People listen for more than three minutes is great been talking to a group for whom this really does matter and can make a difference. The question for the title is medicaid did it survive repealed and replaced . The short answer is yes question mark . Now we do questions and answers. [laughter] obviously it has been a interesting year and you had a great session right before this talking about the political angles but it is safe to say we havent ever program asicaid much in the spotlight in the hot seat as we have had over the past year. We certainly expected that that, thinking again about our conference on election day it was a small election day this year with the gubernatorial races. And thee result last year laid out a pretty clear plan for what congress will address in terms of health carere reform and how that impacts medicaid there were two themes and threads of that with repealed and replaced of the Affordable Care act which despite the attention with a focus of premiums and individual mandateses the Affordable Care act is mostly medicaid at least 50 if you think how muchto money from the cbo, if we can still trust them how much they spent literally half of that was medicaid so that is a big component of the debate. The other component was a totally unrelated discussion around the entitlement reform and medicaid financial reform including whether not to take that openended nature of the medicaided program the federal Financing Partnership to convert that to the percapitae and we all saw how that plays out with a dramatic john mccain from the passing the that doesnt mean any of these discussions, or certainly congress is now turning to the tax reform and we will see how that plays out but the impetus, political, fiscal desires to continue to make those changes whether to aca or medicaid in you heard from the last session how that plays out and what the numbers look like is still uncertain but this isnt the time to say it is all behind on something else. Of a bike to relate to what we focused on so by and largeos, mostly we have remained on the sidelines of a lot of the debates should be repealed the aca or block grant or protect and cap the medicaid l program . That is generally above the pay grade of the state medicaid director. So we tried to do is take that opportunity to educate and inform people so this is a lifelongy journey. Because anything that i have noticed anny almost 25 years is that medicaid has say pretty significant depreciation with Public Policy makers and h unfortunately along the general public as well. Said he would not be shocked if he were to walk away from the debate happening around medicaid and what does that reform looks like we would be blamed for thinking it is the Health Policy program there for low income working a adults to make up the majority of the spending we decided to say that isnt exactly true. I wont throw up graphs or charts for data but some figures to put in context context, medicaid is a big program in his then that way quietly not a lot of people appreciate how much it does covering more than 70 million americans larger than medicare 600 billion combined state andnd federal a very big program 25 of the average date budget but if you peel back what is underneath this . Were they spend their money is what surprises people that is important to impart on the Public Policy makers think where do we spend our money . Between 35 and 40 of all medicaid spending is spent on Medicare Beneficiaries number continues to shock and stunned people largely as a result medicare is a big program serving a lot of people but the problem is for low income or for real seniors in people with disabilities on medicare, doesnt really give them and it has limits on acutecare, a Mental Health and requires a lot of outofpocket copays and premiums and deductibles. Just for a small group called the dual eligibles. Keep in mind medicaid does not do lynch longterm care. My grandma is in a nursing home medicare covers that . In all likelihood know. Is medicaid. Said about 40 of medicaid spending is on the Medicare Beneficiaries the additional 20 is on younger adults and kids with a variety of disabilitieses developmental they are not onf medicare they require services and longterm care. 20 percent of talk about is kids keep in mind in addition to being the longterm care c program medicate also covers almost 50 percent of all births in the country. If youre a fan of west side story. But go back to those numbers 35 percent, another 20 20 , another 20 that is over 75 percent of medicaid spendingil on those who will never be in the workforce. Think about big ticket items and major changes, lydia understand where the g actual dollars go because it is untrue that people will understandd that so we try to educate and it has made a difference we had a session ever annual conference a couple days ago where we had some Health Journalists talking from recapping 2017 and they were remarking we really didnt expect medicaid advocates and beneficiaries to place such ennoble in the conversationon and that is a good thing at the end of the day. Three p. O. And replace never quite got over that threshold that conversation will continue but we want to see that ability to focus on the good it is doing and has done and can do because that is the focus of the states and