Transcripts For CSPAN3 Hearing Focuses On Childrens Health Insurance Program 20170912

Program with the late senator ted kennedy. Before i begin, lets call the meeting to order. Before we begin to take just a moment to say that our thoughts and prayers go out to those who have been impacted over the past few days by hurricane irma. Of course, we continue to keep those suffering from the effects 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 selfsufficiency. C. H. I. P. Was intended to help families. So we needed to be forward thinking taking into account the realities that time with an eye towards future sustainability. 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 read 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 mountain of stret, anxiety and heart ache. At worst, it is a life and death proposition for a great many of some of the most Vulnerable Children in our country. 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 chip 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 just noted to put together a strong bipartisan agreement that upholds chip 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 decades since they led the congress to create chip, the percentage of kids in america living without Health Coverage has fallen from nearly 14 to less than 5 . So chairman hatch 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 ive heard senator casey and others talk about this, it doesnt get any bigger than standing up for Vulnerable Children. S so its important for the congress to act soon. Theres no kicking this can down the road with a short term bill and it cant wait until december. The states run their programs differently. Some are going to run out of founding earlier than others. In that time no family should 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 chip and medicaid work hand in hand. For American Kids and families, particularly those families working hard every day to climb into the middle class, chip adds a level of security to the health care of that single mom and others beyond above and beyond medicaid. But chip can only work if medicaid works. So weve got hard work to do, colleagues, now to uphold the senates promise to kids and families. Were going to hear from a Witness Panel that i think will be fair to say knows chip from a to z. And an independent expert who knows the Program Inside and out. So i see that 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 chip that will last for many years. This is exactly what the important work the finance committee is all about. Chairman hatch is going to have to be doing some juggling here, so im going to call an audible and id like to welcome each of our three witnesses to our hearing today. Each of your perspectives is important with respect to chip. First were going to hear from mrs. Leanna george who will be introduced by our friend senator burr. Thank you, senator wyden. Caleb, wave at everybody. Were glad to have you. Leannas daughter is eligible for medicaid because of her disability. Caleb, her son, is insured by the chip program. She serves as the beneficiary. Shes also a chairperson of a North Carolina council on Educational Services for Exceptional Children is is the secretary of the consumer Family Advocacy committee, a local Management Entity that connects Johnston County citizens and Substance Abuse services. She is not only a mom. She is an advocate in every sense of the word at every level. Leanna, we are honored to have you here today. Welcome. Thank you very much, senator burr. Second we are going to hear from dr. Ann schwartz, commonly known in washington as mack pack. Mack wak pack is the aemggency provides policy and Data Analysis and makes recommendations to congress. The secretary of health and Human Services on a vied variety of issues on medicaid and the state chip program. She previously served as the Deputy Editor of Journal Health a hai affairs and special director to the physician payment review commission. A precursor to the medicare payment advisory commission. Dr. Schwartz has also held positions on the staff of the u. S. House of representatives. And holds a position at john hopkins university. Finally we will hear from ms. Linda neblo who is going to be introduced by our good friend senator warner. Thank you. I want to echo what both you and chairman hatch said about the importance of chip. Its a critically Important Program and id like to present to my colleagues my good friend linda noblo who is the chief Deputy Director for the Commonwealth Agency or as we call them virginia d mass. We go back to the days when bob casey addressed me as his excellency the governor. Linda at that point was director of the division of maternal and child Health Services. Our chip program back in the early 2000s was frankly a dra dreadf dreadful disaster. We were sending millions back because we didnt sign up enough children. We came in and with lindas help 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. Because ive heard from a lot of good folks at dmass, we went from the bottom of the peril to where we signed up our eligible children. We were recognized as one of the most effective chip programs in the country. Shes gone on to serve and has come back to dmass. 