Transcripts For CSPAN3 Hearing Focuses On Childrens Health Insurance Program 20170908

Of Hurricane Harvey in our thoughts and prayers as well. These have truly been horrific events, and i hope and pray for the safety of everyone involved. I join with my colleagues in the commitment to doing all we can to assist our citizens who are in need at this extremely difficult time. We will see what we can do to help alleviate some of the pain. Now, the hearing were having today will come to order. 20 years ago senator ted kennedy and i came together to create the Childrens Health Insurance Program, or chip, in order to provide Health Corner for Vulnerable Children and family who were too poor to afford private coverage but still didnt qualify for medicaid. 20 years ago we were at something of a crossroads. The year before c. H. I. P. Was signed into law a rep Congress Passed and a democratic president signed a welfare reform bill which ended the entitlement to cash welfare. Welfare reform sought to replace a culture of dependency with an emphasis on work. The emphasis was to move families off assistance and towards selfsu fifficiency. C. H. I. P. Was intended to help families. Senator kennedy and i worked in good faith for months to craft c. H. I. P. While neither of us got everything we wanted, the result was a dedicated funding stream for the program to help low income families get good, reliable Health Insurance. From the outset, it was a program that was bipartisan and continues to enjoy bipartisan support throughout the country, and i might add in congress. While it isnt perfect and while in my view some of the changes to the program have been regrettable, i believe that overall people consider it to be a success. Current lay provides federal c. H. I. P. Funding through the end of fiscal year 2017. According to the Congressional Research service, if congress doesnt act to provide additional federal funding a number of children who would likely be eligible for c. H. I. P. Will go uninsured once federal funding is exhausted. Additionally, an action by congress with regard to c. H. I. P. Would cause another layer of unpredictability and anxiety for states that have to administer the program. Of course, this anxiety will pale in comparison to what families who rely on chip will be faced if congress dont act. As we contemplate the future of the chip program there are thresholds we need to consider. The basic question is does the Committee Want to reauthorize or mealy extend chip. Reauthorization would entail more extensive debate and consideration of potential policy changes for the underlying program. As many of you know, in 2015 congressman fred upton, who was then chairman of the house energy and commerce committee, and i put forward a number of substantive policy recommendations for reforming c. H. I. P. While some policy changes are in order for the program, but we need to give full consideration to c. H. I. P reform prior to the expiration of federal funding at the end of this fiscal year. With these concerns in mind someone suggested instead of reauthorizing the entire program we act to extend c. H. I. P funding. Of course, that option comes with its own set of questions. For example, we will need to determine the appropriate length for the extension and whether to continue with the 23 increase in federal matching for c. H. I. P provided under the Affordable Care act and extended in 2015. I know some of our members have strong feelings about both of these questions. These are not particularly complicated issues but they will require some deliberation among members of the committee. Long story short, we have some difficult questions ahead of us. Whether we opt to reopen c. H. I. P to reforms or simply provide another extension, the committee will need to address significant time and effort to find answers to these questions. Today we will continue our discussion of these matters as we hear from witnesses who will testify to the importance of c. H. I. P and the need for it to continue. I hope members will listen carefully to these witnesses concerned with their states and let me know how they would prefer to proceed with regard to c. H. I. P. I look forward to working on a bipartisan basis with my good Ranking Member senator wyden and all of the members of the Senate Finance committee to move forward on a bipartisanship bill. With that, let me now turn to my good friend senator warner for his opening remarks. Thank you very much, mr. Chairman. I want as we start this extraordinarily important effort, mr. Chairman, to note your history with senator kennedy. The fact is it was that bipartisan partnership that got this program off the ground. It significantly reduced the number of uninsured kids in america. Were very appreciative that you set this in motion, and i and i know all of the members on our side very much look forward to working with you to make sure that we get this reauthorized and done quickly. Thank you, senator. Colleagues, you know, the fact is it would be easy for those who are casual observers of political news to get lost right now in whats going on in washington d. C. Theres an awful lot of washington lingo thats justin comprehensible to people. Theres the continuing resolution, the debt ceiling, csr payment, cost sharing, nbaa that is the defense fact and i think all of us could go on and on with others. Today were talking about the Childrens Health Insurance Program, c. H. I. P. It is the only health bill with a time stamp on it. The program is going to expire in a few weeks, and i think our message needs to be on this committee that we see our jobs as putting kids first. That means we are going to have to swing into action quickly here because this program is a lifeline for 9 million, almost 9 million vulnerable kids. It is a source of profound relief for parents across the country, and i want to talk for a moment about the kind of person who really sees this as the lifeline ive described. I might be talking about a single mom who works multiple jobs, pays the bills and handles all of what life throws at her all by herself. The last thing that single mom needs is a government letter stamped notice of termination, explaining that her sick kids are on their own because c. H. I. P funding has run out. That single mom is already juggling an awful lot, and i think it is fair to say she doesnt neread page 817 of the morning newspaper every day because she has too much going on to be able to do that and try to decode all of this washington lingo to determine if the congress is going to act. That single mom sits in her kitchen, and if all shes got is that scary termination letter were going to see a lot of single moms and families in a huge mess very quickly. Thats the prospect families across the country face in a matter of weeks and it is what they dont deserve. Kids who desperately need care might not get it. States are going to be required to start planning for the worst. That means enrollment freezes, belt tightening and emergency steps to try to preserve care for kids currently in the program. But a vulnerable child not yet enrolled in c. H. I. P might have to, in effect, wait until the Congress Gets its act together. That leaves families with a maximum of stress, anxiety and heartache. At worst, it is a life and death proposition for a great many of some of the most Vulnerable Children in our country. So today the finance committee is going to discuss the leading Health Care Issue congress has to address, has to address this fall. The congress created c. H. I. P with one goal in mind. That was to make sure that no american child falls through the cracks of our Health Care System. In the coming weeks weve got an opportunity, as chairman hatch noted, to put together a strong bipartisan agreement that up holds c. H. I. Ps promise to family and gives those kids security for years to come. Im beginning this discussion in an optimistic kind of way because ive discussed this, as i know many of you have, with chairman hatch and know the history. In the decade since they led the congress to create c. H. I. P, the percentage of kids in america living without Health Coverage has fallen from nearly 14 to less than 5 . Chairman hachl and senator kennedy gave us concrete proof again that you can have senators who can have fierce disagreements on a variety of issues finding Common Ground when it comes to big challenges, and i submit and i heard senator casey and others talk about this it doesnt get any bigger than standing up for vulnerable young children. So it is important for the congress to act soon. Theres no kicking this can down the road with a shortterm bill and it cant wait until december. The states run their programs differently. Some are going to run out of funding earlier than others. In that time no family ought to face the panic of being unable to get the care their sick child needs. As i wrap up, one other point is to note how c. H. I. P and medicaid work hand in hand. For American Kids and families, particularly those families working hard every day to climb into the middle class, c. H. I. P adds a level of security to the health care that single mom and others beyond above and beyond medicaid. C. H. I. P can only work if medicaid works. So weve got hard work to do, colleagues, now to uphold the senates promise to kids and families. We will hear from a Witness Panel that it would be fair to say knows c. H. I. P from a to z, a mom who counts on this program, that ensures c. H. I. P runs smoothly in her state, and an independent expert that knows the Program Inside out. I see this as an opportunity for all senators, both sides of the aisle, to learn about and discuss the Critical Program and set the stage for the work to come. Im confident that in short Order Congress can pass a strong and bipartisan extension of c. H. I. P that will last for many years. This is exactly what the important work of the finance committee is all about. Now, chairman hatch is going to have to be doing some juggling here, so im going to call on audible and would like to welcome each of our three witnesses to our hearing today. Each of your perspectives is important with respect to c. H. I. P. First were going to hear from m ms. Lianna george who will be introduced by senator burke. Welcome, lianna. Lianna is a proud parent of two children. Is that kaleb behind you . Caleb, wave at everybody. Were glad to have you. Liannas daughter is eligible for medicaid because of her disability. Caleb, her son, is insured by the c. H. I. P program. Lianna serves takes beneficiary representative on the medicaid and c. H. I. P payment and access commission. She is also a chairperson of the North Carolina council on Educational Services for Exceptional Children and is the secretary of the consumer Family Advocacy committee for Johnston County Mental Health center, the local Management Entity that connects Johnston County citizens with Mental Health, intellectual health and disabilities and Substance Abuse services. She is not only a mom, but an advocate in every sense of the word at every level we have. We are honored to have you here today. Welcome. Thank you, very much, senator byrd. We are going to hear from dr. Schwartz, executive director of the medicaid and c. H. I. P payment and access commission, commonly known in washington lingo as macpaac. It is the legislative agency that provides policy and Data Analysis and makes recommendations to congress. The secretary of health and Human Services on the state on a wide variety of issues affecting medicaid in the state and c. H. I. P program. Dr. Schwartz previously served as Deputy Editor of the journal of health affairs, and special assistance to the executive director and Senior Analyst to the physician payment review commission, a precursor to the medicare payment advisory commission. She is a health