditure exclusion from the cap . Well, of course, we have had three hurricanes in a matter of a few weeks, not to mention the , theng Opioid Epidemic presence of the zika virus. The bill got the Medicaid Program and therefore cuts hundreds and billions in support. To pregnant women, to low income adults, and children over time. Capita cap byer 5 billion, in total for 50 states, over a fiveyear. Over anot adequate fiveyear timeframe is simply not adequate especially when the decision to grant the exception is left entirely to the secretary. Public Health Emergencies are going to continue. And that exemption does not do anything for the greater medicaid needs after a Natural Disaster like these hurricanes. That thennes bill assumes that states have resources on their own to draw down on federal funding and that they are not using that money to plug other holes in the disaster. And i am telling you right now, my state is trying to get every dollar that it can in help from the federal government. Look at Hurricane Katrina back in 2005. Access to billion dollars 2 billion. 5 billion in 50 states over five years, is simply not enough. I am really worried, not just about my own as i mentioned, puerto rico and the Virgin Islands as well. Their Medicaid Programs are already subject to a block grant. And itt adjust, will not adjust if there were a Natural Disaster, and now, their needs are huge. But, i am afraid that is what the bill in front of us wants to accomplish, subjecting the rest of the countrys Medicaid Programs to the same rigid, inflexible flawed, financing structure. Mr. Chairman, i know we have to go in vote, so i will stop right there. Cannot entrust some of those issues though . After he gets through with the recess, sure. Let us go and vote. A recess for 15 minutes. Gavel]