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. Well go right down the row. Its a tradition on this committee if you could perhaps 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 leann george and as the senator indicated im from Johnston County North Carolina. Thank you for the opportunity to be here today and meet with you and share my familys experience and how it impacts families like mine throughout our great country. Im married to a wonderful man named jim. He is a marine corp vet. Hes in the third year of an electricians training program. I have two children, ser ren knee who lives in a group home and my son caleb. Both my children are on the autism speck truck. Caleb has adhd as well as a genetic nur logical. While im not here to testify on behalf of mack pack, it wausnt until i was appointed to the commission i realized chips future was so uncertain. I was not aware that chip was in danger and that the children of working class families like mine were in jeopardy of losing their Health Insurance. And while there is need for the waivers i already said that part. Im sorry. As the commission discussed chip Program Began to wonder just how would losing chip impact my family. How would it affect the month le premiums we pay for our insurance . Would caleb with access to the services he needs . How much would it cost us . With our current Health Insurance plan, there would be no increase to our premium because my husbands plan only covers employees or family only coverage. Theres no employee and spousal coverage. However, it has a very high deductible which already prevents my husband and i from accessing medical care that we need. This in short means that the services that caleb needs would be pretty much out of our financial reach to get for him without chip. These Services Include Occupational Therapy which addresses motor challenges that impact his ability to write. And perform basic selfcare tasks like tying his shoes. He receives periodic mris which allows us to be proactive in treatment which results in Better Outcomes for our children. My son takes daily medication which helps him be able to focus in school which impacts his grades, his ability to learn. Over the years the chip program has provided all these services to us for little to no cost. Even in years when weve had cost sharing, chip is still a tremendous value for my family. Without chip coverage, his access to services would be greatly diminished. Chip 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 that he continued his medication that he needed, but i was able to feel confident caleb had the services and support he needed should he become sick. Im so thankful ive never had to call his pediatrician and say im going to have to cancel our pointment, we dont have insurance. Ive never had to watch him lying in his bed sick with a fever and not be able to pursue medical intervention for him. Chip has meant my son has continued to receive the services he needs without interruption despite what challenges my husband and i were facing. If chip was to go away, families like mine would be forced to make tough decisions for our children. Monetary resources are already stretched thin. Families have to ration medical care which can result in something that appears minor right now that progressing into a very serious condition. Other families may procrastinate which could lead to tragic accidents occurring. If we were not able to afford my sons medication, i know his education would be severely affected. Among sacrifices we have to consider activities that our kids participate in. Caleb is a boy scout. Hes been in scouting since he was in the first grade. He earned his arrow of light this past year in cub scouts. His uncle and his cousin are both eagles and hes so excited about earning his eagle and i want to see him grow into the young man with the principles of the boy scout law. While theres a lot of support for these programs that teach leadership and discipline as well as promote healthy and active lifestyles, losing chip can really put a hindrance on families to continuing these activitying for their kids. Sometimes we have to sacrifice for our children, our parents. My daughter lives four hours away from us. I would like to go more often than i can, but without chip, it would be even more limited in our ability to monitor her needs from where we live. There are 9 million children that there are 9 million children who receive chip. This Program Provides parents and families peace of mind and Financial Security. Without chip, life is going to be will be a lot harder. I dont even want to picture or imagine it but i know its going to be and the impact it will be on our kids for years to come. I ask you today to continue funding chip and i want to thank you for your time to determine the future of this great program. Thank you very much. Thank you, ms. George. I know you speak for a lot of parents. We very much appreciate your being here. Dr. Schwartz. Good morning, senator wyden and members of the finance committee. Im ann schwartz, eck tiff director of mack pack. As senator wyden noted we are charged with analyzing and reviewing chip policies and making recommendations to policy. The secretary of hhs and the states affecting these programs. 17 members are appointed by gao. While my statement builds on the anal cease conducted by macpac staff, it we appreciate the opportunity to share and the consequences for children and their families are significant. Since its enactment with strong bipartis bipartisan support in 1977 it has played from 1997 to 2015, the share of uninsured children in the typical chip income range has fallen dramatically from 22. 8 to 6. 7 . Chip has stayed administered and jointly financed by the federal government and the states. Flexibility and Program Design is one of its hall marks but some States Running chip as an expansion of their Medicaid Programs and others operating entirely separate programs. As you know, without congressional actions, states will not receive any new federal pu funds for chip beion tyond the f this month. 