commission. She holds a doctorate in Health Policy from the school of hygiene and public health, Johns Hopkins university. Finally we will hear from ms. Linda navlo who will be introduced by our good friend senator warner. Thank you, senator wyden. I want to echo what you and senator hatch said about the importance of c. H. I. P. I would like to present to my colleagues my good friend linda navlo, she is with the department of medical assistance services. Linda and i go back to the days when bob casey was addressing me as his excellency, the governor. And linda at that point was director of division of maternal and child Health Services. Our c. H. I. P program back in the early 2000s was, frankly, a dreadful disaster. We were literally sending tens of millions of dollars back to the federal government because we didnt appropriately sign up our eligible children. We came in and with lindas great help turned that program around, make it a much easier process to get through the signup process. Turned a multipage application into a single page application process. Linda and i traveled the state at clinics and other gatherings and because of her good work and the work of a lot of folks we went from one of the bottom of the barrels to where we signed up 98 pearls of our eligible children. Kaiser foundation recognized us as one of the most effective c. H. I. P programs in the country. Linda has gone on to serve with dms and she has now come back. She has a great expertise and great heart for the program and will be a valuable witness. Thank you, senator wyden. Thank you, senator warner. Now we have gotten to the best part, and thats our witnesses. Why dont we begin with you, ms. George. We will go down the row. The tradition of the committee is if you could highlight your testimony in five minutes. Well make your prepared remarks a part of the record in full. Please proceed, ms. George. Thank you very much. Good morning. My name is lianna george, and as was indicated im from North Carolina. It is a very small rural county. Thank you for the opportunity to be here today, to meet with you and to share my familys experience with the c. H. I. P program and how it impacts families like mine throughout our great country. I married to a wonderful man named jim who is a marine corps vet, and he did third year of electricians Training Program to become a fully licensed electrician. I have three children, one who lives in a group home and my son caleb behind me. Both are on the autism spectrum. Caleb has adhd as well as a neurological condition. As you guys heard, he has medicaid and is insured by c. H. I. P. Im not here to testify on behalf of macpaac, it wasnt until i was appointed to the commission i realized c. H. I. Ps future was uncertain. As a child with special needs, i have been advocating for children with disabilities like my daughter. I was not aware that c. H. I. P was in danger and that the children of working class families like mine were in jeopardy of losing their Health Insurance. While there is need for the waivers i already said that part. Im sorry. As the commission discussed c. H. I. P program, yet to wonder how losing c. H. I. P impact my family. How would it affect those that pay for my insurance, when you dont have access to services you need, how much would it cost us. With the current Health Insurance plan there would be no increase to our premium because my plan only covers employees or familyonly coverage. Theres no employeespouse only coverage. However, it has a very high deductible which prevents my husband and i from accessing medical care that we need. This assured me that the services caleb needs would be pretty much out of our financial reach to get for him without c. H. I. P. These Services Include Occupational Therapy, which addresses fine meteor challenges that impact his ability to write and basic health care tasks like tying shoes. He receives periodic mris to monitor progression of his neurological condition which allows us to be proactive in treatment. My son takes daily medication which helps him focus in schools which impacts his grades and ability to learn. Over the years the c. H. I. P program has provided all of these services to us for little to no cost. Even in years when weve had cost sharing, c. H. I. P is still a tremendous value for my family. Without c. H. I. P coverage his access to services will be greatly diminished. C. H. I. P also provides families with Financial Security and moms like me with peace of mind. In january my husband was laid off of work. That resulted in an insurance lapse for him and me. We worked hard to ensure he continued his medication that he needed, but were able to feel confident caleb had the services he needed or he would become sick. Im thankful that i never had to call his pediatrician and say, i have to cancel our apointment, we dont have insurance. I never had to watch him lying in bed sick with a fever and not be able to pursue medical intervention for him. C. H. I. P has meant my son continued to receive the services he needs without interruption despite what challenges my husband and i were facing. If c. H. I. P was to go away families like mine would be forced to make tough decisions for our children. Monetary resources are always stretched thin. Families have to ration medical care with results which appear minor right now progressing to serious condition. Other families may procrastinate paying services on vehicles and housing which could cause lead to tragic accidents occurring. If were not able to afford my sons medication, i know that the medication would would be severely affected. Among sacrifices we have to stop things they participate in. He is in cub scouts. His uncle and cousins are both eagles and is excited about earning his eagle one day. While theres a lot of support for this leadership and discipline from the access to physical healthy lifestyle, losing c. H. I. P can hinder activities for the kids. Sometimes we have to sacrifice to provide for others, their children, their parents who live in situations outside of their home. My daughter lives four hours away from us. I would like to go more often than i can, but without c. H. I. P it would be even more limited in our ability to monitor her needs from where we live at. There are 9 million c. H. I. P family children that are there are 9 million children who receive c. H. I. P. This Program Provides parents and families peace of mind and Financial Security. Without c. H. I. P life is going to be will be a lot harder. I dont even want to imagine it but i know it will be, and the impact it will be on our kids for years to come. I ask you today to continue funding c. H. I. P. I want to thank you for your time to determine what the future of this great program. Thank you very much. Thank you, mrs. George. I know you speak for a lot of parents. We very much appreciate you being here. Dr. Schwartz. Good morning, senator wyden and members of the finance committee. Im anne schwartz, executive director of macpaac. As senator wyden noted, this is a nonpartisan body charged with making recommendations to congress, the secretary of hhs on the states on issues affecting these programs. Its 17 members, led by chair penny thompson and vice chair marcia gold are appointed by gao. While my statement on the analysis conducted by macpack staff it reflect the views of the commission itself. We appreciate the opportunity to share macpaac recommendations on a time when theres congressional need for this. Since enactment with strong bipartisan support in 1997, c. H. I. P has played an Important Role in providing Insurance Coverage and access to health care for million also of children with incomes just above Medicaid Eligibility levels. From 1997 to 2015 the share of uninsured children in the range has fallen from 22. 8 to 6. 7 . It is state administered within federal parameters and jointly financed by the federal government and the state. Flexibility in Program Design is one of its hallmarks, with some States Running c. H. I. P as an expansion of Medicaid Programs and others operating entirely separate programs. Always you know, without congressional action states will not receive any new federal funds for c. H. I. P beyond the end of this month. Our latest projections show the District Of Columbia will exhaust their c. H. I. P funds by end of 2017 and 27 states will do so by the end of second wart of fy 2018. In the face of uncertainty, many state administrators are considering the numerous steps they have to take to either freeze enrollment, scale back or shut down programs. While they do not wish to alarm beneficiaries, states report they cannot continue indefinitely business as usual. Mindful of this, the commission issued its recommendations last january after devoting considerable attention over several years to c. H. I. Ps role in our Health Care System and policy approaches for the future. We reviewed Available Evidence about the quality and affordability of c. H. I. P compared to other alternatives and focus attention on the implications of various policy approaches on children and their families, state providers and the federal government. Based on this review and in light of considerable uncertainty now facing Health Insurance markets, macpaac recommends federal funding for c. H. I. P be extended five years. If c. H. I. P funding is not renewed, 1. 2 million children covered under separate c. H. I. P will lose their coverage. While some children may be eligible for coverage privately, they would have to pay considerably more than under c. H. I. P, creating barriers to needed health and developmental services. In addition, they would lose access to Services Covered by c. H. I. P not typically covered by other payers. Those covered by Medicaid Expansion c. H. I. P would not lose coverage but there would be a significant shift in the funding obligation to the states. The Commission Also recommends extension of the current c. H. I. P maintenance of effort requirement and the 23 percentage point increase in c. H. I. P matching rate through fy 2022. These link recommendations reflect the view that extension to the moe, which is judge it important to retaining gains in coverage, should be accompanied by an extension in enhanced funding t higher c. H. I. P matching rate is also thought to include decisions in some states including florida, utah and arizona to expand coverage to previously uninsured children. Macpaacs recommendations look to a future in which a more seamless system of childrens coverage can be created. Such a system would provide comprehensive and affordable coverage and remove gams that occur when children transition among different sources of publicly and privately financed coverage. Recognizing that states will be the drivers of such change, macpaac recommends a demonstration grant be made available to states in developing approach else. Other recommendations call for extension of other childfocused programs that typically are reauthorized with c. H. I. P. C. H. I. P has clearly played an Important Role in providing access to health care for million also of meshs childr americans children. It removes enrollment barriers and focus on highquality pediatric care. Congress faces an important decision regarding the future of c. H. I. P during a period of great uncertainty affecting other Health Care Markets including both medicaid and the exchanges. Macpaacs recommendations provide guidance on how to ensure a stable source of affordable and comprehensive coverage for low and moderate income children amid uncertainties. The Commission Urges congress to act as soon as possible to extend c. H. I. P to prevent children from losing coverage and access to care and ensuring the state has the they funds to provide services. Thank you very much. Ms. Nablo, welcome. Thank you, senator wyden and members of committee