medicaid directors for years and will continue to be the focus for years to come. So people ask me represent all the states and territories . Isnt that like herding cats . The answer is a little bit yes. Vermont, california, indiana are all very different states. Quite honestly the easy thing for me there are a lot of strong threads and commonality is what they are trying to do with medicaid so i could boiled this down to a simple Bumper Sticker slogan of what medicaid is really trying tord do in every state but quite frankly it is moving away from feeforservice so that means Different Things in different states. But if i looked at the bread , to efforts, one on the delivery and another on the payment incentive to move away from the unmanaged and uncoordinated feeforservice birkenau my old friend dennis to rand medicaid at the federal level likes to joke that feeforservice should stand for fend for self because really that is what requires of people who have multiple chronic conditions than those homelessness issues. So i am pretty healthy. I dont know if i need my care managed but i am not driving the health care system. Its peoples whose health care conditions the 1 of population drives 25 of spending. So what we see from state to state is the half to get away. Medicaid and medicare has way for a long time. Medicaid for much of the past 50 years has been a passive and bill payer now we are now active purchaser of Health Working with everybody in the system plans, a Physician Groups groups, hospitals, Nursing Homes, patience to figure out how to redesign the system of care built around the individual . To be somebodys eyes in the years and teeth and breed with four different ports of the body that all of this part of the whole. And i think we just saw some statistics that said for the firsttime ever more than 50 of all medicaid spending now is in the payment arrangement certainly much more than 50 percent of the people. Is this all traditional managedcare . No. Yes we have bigpr for a profit groups we have smaller Mission Driven but there are a lot of other things that our more suited to the individual states markets and demographics so what goes on in massachusetts . Boston is big. Big hospital systems. Arkansas not a lot of managedcare but they are developing patient centered models to do the same thing. Even in states that really dont have managed care to speak id like connecticut they drive contracting out those plans theyre small enough for sophisticated enough we just pay the middle man and we can do that are self with a managed feeforservice. Look in the Mountain West where i have run into medicaid directors who have no managed care to speak of that conference is vice they were you doing here . Im learning so i can apply that myself directly. So the way its done almost doesnt matter but what really matters is what were moving away from. File is hesitate to say managedcare because it is imagesgi but when i say that really talking about more of what it is not but again something of that historical past and what we need to move beyond but it is in just enough to change the Delivery System fake states like arizona 100 percent capitated managed care ever since theyve had medicaid the longest experience with any kind of arrangement with the sophisticated contractors but even a couple of years ago they looked and said water the plants doing with the money we give to them . There is a provider fee for service under that that is not managed care either. So they embarked on the aggressive effort to say overtime we will have significant portions of that half to slowdown with a value based arrangement some kind of shared savings arrangement in the sea that across the country as well in arizona and tennessee and ohio and arkansas if you think of this from the perspective to figure out how to change that fundamental underlying for initial incentives is kind id like herding cats. If medicaid says to the physicians and dentists and hospitals and everybody else to move away from feeforservice we are hurting 18 of the nations economy. Of course, the secret answer have you heard cats . You move the food. So the food is the money in this case. There is a great story coming out of arkansas a couple years ago where they tried to pioneer the shared savings approach so they talk to their primary care physicians in the state the vast majority were wonder to packages across the state they had a pie chart of Health Care Spending. D. C. These pieces . This big one is hospitals 35 percent of all Health Care Spending this big one Nursing Homes 30 . Your piece 2 . Is tiny. But we are composite we enabled a system where we dont pay you to do the right thing. This is the fundamental nature of this conversation which is we have to acknowledge medicaid and medicare in the markets have built up over time inefficiently and in ways that the financial incentives simply do not align with what we Want Health Care to do. At the end of the day what we want it to do is to get people healthy and keep them that way hopefully that is not too radical but the challenges in the feeforservice model, we dont pay anyone to get and keep people healthy in fact, when they do, what happens . They tend not to go to the hospital for coming in for services. So people are paid less or not at all so we have to figure out