27 states will do so by the Second Quarter of fy 2018. In the face of uncertainty many administrators are already considering the numerous steps they will have to take to freeze enrollment, scale back or shut down programs. While they do not wish to alarm beneficiaries, states report they cannot continue indefinitely with business as usual. Mindful of this date the commission issued its recommendations last january after devoting considerable attention over several years to chips role in our Health Care System and policy approaches for the future. We reviewed Available Evidence about the quality and afford ability of chip compared to other alternatives and focused attention on the implications of various policy approaches on children and their families, states, providers, plans, and the federal government. Based on this review and in light of consider uncertainty now facing Health Insurance markets macpac recommends federal funding for chip be extended five years. If the funding is not renewed 1. 2 milli 1. 2 million children will lose their coverage. While some may be eligible for coverage privately, they would have to pay considerably more than under chip creating barriers to needed health and developmental services. In addition, they would lose access to Services Covered by chip that are not typically covered by other payers. Those covered by Medicaid Expansion chip would not lose coverage but there would be a shift in coverage to the states. The 23 point increase. These linked recommendations reflect the view that an extension to the moe which judge important to regaining gains in coverage should be acompanicomp by enhanced funding. Some states to expand coverage to previously uninsured children. Macpacs recommendations also look to a future in which a more seamless condition of childrens coverage can be created. It would remove gaps that occur when children transition among different sources publicly and privately financed coverage. Recognizing that states will be the drivers of such change we recommend that demonstration grants be made available. Our other recommendations call for an extension of other wild focus programs that are typically reauthorized with chip. Chip has clearly played an Important Role in providing access to care for millions of children. And has provided a platform for state to reach eligible but unenrolled children and focus on high quality pediatric care. Congress faces an important decision regarding the future of chip during a period of great uncertainty of other Health Care Markets. Our recommendations provide guidance on how to ensure a stable source of affordable coverage for low and moderate income children amid uncertainty and act as soon as possible to extend chip to prevent children from losing coverage and access to care and to ensure the states have the necessary funds to provide the services. Thank you very much. Ms. Nablo, welcome. Lets make sure your light works. The lights on. Now it is. Its going fine. Okay. Thank you. Thank you for allowing me to speak to you today on the importance to states of continued funding for the Childrens Health Insurance Program and thank you senator warner. I remember well when you were governor and enrolling every eligible child was your top priority. I particularly remember how you would ask every friday without fail how many more children we had gotten covered that week. So before you ask let me say th virginia there are 614,100 children covered by medicaid and chip. These are the Health Insurance plan for what is slightly below the national coverage. However theyve chose tone design their program it plays a vital role for all of us to children have access to appropriate health care by building on top of a much larger Medicaid Program. Chip 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 chip is vital to the health of children and second, that there are serious consequences lumi consequences looming if you delay reauthorizization even for a few moments. In va there are over 58,000 enrolled in medicaid but funded by chip. There are 65,000 plus enrolled in our separate program we call famous. We also have a chip waiver to provide prenatal care to pregnant women and about 1,100 are currently enrolled. Virginia receives 88 federal funding for this program and in the last two state fiscal years has this money has paid for hundreds of thousands of well child visits and imnieizations. Over 21,000 pairs of glasses and well over 67,000 visits to the dentist. But also 258 heart surgeries, two liver transplants and one heart transplants. 31 children living with h. I. Vichv. Obviously chip 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. They can seibert in school or get their teeth fixed. For other children chip has provided life saving treatments. This is true in my state and in yours. But without congressional action soon states will be forced to start preparations to shut these programs down. You have heard that most states will not actually run out of chip dollars until sometime in the Second Quarter of 2018. Some might believe this means you can safely delay action on chip 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 chip dollars in march. However virginia likes many states covers these children through managed care plans. We pay them a rate retrospect tiffly for the previous months coverage. In march we will not have sufficient funds to pay for the month of february. We will therefore need to terminate our separate chip program at the end of january chl. In in order to give those families adequate notice we will need to send them letters on or about december 1st. Before then we will need to train workers, Call