for allowing me to speak. Lets make sure your mic works. The light is on. Now it is. Im here to speak on the importance of continued funding for the Childrens Health Insurance Program. Thank you, senator warner. I remember well when you were governor and enrolling every eligible child was your top priority. I remember how you would ask every friday without fail how many more children we got covered that week. Before you ask, let me say that the virginia today there are 614,100 children covered through medicaid and c. H. I. P. These programs are the Health Insurance plans for almost one in three children in the commonwealth, which is actually slightly below the national average. However states have chosen to design their c. H. I. P program, it plays a vital role for all of us in eninsuring children have access to affordable and appropriate health care by building on top of the larger Medicaid Program. In fact, c. H. I. P just turned 20. It is now a Mature Program but is woven deep into the fabric of Health Care Coverage in all states. There are only two points i want to make with you today in my few minutes. First is that c. H. I. P is vital to the health of children and second that there are serious consequences looming if you delay reauthorization even for a few months. In virginia as of september 1st there are over 58,000 children enrolled in medicaid but funded by c. H. I. P. There are 65,000 plus enrolled in our separate program we call famous. We also have a c. H. I. P waiver to provide prenatal care to pregnant women, and about 1100 are currently enroll. Virginia received 88 federal funding for this program, and in the last two fiscal year this money paid for hundreds of thousands of well child visits and immunization goes, over 21, pairs of glasses and also visits to the dentists but paid for 258 heart surgeries, six brain cancer surge i haves, two liver transplants and one heart transplant. We provided services for over 1100 children diagnosed with cancer, 31 children living with hiv, and 32 babies born with neonatal syndrome. Obviously c. H. I. P helps children lead healthy and normal lives. For example they can play sports. You know, you have to have insurance to play sports. They can control their asthma, see better in school or get teeth fixed. For other children c. H. I. P provided lifesaving treatment also. This is true in my state and in yours. Without congressional action soon, as senator wyden clearly explained, states will be forced to start preparations to shut down these programs. You heard most states will not actually run out of c. H. I. P dollars until sometime in the Second Quarter of 2018. Some might believe this means you can safely delay action on c. H. I. P while you deal with your very full calendar, but let me explain the reality for states. According to all estimates, virginia will run out of federal c. H. I. P dollars sometimes in march. However, virginia, like many states, covers these children through managed care plans. We pay those health plans a rate retrospectively for the previous months coverage. So in march we will not have sufficient funds to pay for the month of february. We will therefore need to terminate our separate c. H. I. P program at the end of january. In order to give the family also of those 65,000 children adequate notice we will need to send them letters on or about december 1st. Before then we will need to train eligibility workers application assisted Call Center Operators and others so theyre able to answer questions and provide whatever assistance they can to these frightened families. We will also need to inform providers and prepare to deal with their questions as well. We will need to expand c. H. I. P funds to reprogram automated eligibility rules and to modify online and paper applications and notices. Countless other contracts for managed care plans, prior authorization is used, auditors, et cetera, will all need to be amended. I suspect for states without a high degree of managed care the situation will be even more precarious as their costs are less predictable. Remember, virginia is not one of the first states to run out of money. Please be aware that your state will soon be making difficult decisions about if and when to freeze enrollment so as to preserve current coverage as long as possible and what to tell families and when to tell them as the end of funding approaches. Because we have come so dangerously close to the wire this time states will be grateful for any quick extension of c. H. I. P, but i want to make the point that funding this program in one or twoyear increments can generate instability, dampen innovation, may limit state investment and freeze programs where they are when the future is so uncertain. I hope at some point you are able to consider the recommendation of macpaac and other organizations of reauthorizing and funding the program for at least five years. Finally, please be aware that for virginia alone if Congress Reauthorizes c. H. I. P by september 30th but reduces the federal match rate to previous levels, we will experience over 57 million shortfall for the current state fiscal year which began in july and an 83 million shortfall in the next. Senator wyden and members of the committee, as you know c. H. I. P has always had strong bipartisan support. With all of the very difficult and complex decisions you have to make about health care in america, surely whether or not to expand c. H. I. P is not one of the hard ones. On behalf of state im here to ask you to please continue your support of the Childrens Health care by straightforward reauthorization for continued funding mu funding of c. H. I. P at current levels and please do it before we have to send those letters. Thank you, ms. Nablo, well said. I also appreciated hearing how it was morning in virginia when mark warner was governor and everybody got a daily report on kids getting coverage. Let me start with a couple of questions. Ms. George, i would like to hear what it really means in a parents kind of case in terms of what they would give up if the program expires. For example, i think it would be helpful to know, how would you pay for calebs medications . Because it sounds like those are pretty pricey and you talked to us about a whole variety of circumstances which obviously a parent cares about, but how would you pay for calebs medication . Right now im not really sure. I probably would ask my mother for a lot more help than we already get. We probably right now caleb and his father take a class, a martial arts class. Also has him with some arthritis challenges and it helps caleb immensely, but that would be one of the first things we would have to drop. Right now we put aside money each month to have money when the boy scouts go to summer camp, you know. Thats another area, because were looking at 3,600 dollars a year we have to find savings for for his medication goes, and thats if they dont go up again. You know, thats a third it is no, it is not a third of our income. It is about a fifth of our income actually though. Trying to find that savings would be a challenge. We probably can get half of it through some as the martial arts classes that he takes, but the rest of it im not sure where it would come from. That was my sense. I appreciate that because youve described how basically every single month youre trying to watch how you allocate your dollars and it is tight but you get along and you try to do obviously right by your kids. I just kept looking at calebs medications, and i cant figure out how you would be able to, you know, pick those up without some magical yes. Approach that we havent talked about. So were probably going to have to think more about it. Ms. Nablo, question for you. You really gave us a concrete and specific case about the kind of bed lalam we would see in th state of virginia if this program, you know, was delayed. Can you tell us, because youre an authority on this subject, you know, what would happen in other states . In other words based on your knowledge and your expertise about the program, tell us a little bit about whether virginia does is representative, would other states have other problems. Walk us through some of the other states. I would say virginia is probably somewhat fortunate in this situation in that federal funding doesnt run out until march, even though the program would have to close the problems you described would essentially be worse. Absolute lip. As has been stated, there are several states that will run out of funding before the end of this year. They have to be thinking about notifying those families very soon. In addition, i believe there are some states that actually have state law that says if the funding level from the federal government is reduced or goes away, they have to shut down their programs. Every state is a little bit different and every straight is constructed a little differently. There are some that i think are really kind of reaching the desperation point now. If they dont hear something in the matter of a couple of weeks, several states will be sending those letters or being in the paper trying to warn parents. Your message and thats particularly helpful is anybody who thinks they can wait around until december 15th to get serious about this that would shut down a program before. Well said. You are talking about people getting a signal in a couple of weeks, and if Congress Plays ball on this there are going to be real consequences . Yes, very scared families and our phones will ring off the hook in state offices and local offices. Very important to know. One other quick question. Dr. Schwartz, we feel very strongly that this program be multiyear and were going to push for the most generous funding that we can. I mean obviously, you know, were going to have to have discussions back and forth on that, but that is my objective, thats our objective here. What in your view is the value of a multiyear extension and why is that preferable . I mean my sense is that gives some predictability, but youre the expert on this. Certainly. Last time that macpaac made a recommendation in advance of the extension that you passed, our recommendation was for two years. At that point there was some hopefulness some of the uncertainty in Health Care Markets that were even in the future, in the congressional debate at that time would be solved. It is clear that now, if anything, theyre even more uncertain. Were not sure about what coverage would be available to kids Going Forward with the uncertainty affecting medicaid and the Exchange Market as well as privatelysponsored coverage. It was the commissions view that it is important to put kids in a safe space while these other bigger issues are debated and figured out. That was why the Commission Recommended a fiveyear extension to ensure that families would have stability and Insurance Coverage, that states wouldnt be in a situation where they were constantly having to sort of be in sort of a ground hog day situation of going through steps they would have to take. Thank you. My time has expired. Senator heller. I want to thank you, the Ranking Member and the chairman, for holding this hearing today. It is a Critical Program and it is a program that helps millions of children. So i want to thank our witnesses and mrs. George for being here and sharing your story, and for the other witnesses for your help and support of this program. In nevada c. H. I. P provides medical coverage for roughly 25,000 children who otherwise may not get care. Over the years this program has been responsible for increasing coverage for lowincome children throughout my home state. Nevada has made Great Strides when it comes to improving uninsured rate, making sure our kids have access to Affordable Health care, and this is something that the governor and myself are quite proud of. So it is my Hope Congress will act swiftly to reauthorize this program, get families in nevada and across the nation the certainty they need when it comes to Childrens Health care. With that, i would like to ask a question or two, specifically to you, ms. Nablo, because of your background, expertise and were able to accomplish in virginia. 