a way to break through that to say we have to figure out a way to pay you more when you do something that matters to get people healthy. That is where you should be hitting the sweet spot so the approach is not different from others but it was the shared savings model. Precontract your patience in these various categories or conditions we know what they spent absent any radical change with delivery of care and if at the end of the year the actual spending is less, then we will give you half. Sova this was a huge watershed moment that could really change incentives in the Business Model. End that is the key so in order for this to work for the managedcare and the pavement incentive we have to figure out how to make those changes attractive and accessible and sustainable and that is the process because not only do you have to communicate why that Current System is no good to recognize people and spent decades building a Business Model and Profit Margins and their practice around financial incentives. So you have to communicate why the Current System must change. But also articulate what is it you want to do . Feeforservice is not a good water rigo into . It is more than that. How would you hold their hand to make sure they transition from the bed the business bottle model 82 Business Model b can be done . Maybe that is easier with a big Physician Group for hospital practice and it to person group in arkansas but you have to focus on the practice transformation and show people how to get there it helps them with the tools that they need to get there. What type of hardware or software . How do you think differently . So many people said how do you expect us to make this work . My patients come in in prison symptoms and i diagnose them and they go out the door. Are they following my plan of care taking their beds or engaging in their therapy . Reverting back to unsafe behaviors or activities . Hot dogs for lunch every single day. Now the social worker looked at them shall we get a nutritionist nutritionist . We have to get on this system and they sort of thought about it and said no, no, 89 had a hotdog every day for her whole life. Thats not the problem. In fact maybe thats whats keeping her alive. What is the actual problem and again this is something you would never know unless you had those boots on the ground. She watches this woman cooking a hotdog. She is cooking it on a frying pan on the stove. The only way she can do it is shes fourfoot 10 inches. And shes watching this and shes like i see how. Theres a knock at the door and a dog working in the phone ringing a momentary distraction to see this woman while she is cooking the hotdog. A trip to the hospital and er hospital stay inpatient maybe some rehab therapy. 30,000 maybe shes back home. We dont want to do that. Go down to walmart, by a microwave oven, install it in her house and show her how to use it. Boom. We are going to bill it or charge it but we know that 80 investment is not going to guarantee something doesnt happen. If youre thinking about, they are getting paid the same amount if this woman has a 30,000 dollars adventure or not. That kind of investment makes sense. We are seeing that everywhere. We are seeing that with the individual who is in the hospital, the er, 200 times a year. Shes homeless. Currently costing the system 300,000. Year. If you just invest a little bit and subsidize housing, you will never see that guy again. Again, medicaid will pay for housing, no. This creates larger challenges because we had to figure out how we can pay for this and who will put the seed money up. Who will make the investment in the microwave oven, in paying for utility bills. The seniors who live in a highrise, people who have a three 100 higher chance for going to the hospitals for copd because the air conditioner doesnt work. There is a lot of work that has to be done to figure out how we pay for this. There is another issue at play here. We continue to struggle with highlevel questions around what is the proper role for government for healthcare in this country . We dont have an answer. These are very thorny issues. I think back to four or five years ago to the last election. There was this hubbub over the obama bone. Turns out the administration, president obama was given away free cell phones to poor people in order to buy their votes. Thats pretty outrageous. He got a lot of criticism. Again when you dig deeper, you realize it was actually a bush era program. The push was to get cell phones to lowincome people so they could have regular access to their primary care physician or be able to call into a work situation, but almost didnt matter because the optics of it were governments not doing something thats critical for people, its doing something that is a luxury. As taxpayers look at that they say i dont have a cell phone, i work hard, i make sacrifices, whats going on over here. As we move forward in a lot of these areas, i think part of our challenge will be how do we maintain the political and the optical sustainability of some of these policies. There is no question that an individual, if you make these investments in housing or Food Security or microwave ovens, you can make a big difference. That turns into government giving away free apartments or whatever, that becomes harder to sell. I think one