Center Operators and others so they are 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 expend chip funds to reprogram automated eligibility rules and to modify online and paper applications with notices. Countless other contracts for managed care plans, prior authorization reviews, 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 precarious as their costs are less predicted. Virginia is not one of the first states to run out of money. Your state will soon be making decisions as when to freeze enrollment so that to preserve coverage as long as possible as the end of funding approaches. Because we have come so dangerously close to the wire this time, states would be grateful for any quick extension of chip. But i do want to make the point that funding this program in one or two year increments may limit state investment and Freeze Program wrs th programs where they are when the future is so uncertain. I hope you are able to consider the direction of macpac of reauthorizing and funding the program for at least five years. Finally please be aware that for virginia alone if Congress Reauthorizes chip by september 30th but reduces the federal match rate to previous levels, we will experience over a 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 chip has always had strong bipartisan support. With all the difficult and complex decisions you have to make about health care in america, surely whether or not to extend chip is not one of the hard ones. On behalf of states, i am here to ask you to please continue support, your support of the Childrens Health care by straightforward reauthorization for continued funding of chip at current levels and please do it before we have to send those letters. Thank you. Thank you, ms. Nablo. Well said and i also appreciated hearing how it was morning in virginia when mark warner was governor. And everybody got their daily report on how many kids got covered. You all have been excellent panel. Let me just start with a couple of questions. Ms. George, id 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 kay for calebs medications . Because it sounds like those are pretty pricey and youve talked to us about a whole variety of assistances which obviously a parent cares about. But how would you pay for calebs medications . Right now im not really 100 sure. Id probablying asking my mother for more help than we already get. Right now caleb and his class take a class that helps my husband with some arthritis challenges and helps caleb immensely. That would be one of the 50 thin first things wed have to drop. We put money aside each month so when the boy scouts go to summer camp. Were looking at 3,600 a year we have to find savings for for his medications and thats if they dont go up again. Lae thats about a tenth of our income. Just trying to find that savings can be a challenge. We can probably get half through 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 its tight, but you get along. You try to do obviously right by your kids. I just kept looking at calebs medications and i cant figure out how youd be able to pick those up without some magical approach that we havent talked about. So ill probably want to ask you some more about it. S in nablo, question for you, you really gave us a very concrete and specific case about the kind of bedlam that we would see in the state of virginia if this program, you know, was delayed. Can you tell us, because youre an authority on this subject, 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 what virginia does as representative, what other states have other problems and just walk us through, if you would, 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. So the problems you described would essentially be worse elsewhere. Absolutely. We have obviously as has been stated, there are several states that will run out of funding before the end of this year. Theyve really got to be think being notifying those families soon. 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 states a little bit different and every state is constructed a little differently. There are some that i think are really kind of reaching the desperation point now. I suspect if they dont hear something in a 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 has never shut down a program before. Okay. Well said. Youre talking about people getting a signal in a couple weeks. If Congress Plays stall ball on this, there are going to be real consequences. Absolutely. There will be some 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 thats preferable . I mean, my sense is that gives some certainty and predict zaib ability, but youre the expert on this. Certainly. Last miatime we made a recommendation, our recommendation was for two years. And at that point there were some hopefulness that some of the uncertainty in Health Care Markets that were even a future in the congressional debate at that time would be solved and its clear that now, if anything, things are more uncertain. Were not sure about what the source of coverage would be available to kids Going Forward. With the uncertainty affecting medicaid and the Exchange Market as well as provide coverage. It was the commissions view its important to put kids in a safe space while these other bigger issues are debated and figured out. And that was why the Commission Recommended a five year extension to ensure that families would have stability and assurance of coverage. That states wouldnt be in a position where they were constantly having to be sort of a groundhog day situation of going through the steps that 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. Its a Critical Program. Its