25,000 nevada children are now covered. It is estimated probably 9 million i think, mrs. George, you said that, across the country children that benefit from the program. But theres roughly estimated 5 million children remain uninsured today. With your expertise and background and knowledge of this program, can you share what some of the barriers are that would produce what we have today of 5 million uninsured children and their inability to get into a program like this . Certainly. I would say the first barrier is always awareness. It is amazing how many individuals still dont understand that this program can actually cover the children of working families, and there are many families who never in their life considered that they might be eligible for a publiclyfunded health care program. And someone loses their job or their hours get cut back and all of a sudden they are eligible. They never paid attention to the ads before. They never theres a constant need, a constant drum beat because theres always a new population. A plant closes, whatever, that creates a new population. Thats one. Plus, there are certain populations that have higher uninsurance rates. Theyre more difficult to target and states really need to make those efforts. Teenagers are much less insured than young children. Hispanics are classically underinsured. So it takes special efforts, special outreach and, quite honestly, funding for outreach is one of the things thats a problem when states get strapped. It is a Constant Campaign to keep that up. I think perhaps and maybe macpaac has done analysis of the five million children still uninsured. A good percentage of them, i think it is 60 some percent of them would be eligible for c. H. I. P or medicaid if they would apply, if they were aware and took the action to apply. Dr. Schwartz, could you add anything to that . Yeah. I dont have those numbers at my fingertips, although we could get them for you. I think also it is important that that number of children who remain uninsured include undocumented children who would not be eligible for programs. Do you anticipate this number is climbing or is it Getting Better at this point . I think weve seen consistent drop in the uninsured number for children going back to 1997, and that was the primary motivation for the commission to recommend extension, wanting to secure those gains in coverage and make sure that the number of uninsured children doesnt go back to where it had been historically. Ms. Nablo, based on the barriers you just spoke about, what can we do better in congress to address some of those issues . One of i think theres a recommendation of macpaac that money that is set aside specifically targeted for outreach, right now states generally take that money out of their admin dollars that are allowable under the c. H. I. P program. Those admin dollars get stretched to all kinds of other things. So having a setaside, if you will, that is about meameant to states continuously promote this program would be helpful. There are policy changes that could make it easier for people. There are some states that still have a required period of uninsurance before a child can become eligible for c. H. I. P. Thats my least favorite policy in the program. Does the law allow any outreach in the c. H. I. P program . Does it allow it . Yes. Yes. You can take it out of your admin dollars. Every state can spend up to 10 on admin of what they spend on medical care for kids. So the bigger your program your get, the bigger your admin budget gets. But that needs to pay for workers and i. T. Systems and all of that kind of stuff as well. Thats where most states are able to find dollars for outreach. Thank you very much, mr. Chairman. Thank you, senator heller. Senator casey. Thank you very much. I want to thank the Ranking Member for his leadership on this issue over many years. Of course, i want to thank the chairman, chairman hatch, for his work today as well as his leadership over many years in a bipartisan fashion. This is an issue were particularly the witnesses are here, but were also grateful that youre here at this time because we need your voice and we need your expertise, your advocacy to inject a sense of urgency in a place where urgency is often not the order of the day. I want to start with ms. George. Were particularly grateful that youre here to bring your own not only expertise, as all three members of the panel bring, but you bring a personal dimension. Your testimony has, i think, in some ways added value and significance on a day like today . I was noting from your testimony about all of the not maybe an exhaustive list, but some of the services that you testified that caleb benefits from. Im looking at i guess the second page of testimony where you talk about weekly Occupational Therapy to address fine motor challenges that affects caleb, periodic mris and ultrasounds to monitor the progression of his neurological condition, third, daily medication which helps him stay focused on his school work, and you say, the c. H. I. P program has provided these services for little or no cost. C. H. I. P, and im coating again, quoting again, and you talk about peace of mind. All of that is critically important that we hear from you as a parent and hear we hear fr parent and hear from you as someone whos deeply concerned about your son. And guess my first question would be if you were to receive a termination of coverage notification how would that affect your family . Well, first thing id be looking for is a way to appeal the termination. Right. But it would just be a challenge because i look at kaleb with his needs and education. His education pray maerl is so important because without research, he could barely complete a worksheet in kinger garten. This medication allows him to stay focused. Without being able to focus on what youre doing, you cant do more complex math. Put that aside because theres too much involved in long division. Its just so important he keep his medication. So thats the first thing, how are we going to pay for his medication. How are we going to address his penmanship . We started with not being a able to read it at all this summer to now he writes fairly well. Its just so critical that its going to impact him not just today but as he goes into high school, as he goes hopefully into college and into being an adult. If he doesnt have these skills, then hes not going to be able to achieve what he could have achieved. As a family member, it would just be devastating that all these things weve done to build him up wed no longer have access to. Were grateful for that testimony. You just mullify that in my state like pennsylvania, as of august we had 176,000 children enrolled. And that number goes up and down depending on what day of the month or what time period. But lots of children benefit, im sure, in the same way that kaleb does. So were grateful for that testimony. D dr. Schwartz, i wanted to ask you im sorry, i want to ask dr. Naburo this. Has the Chips Program made a difference to your out reach . It did boost our enrollment again, but we have left those funds we let that expire. I think in part because of funding but the other part is are we driving people to a program thats going to close soon. I think there are other states thats had much more serious consequences. There are states that have prepared those notices, that are really actively engaged in shutting things down or being ready to pull the trigger. Great. Dr. Schwartz, ill send you one in writing. Thank you very much. Thank you to the panel for being here this morning. Your husbands services to the marines is greatly appreciated. As many of our colleagues know i have a passion of helping our kids in education. Anyone thats ever stepped into a classroom knows that it plays an Important Role. The chip plays a vital role in ensuring that our young folks are healthy enough to learn and thrive in school and in life. Considering the way chip shapes the educational outcomes, we need loo look at asthma. A leading cause of disability, and with wrong kite s, it is the leading cause of hospitalization among children in south carolina. It is also one of the leading causes of absenteeism in school. Whether the child is struggling with asthma or another condition that impacts their ability to squeeze in school, chip can help remove some barriers for families that are often up against other challenges. By producing healthier children, we also produce children that can be fully present in the classroom, fully invested in their studies and fully prepare frd a fruitful educational journey. Short changing Childrens Health produces a vicious cycle whereby poor healthcare leads to poor academic children and in term diminishes longterm health. Ms. George, first time off i want to say again thank you for your story. Can you please talk with us as the chair person for Education Services for kpengzal children and how youve seen the connection between Health Services that children have achieved and the successes theyve been able to achieve in the classroom in. Well, as you know after idea, theyve been able to obtain services in therapy and the list goes on and on. And the abilities there is its just very beneficial to them. Excellent. As a mother youve come before us and i want to understand and appreciate weve certainly heard senator warren and others talk about the importance of chip as it relates to your son. Can you perhaps expound upon the services and the way that it impacts his academic achievements as well . Well, with the cotpational therapy as i shared a little earlier, with his penmanship, we started home schooling him in fifth grade last year. We were in our second year of home schooling, and we could not read his handwriting despite having Occupational Therapy in the Public School system. So hes started having private therapy. If you cant read somebodys handwriting, you cant write a letter, cant file a job application. Even in this technologybased world, its still a vital skill. As well as doing multiication and long division, he has to lin up his answers. If he cant read the answers he wrote, he couldnt get his answer. And that impacts his education there. Thank you very much. Thanks, senator scott. Senator warner is next. Let me again thank all of our witnesses. Its great to see you again. Im going to direct most of my questions i hope appropriate with respect to by the way, when you referred to the days that mark warner was governor, were you referring to the dark days . No, he had already called its rare to have a program where people on both sides of this dias are all saying good things about this program. And i appreciate all the broader policy goals youve looked at and the kpengz time youve set. I think a fiveyear on the extension at least. And one of the things id like to talk about one of the things i recall in the past, some of these families their incomes fluctuate so much between month to month. And they may be eligible medicaid eligible at one point and chip eligible at another point. Our Going Forward basis, are there better ways to make sure people dont have to constantly reapply and we can stream line and people all fall within eligibility dont have to spend their time as they bounce from one Program Qualification to another . There is an option for states making the Medicaid Program or chip program for children, you would be continually eligible for a 12 month period. So even though your income may fluctuate and may not be eligible for the program, but you wouldnt