of the really important things we are seeing is that based on the debate over the past year, there is not a really Strong Political constituency for medicaid in congress. Just enough to not do repeal and replace by a vote at midnight, and when there isnt a really Strong Political constituency in congress, its really important to have a Strong Political constituency for medicaid at the state level. That is one of the things that we are addressing now. I mentioned we had our annual meeting a couple years ago. They talked a lot about what the new administrations priorities were going to be around medicaid and around thinking about how too do some things differently. It was a message that, a large group of people, some people agreed with, some people disagreed, but i think i would argue that if you think about it from the perspective of clearly sending the signal that they are going to be open to thinking about it in a different way in terms of work requirement and lifetime limits or other types of personal responsibility or community engagement. Collectively i dont think our members have a clear answer to that. Some will love it, some will hate it, some will say thats fine for you to do it but dont make me do it, but i do think its important that we strengthen the ability or we strengthen the political community. Who has been the most vocal, vibrant, eloquent, passionate defender of the Medicaid Expansion or medicaid in general . It was john kasich in ohio. He took it and said medicaid is how i am fixing a huge problem in my state, the opioid crisis. He is a strong proponent of a job at being the best social program, but is also cognizant that if you cant get a job because you cant pass a drug test, those are just words. Hit. His advocacy was critical. I firmly believe, if we had, over the past couple of years been more flexible in how certains dates wanted to approach Medicaid Expansion, keep in mind we have 31 states who have done it and another 20 including d. C. And put maine aside for a second who havent, if we had gotten more states who had done the expansion, im not sure we would be having the same debate over the past year. I know theres a heated debate on things like work requirements and Health Savings accounts and other approaches, but what i say to folks is dont have that debate in an ivory tower. You have to have that debate where it matters where that matters is that the state house. Think about indiana and arkansa arkansas. They did very different approaches to medicaid expansio expansion. They say those arent as good as regular medicaid, you shouldnt do that. It was never a question of should they do Medicaid Expansion or should they do the different thing, it was should they do this different thing or do nothing. Thats where so many of these other states are. I think its important, as we are moving forward in working with cns to forge a new state federal partnership, its got to do two things. It has to strengthen and empower states to make the reform that are necessary and which will look different in one state versus the next, but also acknowledge that a key component of this is going to be that Delivery System reform and that payment reform. I dont know what the future is, but i do know that if we take our foot off the pedal of making the move, making the investment in value based purchasing and system redesign , we will squander best opportunity weve ever had to really fundamentally address the underlying cost drivers of healthcare and not just the fig leaf that people see around your insurance premiums or whatever. We have got to figure out what those underlying cost drivers are and we have to be bold and aggressive about dealing with it. We have to be realistic and rational about it too because at the end of day, if you try to cram something through, if you force reform down unwilling throats, they wont be sustainable. If you say to physicians or any group out there, medicaid is doing this and ohios doing one thing and arizonas doing one thing, on medicares doing that and the commercial markets are doing that thing over there, then youre not saying to people its time to change a Business Model, youre saying is time to change her Business Model five general ways. Thats probably not sustainable either. We have to figure out a balance of being able to approach these in a thoughtful way and keep them sustainable. I heard someone describe leadership once as the ability to disappoint people at a rate they can sustain. I truly believe thes this is our opportunity to be leaders in the sense that we are not doing things that are easy. We recognize that system transformation and payment reform is, and in the words of my board chairman, the hardest thing ive ever done in my professional life. We know these things are hard, but we need to do them and we need to do them in a Sustainable Way because these are the lives of the people we serve that are in the balance. I hope we can Work Together on a lot of that. I dont know if i have any time left for q a, but if there is, i would love to take it. Thank you very much. We are at time. Thank you very much. I appreciate your comments. Satt noon eastern on book tv. Next a hearing on military caregivers. We have testimony from former senator Elizabeth Dole and actor director brian filby. This is two hours ten minutes