a program that helps millions of children. I want to thank our witnesses and ms. George for being here and sharing with us your story but for the other witnesses your help and support of this particular program. In nevada chip 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 low income children. Nevada has made Great Strides when it comes to improving or uninsured rate. This is something that both governor sandoval and myself are quite proud of. Its my Hope Congress will act swiftly. To reauthorize this program. Give families in nevada and across the nation the certainty they need when it comes to Childrens Health care. With that id like to ask a question or two, specifically to you ms. Noblo because of your background and expert tas aise what you were able to accomplish in virginia. Thats 25,000 in nevada children are covered. Its estimated probably 9 million across the country that benefit from this program, but they also estimate theres roughly 5 million children that remain uninsured today. So with your expertise, your background, your 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 Actually can cover the children of working families. And there are many families who never in their life considered that they might be eligible for a publicly funded Health Care Program and someone loses their job or their hours get cut back and all of a sudden they are eligible. Theyve never paid attention to the ads before. So its a constant need, a constant drum beat, because theres always a new population. A plant closes, whatever, that creates the progress. Thats one. Plus there are certain populations that have higher insurance rates that are difficult to target but states need to make those efforts. Teenagers are much less insured than young children. Hispanics are underinsured. So it takes special efforts, special out reach and quite honestly funding for out reach is one of the first one that goes when states gets strapped. Thats a Constant Campaign to kpe keep that up. I think perhaps maybe macpac has done some analysis of those 5 million still uninsured, a good percentage, i think its 60 of them would be eligible 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. Also its important that that number of children who remain uninsured include undocumented children who would not be eligible for programs in different states. Do you anticipate that this number is climbing or is it actually Getting Better at this point . I think weve seen a consistent drop in the uninsured number for children. Going back to 1997 and that was the primary motivation for the commission to recommend an 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. Noblo, based on the barriers that you just spoke about, what can we be doing better here in congress to address some of those issues . One i think theres even a recommendation of macpac that money that is set aside specifically targeted for out reach right now states generally take that money out of their admin dollars that are allowable. Those dollars get stretched to all kinds of other things. So having a set aside, if you will, that is meant to help states continuously promote this program i think would certainly be helpful. There are some policy changes that could make it easier for people. There are some states that still have a required period of uninsurance before a chip a child can become eligible. Does the law allow any out reach . Yes. You 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 gets, the bigger your admin budget gets. But that needs to pay for workers and i. T. Systems and all that kind of stuff as well. But thats where most states are able to find some dollars for outreach. 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 and of course i want to thank the chairman hatch for his work today as well as his leadership over many years in a bipartisan fashion. This is an issue and were particularly grateful our witnesses are here, but were also grateful that youre here at this time. Because we need your voice. 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. And im going 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 so 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, quote, the chip program is to provide the services for little or no cost. Chip, and im quoting again, is a tremendous value. You talk about Financial Security and peace of mind. All of that testimony is critically important that we hear from you as a parent and hear from you as someone whos deeply concerned about your son. I 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 i would be looking for is a way to appeal the determination as an advocate. But, you know, it would just be a challenge because i look at caleb and his needs with education. His medication primarily is so important because without his medication, he can barely complete half of a worksheet in kindergarten. Within a week or two of having the medication, hes now completing two worksheets. This medication allows him to stay focused. Without being able to focus on what youre doing, you cant do more complex math. Right now were doing long division. Without his medings, put that ae because theres too much involved in that. How are we going to pay for the medication . How are we going to address his penmanship . We started Occupational Therapy over the summer. He started from not being able to write leg ibly. Now he writes fairly well. Its just so critical. It will impact him not just today but as he goes into high school. As he goes hopefully into college. Into being an adult. That if he doesnt have these skills, then hes not going to be able to achieve what he could achieve. Thats why i think its