have to report a constantly changing income, and your child would be covered for one year until their annual renewal date. Not every state by far has adopted that policy would you keep that as an optional baize . If we really truly wanted todries that concern, it wouldnt be the program. It would be the way it was structured. It does say if your income goes up, you have to report that. But youre absolutely right. Theres a lot of Seasonal Workers here, people that get extra jobs over christmas when their income changes. We have schoolteachers on chip. So its a constantly moving target and fluctuating environment for family. To realistically expect families every time someone works a few more hours to report that and ask an eligibility worker to figure out if that makes a change or not is really not the smart way to have this covered. Right. There could be a retroactive look back after a year. But this bouncing between and you may lose a provider. You may still be eligible for coverage and medicaid but perhaps your provider isnt a medicaid provider. And i think we heard from senator scott, making sure that child, kaleb, goes to School Healthy and being prepared makes him a better student and hopefully you look at the long road and long picture. And does it make sense where we have programs where families could potentially bounce back and forth from almost month to month. Talk to me a little bit about the outreach and particularly rural outreach. Many families may not feel comfortable going online or going to a library and putting very personal data into a computer without an outreach worker. Certainly. As you know very well the state, we employ a few outreach workers. And we do try to position them around the commonwealth. But another thing we do in virginia is we use some of our chip admin dollars to help support a foundation of which youre the chairman. And of that program you also get to do the same. And their reach is expensive in trying to help families. And even in this day and age we still get a healthy portion of our applications on paper. Its shorter than it used to be, but you still have to answer all those questions. And so we still get a surprising number of people who submit on paper. We have working families, working mothers who cant take off during their work hours and go to the local social Services Agency and sit across the desk of an eligibility worker to help complete that form or follow through. Thats where the outreach worker, theyll reach you at mcdonalds, reach you at your home. They will find a way to sit with you at a time and place that works for you and help you through that process, help you understand the questions and get that information in. And then theyll do the all too important followup on your behalf. Because as much as we would like to think were all about helping people, were still a bureaucracy, and it is not easy to deal with the system. So without that hand holding and personal touch especially in rural areas for families that have limited english capacity, its absolutely essential. Which is why we have, still, several million children who are eligible and not enrolled. Well, thank all of you. Particularly thanks for your work with the commonwealth. Thank you senator warren. Senator bennett. [ inaudible ]. Thatll be fine. And if we can just have the people in this room, well have to see if others come. Casskill. Ms. George, how did you find out about chip coverage . He was tranceferred over from medicaid to the chip program in North Carolina. And i guess executive director schwartz can you talk about im not sure you can talk about this country wide, but im really curious what kind of outreach and going on in these rural communities. Is there an aggressive outreach . I dont recall ever seeing anything, but maybe its more targeted, the outreach so that in terms of radio or bill boards or anything hike that, i dont ever recall seeing anything talking about chip in my state. Is it a more targeted through the medicaid population . There are some children qualified for this in my state that wouldnt qualify under medicaid . As with all things chip and medicaid, it definitely varies from state to states. States can use some of their admin dollars for outreach enrollment as linda mentioned. The grants, the federal grants allow to partner with Community Based organizations, which could be churches or a community organization, schools. And so it can range tremendously across states. I do want to echo obviously the add buys are the things we do notice. We do hear quite a bit in medicaid of people wanting that personal touch when signing up. Many people who have been very nervous submitting an application, they want to make sure everything is correct. So that last touch with an outreach worker really gives them a peace of mind theyve done everything properly to ensure the enrollment goes through properly. That would be similar . Its very similar. And by the way, i would point out they just cut the budget by 80 for and ada. Could the two of you address what impacts to cuts to the Medicaid Program have on your work, assuming that there was success, which we hope there wont be if there was success in cutting the Medicaid Program as has been proposed a couple different times in the context of an aca replacement, what impact would that have on the chip program . Well, chip is separately funded from medicaid. But in most states the two programs work hand in hand. The medicaid proposals that had been considered over the past few months would put significant constraints on states, particularly Going Forward on how they use those dollars. And presumably if states had to make changes or choices that would reduce eligibility levels in medicaid, also they would have to reassess their chip programs. Its hard to predict how individual states would make those choices. But clearly i think thats very much on the mind of state administrators. Absolutely. And i would just add that medicaid, you know, obviously, takes care of the lower income children. It also frequently takes care of the sicker children. Waivers, disability waivers, et cetera. Oftentimes a child may well be in the chip income range or evp in the private insurance income range, but given the extent of the disability they become eligible for medicaid. If medicaid is curtailed, if enrollment has to be rolled back because of funding, if those children were to become eligible for the states chip program, i think youd see us running through that funding much faster. So what would happen is some of the sickest children potentially would be removed from the medicaid rolls and put on the chip rolls, which would put incredible pressure on the funding levels of chip, which would squeeze out at some point people under coverage from the chip program . That would be my assumption, yes. Thats the way i think its been looked at is you cant look at medicaid cuts in isolation and assume other parts of the system arent going to be put under pressure and ultimately folks in an up in an emergency room uninsured and in the most expensive care possible. And all those costs are passed onto us. The ever gracious michael bennett. Thank you, chairman. And to adr add to that, let me say words that have not been said in the senate before. My questions have been asked. And i have spent but not everyone has asked them. Thats true. Thats a habit im trying to have us break. But ive spent the morning in the Health Community where were trying to work on a bipartisan solution to the Health Care Issue. So i apologize to this very able panel. Its really critical we authorize this program. Chip has provided Health Insurance for about 9,000 kids who do not qualify for medicaid in colorado. Colorados working families have benefitted from chip by increasing coverage for kids driving the percentage to an alltime low now to 2. 5 . On both sides of the aisle everyone in this room can agree our children need to be covered through chip or medicaid who covers 140,000 kids in my home of colorado. Without reauthorization as these witnesses have stated, this month colorado may stop enrolling new children as of october 1st. Theyd have to move forward with Emergency Planning that would be a disaster for us. So mr. Chairman, all id loike o do with your perpermission mission submit a letter to the chip coalition asking for reauthorization for the program. That is ordered. Thank you, mr. Chairman. Thank you senator for your leadership and the chairmans leadership. This is an issue thats been traditionally bipartisan. Im very hopeful were going to continue with the longTerm Extension in a bipartisan way and do what children across michigan and across the country are counting on us to do. We know before chip was created back in august 1997, millions of hardworking families couldnt take their children to the doctor and give them the care they needed. And ms. George thank you for speaking for your family and your experiences. I can tell you in michigan right now the good news is 97 of our children can go to the doctor. Thats a very big deal. Its the highest ever because of changes that weve made through the Affordable Care act and through Childrens Health insurance plan. We want to make that 100 , but 97 is very good. Unfortunately, as has been said and youve been talking about the sense of urgency, were about to see that health care go away. And we dont need a shortTerm Extension. What we need is to fully fund the program and give states and more importantly families the peace of mind they can continue taking their child to the doctor and give them the certainty that they need. So we need to act now. We need to act now. And im hopeful that were going to do that and do it in the right way for families. I want to just share one story before asking questions. Ive talked to so many people in michigan, so many families that im so glad that they have the opportunity to not worry in the middle of the night whats going to happen if the kids get sick, but know theyre going to have the confidence to be able to take them to the doctor and get the care they need. One of my constituents, jan, wrote me a letter saying from the time my daughter suzy was young wreesh knew she was going to need extra help. She was diagnosed in second grade with adhd and we proceeded to try a medical solution for attention problems. As she got older she say diagnosed with bipolar and we tried a different approach to control her mood swings. Without having access to Quality Health care, we would have been lost. And thanks to the michigan chip program with a premium of only 10 a month, we were able to afford the help she needed. We are so grateful weve been able to get the help necessary to help her get to this point. So todays hearing is not about numbers. Its about people. Its about suzy. And i want to thank you again, ms. George, for coming today. I want to take a moment because of my questions on the cost of prescription drugs were ably asked and answered because that is such an important part of health care today and the drivers on health care. But theres another piece that senator grassley and i have been working on that i think would be wonderful to add to chip in terms of quality measures for prenatal care and for making sure that we are providing through chip and medicaid a set of maternity and infant quality measures that have not been there. And weve been working on this for some time together. Theres a Broad Coalition of organizations supporting this. Theres so many that its hard to know who to thank. But i want to thank the march of dimes in particular for incredible advocacy on this. But i wanted to ask, dr. Schwartz, if you could speak to the desire, the need to have a set of measures as it relates to quality standards. I know that mack pack recommended a five year extension of the Pediatric Quality Measures Program, which were building off of. So i wupdered if you might indicate whether or not you agree there are gaps in the measures right now for labor and delivery. And could you discuss some potential quality measures and how they would benefit moms and babies . Certainly. Im not an expert on quality measurement for maternity. I would note that the Pediatric Quality Measures Program is intended to help fill gaps and also to work with the users of measures to make sure that measures are not some academic exercise but can actually work for in terms of reporting and their usefulness in providing feedback to plans and providers about the experience of care. That work informs the inclusion of measures in the adult and child core set that cms uses. And there are measures related to labor and delivery and prenatal care in both the adult and child core set. Thats obviously a dynamic process. And over time measures have been introduced into the core set and taken out of the core set as our understanding increases. And i do think its important we talk about value to the beneficiary and the value to the tax pay, these programs and certainly the availability of valid and valid measures is a certain part of that ekwauquati. I want to thank you and the chairman. It is strongly bipartisan. It is noncontroversial and would add to the strength and the quality of whats before us now. And im hopeful we could include it in the final bill. I very much appreciate what senator and senator grassley are trying to do here. At this point the also gracious senator cardin has said that while hes next, it would be fine if senator grassley went. I think senator grassley i think had a relatively short amount of questions. Go ahead. And i appreciate it. Everybody appreciates everybody. I think a have a fairy easy question for dr. Schwartz. But before i do that i want to say that we have this program that is a chip program for my state of iowa called hawk not exactly spelled the same way as the hawk eye football team. Its the health and well kids in iowa program. We had 83,480 children covered by hawk eye program. In addition children are checked to make sure theyre developing appropriately. This is a program that ive supported in the past and look forward to its reauthorization. So dr. Schwartz, i want to ask you about childrens access to care. As you may know i have introduced 428, the advancing care for exception kids act. We call that the ace kids for short. And i have introduced that with senator bennett whos already spoken here. The goal of this legislation is to ensure that sick kids have access to the very best care. However, there are some statutory and regulatory barriers which can require childrens hospitals and specialized Pediatric Hospital additional work in order to care for these children. My two questions, has your organization mack pack, done work on this issue, and are there potential solutions that maintain or even strengthen the program but make caring for these children more stream lined . Its my understanding that the ace kids act has evolved over a number of months or perhaps even longer than a year in terms of its scope and size. We have not looked at it recently. Its something that we would be very willing to do both at the staff level and the Commission Level and would stand ready to provide any advice and feedback on that for you. What about just generally have you solutions that would strengthen Program Integrity and make caring for these children more streamlined, looking at it without the bill i asked about . I think the population of kids, its my understanding that the ace kid act folked on children tend to have a lot of hospitalization. They need specialized care and maybe in another state. So that does create potential challenges for states who are very skupulous of Program Integrity and knowledgeable about the providers in their state. So certainly that is a challenge when you have a kid that needs to have care across state lines. And as i said, we would be happy to look at any specific provisions and provide any guidance. Okay, well any advice you can give about the bill but also any consideration you can give without even the legislation of enhancing that would very much be appreciated. I thank you and thank senator cardin. Thank you, senator grassley. Now the patient senator cardin. Thank you, mr. Chairman. Everyones thanking everybody else. I heard your Opening Statement and identify with it on the chip program. I just really first want to under score how important it is for us to timely authorize the chip program. Theres 143,000 marylanders that are covered under the chip program. In this fiscal year the cost of 275 million. Of that total share of 241 million. The border works of maryland just approved a budget cut to term because of the budget deficit in our state. Theres no conceivable possible way that the state of maryland can fill the gap under the chip program if its not reauthorized in a timely way. So if we dont reauthorize in a timely way, theres 143,000 maryland children who are at risk. And i just really wanted to under score that. I was proud in the 2009 reauthorization offered to include mandatory dental coverage was included under the chip program. Now, mr. Chairman, many of you have heard me talk about this before. This was as the result of a tragedy that took place in maryland in 2007, two years before the reauthorization was enacted into law. And it occurred about seven miles from here in maryland a driver, a 12yearold, who died because he could not get access to dental care. He had an abscess tooth, needed to find a dentist that would provide about 80 worth of dental care, and could not be seen. It ended up being abscessed into his brain. A couple of operations later and 250,000 and he lost his life. We recognize that tooth decay is the number one disease affecting children in this country, and it is preventable. I went to many schools in maryland and saw children and talked to teachers and learned exactly what healthy oral health meant for successful stunlts in our schools. You cant really learn if you have tooth problems and pain. So weve made tremendous advancements in dealing with pediatric dental care as a result of coverage in the Childrens Health Insurance Program. And im proud of the progress that weve made. After we included dental under the chip program, we also included pediatric dental under the Affordable Care act. So one i think now if chip is not reauthorized under the Affordable Care act . The answer is yes but not to the same extent that we have under the Childrens Health Insurance Program because of the match, cross sharing and so i would just like to get the view of our distinguished panel of witnesses as to how important the chip program is for our childrens dental care and what changes weve seen occur nationwide as a result of the coverage for dental care within the chip program. Dr. Schwartz, would you one of the areas for the commissions analysis and consideration and thinking about the future for childrens coverage was the availability of different types of benefits for children in chip versus other sources. And as you pointed out pediatric dental is an essential health benefit. But the way exchanges cover dental, its often not included in a comprehensive package, can be purchased separately, but it is in fact much more expensive. So we did not find a number of differences between exchange and chip. But dental was one we called out just as you say. Within the prime contract, wed have to have a separate policy. But there are places in the country where youd have to get a separate policy. And youd run into the cost sharings and caps that would be different, which could cause problems. Would you want to comment . We are always very cognizant when we do outreach for the chip program that it involves denticle care. That is extremely valuable to parents. And i think for parents who dont have a particularly sick child at this point, that is one of the drivers that brings them to our door to apply for chip coverage. Because it is not common with private insurance or Exchange Coverage for those children to have access to dental care. I want to point out one of the side benefits for chip program and oral health for children is we now have dental access in communities that didnt have that access before. So its not just coverage but also that providers are now in communities that they werent before as a result of the chip program. Thank you. Thank you senator cardin. And thank you again for highlighting the importance of dental care. Here we are in order. Senator thoom, senator cantwell and our colleagues from delaware. Of course i want to thank all our witnesses for joining us as well, especially ms. George who shared her personal experience with the chip program. In my home state of florida, like many states we run a Combination Program in our state and projects that if chip expires nearly 12,000 kids would shift to medicaid and nearly 3,500 would lose coverage all together. Its critical we Work Together it ensure kids across the country continue to have access to uninterrupted coverage. And it sounds like the ground has been plowed a little bit already. But i wanted for purptsess of my states interest ask the question of ms. Nabulo, and the administrators talked to us about the importance of maintaining state flexibility to determine benefit structure moving forward. And you mentioned that in your testimony as well from the a state perspective, are there other areas where greater flexibility might be best needed so states can meet the needs of their populations . I would say that the virginia experience is one of continual change and continual improvement of the program to best meet the needs of families in our state. Certainly some flexibility in the benefit structure is helpful. For example, virginia just added a very robust package of stuns use disorder benefits to help address the Opioid Epidemic. We added those for children in our chip program and for the pregnant women in our chip waiver. So the ability to be able to do that was very helpful. The story envirginia is we started out with a very restrictive program. We had some of the most restrictive policies in the country. For example, we started out with a 12month forced period of uninsurance before a child could be eligible for chip. That then went down to six months, and then down to four months and weve since abolished it. But that is the ability of the state. And given where the legislator is and what people learn as they go along with the program as whats needed and become more educated about familys needs, theres a constant and continual improvement to the program. I think states probably appreciate the flexibility in chip a great deal. Its one of the most attractive features probably originally for states taking up this offer in the first place. And i think they would be very concerned if that flexibility went away. Okay. Dr. Schwartz, south dakota also raised the importance of states continuability to carry over funds. You raised this issue in the context of how long states would be able to continue to raise chip programs and also operations associated with extending the program. How quickly can states respond to congressional action, and i would also, i guess, direct to ms. Nabulo if you can comment on how quickly you expect virginia to respond. Dr. Schwartz . When mack pack made our recommendations,ee set a deadline of having it available at the end of this congress so you could allow quickly for states to plan for the next fiscal year. Obviously many months have elapsed since then. States have held off on making changes to their programs for not wanting to alarm beneficiaries unduly and also to not cause disruption for the plans and providers. I think that the clock really is very close to having run out. I think the other point i really want to make clear is that mack pack has put out these figtures noting when states will run out of money. And that is not meant to say that congress can wait until that deadline to make a decision. Its really important for states to have the certainty right now so that they can plan appropriately so that these programs are run in a deliberate and professional manner. Thanks. Ms. Nabulo, any response in term of virginias . I would say the challenge is much more how long can we wait until you tell us with certainty there will pea funding for this program and what level it will be. I think for some states were a few weeks, maybe a couple of weeks away before they start having take proactive measures to start shutting down. For virginia as i said earlier, i have a long todo list. I actually have in my briefcase today of things that will need to happen. And that starts in october for us, beginning to do the changing and the system changes ask all the things well need to have. If the funding if the chip is authorized but the funding is reduced, that causes immediate budgetary problems in the state of virginia. We have an immediate 57 million shortfall in this state fiscal year. Our legislator comes to town on january 10th. And i guess hathereat would be one of the very first problems they would have to face is what do we do with that kind of hole in the budget, ask it grows the next year. So its reallyplore of a matter were waiting with baited breath to hear from congress. Thank you. Thank you, senator thoom. We started an hour ago with that question, and im glad youve now highlighted that again. Because this is not a washington situation where you can have an amendment, an amendment and maybe it moves and maybe it doesnt. Your question again has now highlighted from that this morning this has real consequences. And i appreciate you bringing that up. Senator cantwell. [ inaudible ]. Whether it is talking about chip or what have you. But i so appreciate your testimony today. Being here you really highlighted what this is about and taking care of the needs of families bay buy making sure they have coverage. And i wanted if we could just i was so touched by your story, is it okay if we give him a round of applause . [ applause ] 6. So i dont think we can ever forget people affected by this program and what it means. And i think when i think about ms. George and her family and what shes been able to accomplish, i think about the modernization of chip. So in our state we cover children up to 211 of property and cover up to 300 through chip. And yet we have families at Different Levels of funding weve seen in new york is a front door that allowed families in chip no matter what the entryway was, to then get coverage. It also has driven down costs. Its driven down costs for everybody. Its driven down cost for the state, for the federal government. Its made the program streamlined and efficient. Do you think theres more to do in streamlining this program, thinking about what children and adults, making sure theres coverage and cost savings on the administration side of this . Theres certainly always work to do. I think one of the things that the Commission Recommended was a demonstration grants to states to try and think about how to better coordinate different sources of coverage. We know that the answer may be different in different states and wanting to provide an opportunity for states to experiment that way to smooth these transitions across coverage so you dont have situations where families lose coverage due to change in their life circumstances and you lose continuity and have gachs in coverage. So theres certainly work to be done. Mack pack and meeting next week, and one of the things were taking up is a broader inquiry in medicaid to sort of assess where we are in the streamlining of eligibility and enrollment and renewal processes to say what have we accomplished and what more work needs to be done. Apparently my mic wasnt working, so i dont know if everybody heard the question i asked. I would agree with dr. Schwartz. Both from the Health Care Arena and also just other federal programs like snap and tanf, et cetera. Theres a great deal of difficulty where, disparity and differences how those are administered and income and et cetera thats extremely confusing for families and very difficult to administer. And even if you are successful, for example, in the Health Care Arena moving from chip to medicaid or back or your family gets coverage on the exchange or whatever, the benefits can be very different. The doctors can be very different. The copayments, deductibles can be extremely different. And it just creates an extremely confusing atmosphere. Well, i think it probably creates cost, too. And cost. And to me streamlining that so that theres a front door so that families are covered and we do gnat in the most costeffective way considering theyre likely getting coverage, its just not in a uniform way. I, mr. Chairman, regret we identified this when we were doing the Affordable Care act, but some of our colleagues thinking more about chip at the time, less about the confluence that was going to happen. But i wish then we would have offered some innovation to streamline. Because then i think we could have reduced cost. So i certainly hope well take a look at that now, because i do think its one of the keys to making this more affordable to everybody. Thank you. Thank you senator cantwell. And oregon has always seen itself in a partnership with Washington State on these efficiencies. And i think the point you made is extremely important because inefficiency wais inefficiency wastes money. I thank my colleague. Im not sure senator brown was in line before you were. Okay, thanks. To our colleagues here, all the senators in the room right now are democrats. And i would just note that, chairman, a lot of important accomplishments in the time he served here but maybe none more than important than his work i think with senator kennedy on the Childrens Health Insurance Program. And i look forward to working with the colleagues that are here but certainly senator hatch to extend funding ensuring that millions of kids, including about 18,000 in delaware continue to receive Health Insurance coverage under this program. And i was actually in the white house with president clinton and Hillary Clinton the day this was rolled out at the white house. So this is one that has special need and privilege for me to represent. I have a couple of questions id like to ask of our witnesses. Thank you so much for being here. And are you from virginia . You work for the governor there . Say it again. You work for the governor there . Yes, i do. Tell him sends his best. We look forward being back down there to launching that program with joe biden in several months. In our neighboring state i think senator cardin who was just here said about 14,000 kids in maryland are covered. If we allow chip to expire at the end of this month, many of the children in our state are going to either become uninsured or either under insured. And im going to ask dr. Schwartz, can you speak to whether Insurance Options for kids would be able to provide for these children if chip expires. And how do these options compare to cost sharing protections, pediatric benefits and Pediatric Networks through chip . Certainly. Our Analysis Shows if chip funding comes to an end theres two different scenarios depending upon whether a child is covered under separate chip or expansion chip. Separate chip programs would end. And we estimate that 1. 2 million of those children would become uninsured. All of those children would be eligible for either subsidized coverage or sponsored coverage. But for most of them the cost of those cost sharing would be prohibited, and thats why they would become uninsured. For those that do enroll in esh change coverage and those that enroll in employee sponsor coverage would experience a most higher rate of cost sharing. I think it very likely as well they would experience a change in provider in moving to a different plan. Okay, thanks. Ms. Nabulo, you mentioned the importance of chip for access to Mental Health services, for Substance Abuse treatment, immunizations, basic health care for children to be able to live a normal life. Can you describe the role chip plays in Mental Health conditions and as well as combati combating opioids . Chip has always covered well i take that back. Over the years chip in virginia was originally designed over the state Employee Health plan. Over the years additional benefits have been added bringing it much close door the medicaid package of benefits. Not the full coverage of medicaid. But its become a very robust child centered medical package. But in reaction in the last several years, the awareness of Opioid Epidemic virginia has taken a very aggressive stance to try to combat that epidemic. And a big part of that initiative is to add addiction treatments that are evidencebased by adding or recognized by National Associations as being effective to both medicaid and to chip and tool our pregnant women coverage to both of those programs as well. Weve just done that. Most of those benefits became effective april 1. We just added another one as of july 1. So i think its a little too aurally to talk about the effect on individuals, what we have seen. Because along with adding those benefits, we also increase provider rates. So we have seen Significant Growth in providers offering these evidencebased practices into the southwest of virginia. So were very excited about the Provider Network and hope that will grow into other outcomes. Thank you. Thank you senator. Senator brown. First of all, i thank the witnesses. I appreciate you being here and speaking out for one of the most important things we should do this fall. Id like to submit for the record two letters. One for the Ohio Department of medical services. Without objection so ordered. Thank you, mr. Chairman. And i would add that ohio still has freestanding hospitals in any state of the country. And i know that my senator from ohio went to these hospitals. Id like to ask each of you the importance of extending chip for two years. Many have written in support of a longer period as much as four or five years. When secretary price testified, i asked him the question of longer extension. I suggested eight years. He conquered and said eight years could make sense. Mack packs recommended we extend fiscal funding through 2022. Explain briefly youre probably tired of hearing these questions anyway but explain briefly my mack pack has a five year extension . The primary reason is the tremendous uncertainty in markets, whether thats relates to medicaid and certainly the volatility of private coverage and really the notion its important to secure the coverage that the chip program has brought and put kids in a safe place while coverage is available to them while all these other problems are sorted out. We have had quite long extensions of chip in the past. The first one was for ten years. 2009 to 2013. And so certainly there is a track record in the congress. Thank you, dr. Schwartz. Ms. George, thank you for coming today. I understand your son kaleb is here and hes aiming to become an eagle scout. And i know the work he will do to become an eagle, and i assume that his mother having the peace of mind knowing that chip will be there to raise her healthy young future eagle scout so talk to me about what extension means for peace of mind, what that means for a mother of a young man like kaleb . Well, probably for me the biggest thing for me is knowing that hes covered. Right now my husband had insurance the last couple of months ago because of changing employers, he was not affected by that because he had chip. Just that peace of mind of knowing no matter what happens to you, what happens to your loved one wheres that your child has the coverage they need to be healthy to have everything they need for school, for developing into the young man they can become is just tremendous. And thats just why its so important for us. Good luck. Let me know of years. My home state of ohio has been a leader in innovating within chip and medicaid to lower costs and improve outcomes. We still are embarrassingly awful in terms of infant mortality. Chip has helped us be more than marginally better. The Kasich Administration tells me it is difficult when it is uncertain. Talk about what certainty means in terms of stability and running a department and making this all work. When you are looking at, we have come extremely close to the wire this time. So what does that mean for the future . If there is a one year extension or two year extension what that is saying i think to states is we are going to potentially be right back here two years from now up against the wire again. So the question you have to ask yourself i think as a state is what kind of an investment are you going to make in this program . How much outreach are you going to do to drive children to this program when it may not be there. There is a feature in chip called Health Services initiative where states that have sufficient admin funding can actually fund, help support other programs like poison control centers. I understand there is one state that is now using funding to help supply opioid, those kits that help somebody immediately recover from an overdose to help pay for some of that for children. So do you as a state begin to invest in Something Like that when by the time you get all the paperwork done and money flowing it needs to be more than two years. I will take anything at this point. But i absolutely absolutely five years or longer would be a very welcome thing for states. I know the chairman agrees with this. We will continue at least many of us that care will continue to advocate for at least five years. Thank you all. Thank you. I want to just wrap up with a couple of thoughts picking up on senator browns really thoughtful case for how important a long Term Extension is. And you have done an extraordinary job this morning laying this case. I have agreed with every single thought, save that one at the end about you take anything. I want to leave this hearing saying that i think we all understand and you didnt mean it that way, of course, is that kids deserve the very best. I want to kind of recap a little bit on where we are on this issue. The Childrens Health program did not come about by osmosis, didnt just kind of magically show up in america and everybody said we are going to cut the rate of uninsured kids in america. It happened because two very strongwilled United States senators, late senator kennedy and chairman of this committee acknowledged that they will have plenty of differences on plenty of issues, but both said we got to do right by kids. We got to step up and the reality is that without the two of them doing it i dont see how it would have happened. And so what we are talking about today is asking United States senators to pick up on that extraordinary legacy and step up. And youre going to hear a lot this fall about how they are all kinds of priorities on the senate. Im sure caleb was not paying attention to the government lingo. The real question behind our job is to make sure the chip is way up that doesnt put us in a situation as described very eloquently. Kicks in if somehow people say we have other things to do and that sort of thing and it starts to happen pretty darn soon if it doesnt get the attention that it is deserving. Now, the last point i want to make is that im sure we will have a discussion about cost and america has a lot of challenges in terms of the budget. I just hope what we say is when people say can we afford a generous funding package for chip, i hope that we say on the basis of the really thoughtful comments that you all have made and for caleb sitting behind his mom, i hope we say america cant afford not to cover chip in a genr generous kind of way because we heard testimony about what it really means to be able to afford these sky rocketing medication prices. I noticed your comment was, well, you know, we probably could figure out a way to do this, but, you know, thats not considering all of the perspective price hikes. So what we know is that if you dont get there early for these children you end up playing catch up ball for years and years to come. So we either get there for kids like caleb and ensure that they can afford medications and you spend a modest amount of money in order to get that coverage or you basically say were not going to do it and well pay and pay and pay some more in the years ahead as a result of that short sided thinking. So we have got a lot to do to talk about how we cant afford not to do this. We have a lot to do to make sure that this gets up the priority list. We have a lot to do to show that this didnt just come about by accident, came about because of the extraordinary leadership of our chairman and the late senator kennedy. The three of you have really given us sort of a road map on how the congress ought to come together and why it ought to come together. Each one of you brought a unique experience. I sat in on a fair number of hearings on this committee and have tried to specialize in health care since the days when i was director of the gray panth panthers. This has been one of the best Health Hearings we have had in the finance committee. It is because the three of you laid the case out so well. You can see a great interest among members on both sides of the aisle. We are walking out of here today knowing that the job is going to be tough in the days ahead but you have given us a path for the important work that has to be done. I have one bit of business on behalf of the chairman. And the chairman wanted to make sure everybody understood we appreciate their attendance and that he feels this is very important conversation. Senators meet to talk through ideas and suggestions and believes they are confident. And the clast request is that he would like to make clear that for any members of the committee who have written questions for the report would request that those written questions be submitted by the close of business on september 14. And with that Senate Finance committee is adjourned. This is urgent business because we have experts describe how the consequences of delay kick in quickly and how we end up wasting money that ought to go to children instead. I see it as my job working with the chairman who as they heard me say has done extraordinary work on this over the years to make sure that [ inaudible ] whether a block on the agenda it cannot get short. This has to be way up the priority list. Failure to do it will have [ inaudible ] in particularly for children. More and more work with respect to children [ inaudible ] ends up costing more and the costs kick in pretty quickly. The cost can get caught up in various challenges. I know there are a lot of priorities. To not make this top priority and you heard democrats and republicans say that they felt the same way. When are you hoping to get a bill out of committee . By the end of next week . I would like to have a chance to talk to the chairman about it. Im not going to do any front running. I will have a chance to talk to the chairman about it. Obviously, i was trying to convey the urgencyism i think the chairman and staff work very closely with my staff and i and i am very appreciative of the partnership and i really do see nobody could ever replace senator kennedy. I have joked with chairman about that. Senator kennedy was the Gold Standard in terms of public service. I will do everything i can to step up in every way possible. You know i am a strong supporter strengthening Health Services. I will have to talk to the chairman about the details of the bill. There is a stabilization effort going on also attaching some of that. Would you support a rider . I will not speculate about various legislative processes other than the fact as the author of the state waiver anybody who tries to turn this into a program where they can roll back fundamental Consumer Protection will have to roll over me and would be violating the letter and the spirit of the 1332. Used existing provisions in the law. They used existing provisions in section 1332 to get the reassurance programs off the ground as i understand it. The existing law came out of this. Some of the ideas yesterday around 1332 were very procedural. You think that is the case that maybe there could be changes there . I have always said, remember 1332 is really born in my bipartisan bill with 16 senators equally divided between democrats and republicans. I am always open to new ideas, good ideas. One of the things i honed in on is that if governors can give us the specifics about process aspects of 1332 that they feel will i think i do want to come back to that what the states have been most interested in is the reassurance and the two example wheres apparently the states are pretty darn happy, both were done under existing law. Are you going to follow the tax recommendation and push for a fiveyear reauthorization or are youope toon maybe four year or three year . I want longest possible extension and the most generous funding. Does that mean two years is off the table then . Let me have a chance to work with the chairman. I stated my preferences and heard my colleagues even when senator brown eloquently made the point and picked up on it, too. Nobody is going to have trouble deciphering my preferences. I want to be clear. I want the longest possible extension and the most generous funding possible. [ inaudible ]. I think it is raising questions. I have made it clear to my colleagues that we feel strongly. Asked for details about specifics. I dont want it to come of that. Just now starting to talk to them about this. On friday the republican governor of ohio, john kasich and colorado governor discussed their bipartisan proposal to fix the u. S. Health care system at an event hosted by the American Enterprise institute. Live coverage begins at 9 15 a. M. Eastern here on cspan 3. This weekend on book tv saturday at 7 30 p. M. Vermont senator and former president ial candidate Bernie Sanders offers his thoughts on how to bring about change in america. What is the agenda . What should we be doing as a nation . If you have a middle class which is shrinking, if you have millions of People Living in poverty and sometimes in desperate poverty the first thing i think we have got to do is demand that if you work 40 hours a week in iowa, vermont or in america youre not living in poverty. Then at 9 00, Fox News Contributor discusses his book, america and the age of trump, opportunities and oppositions in an unsettled world. My book, america in the age of trump tries to forge Common Sense Bipartisan Solutions to the problems we are facing. And i would argue that those problems are getting worse and they are being to a great degree made worse still by our political leadership. And sunday at 9 00 p. M. On after words, Harvard University professor examines the issue of mass incarceration in her book. She is interviewed by author wes moore. Prison system as big as ours, 25 of the worlds prison population in our prisons despite the fact we have five percent of the worlds population touches everybody. There are a lot of stories out there that we are not tilling. Yes, im not telling those stories. We are letting this thing live. We have to get the stories out so we can see the damage that we are doing and fix it. For more of this weekends schedule go to booktv. Org. At a house hearing Legal Council to the epa Inspector General and Government Accountability Office Official talks about recommendations for improving efficiency at the