such a tremendous value with the early intervention. As a Family Member it would be devastating to find out that all these things weve been to build him up were no longer going to have access to. Were grateful for that testimony. I know if you must just multiply that in one state like in my case pennsylvania as of august we had over 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 caleb does. So were grateful for that testimony. Im almost out of time, but dra schwar dr. Schwartz, i wanted to ask you im sorry, i was going to ask director noblo this. Has the risk to chip funding already impacted your state in administering the program . I will say no. Weve been very cautiously optimistic so we havent made cut backs. We just ended an outreach campaign. It was the first media buy we were able to do since senator warner was governor and it did boost our enrollment but weve 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. I think there are other states that have had much more serious consequences. There are states that have prepared the notices, that are actively engaged in shutting things down or being ready to pull the trigger. Dr. Schwartz, ill send you one in writing. Thanks for much. Thank you, senator casey. Senator scott. Thank you, sir. Thank you to the panel for being here with us this morning. Ms. George, thank you and your family for your service to the country. Your husbands service as a marine is greatly appreciated. I will say that as many of my colleagues know i have a passion for helping our most vulnerable. Our kids access quality education, whether thats through school use programs or apprenticeship the. Anyone ever has stepped into the classroom appreciates how it helps in the classroom and life. For children across the country including 80,000 in South Carolina chip plays a role in ensuring that our young folks are healthy enough to learn and thrive. Considering the way which chip shapes educational outcomes for many of our students we need to look no further than the issue of asthma. It is the most common chronic condition among children, a leading cause of disability and with bronchitis it is the leading cause of hospitalization among children in South Carolina. It is also one of the leading causes in absenteeism. When a child is struggling with asthma or another condition that impacts their ability to succeed in school, chip can help remove some barriers for familyings that are often up against a lot of other challenges by producing healthier children we also produce children who can be fully present in the classroom, fully invested in their studies, and fully prepared for a fruitful educational journey. Shortchanging Childrens Health produces a vicious cycle whereby Poor Health Care leads to lower academic achievement and poor academic out comes. In turn diminishes long term health. Ms. George i want to say thank you again for the opportunity to listen to your story and to understand and appreciate that youre here not only as an advocate but as a mother. Can you please talk with us as the chairperson of the counsel of Educational Services for Exceptional Children and how you have seen the connection between Health Services that students with exceptional needs receive and the success that they are able to achieve in the classroom. Well as you know through i. D. E. A. Public School Students have access through free and public education. And their ieps. Other services such as Occupational Therapy, physical therapy, speech therapy, the list goes on and on. Some of that is funded through public insurance such as chip and medicaid. The abilities there is a lot of students receive these services. Its just very much beneficial to them. Excellent. Same question for you, maam, as a mother, youve come before us and i wanted to i understand and appreciate we certainly have heard senator warner 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 Occupational Therapy as i shared a little bit earlier, with his penmanship, he was completely ill legible. We started home schooling him. Were in our second year. We could not read his handwriting. So we were able to get private therapy and hes made tremendous progress between that and constantly redoing it at home f. You cant read somebodys handwriting, you cant write a letter. You cant fill out a job application. Even in this Technology Based world, its still a vital skill. As well as i notice with him when doing multiplication and long division, when hes trying to lineup and add his numbers, you couldnt read the number he wrote and hed come up with the wrong answer and it impacts his education there. Thank you very much. Thank you, senator scott. Senator warner is next. Thank you, senator wyden and let me again thank all of our witnesses, ms. George, dr. Schwartz and, linda, its great to see you again. Ill direct most of my questions i hope with appropriate due respect to ms. George and dr. Schwartz. I also want to commend by the way, when you referred to the days that mark warner was governor, did you mean the dark days . They were already called mourning in virginia. But i think one of the things that i hope particularly ms. George will take back is that its area to have a program where people on both sides of this are all saying good things about the program. I hope it gives you a little more faith that we can get our act together and get it done in a timely way. Dr. Schwartz, i particularly appreciate all the kind of broader policy goals youve looked at and the extension time youve set. I think five year beyond the extension at least. One of the things id like you to talk about, i dont want to be so many of these families, their incomes fluctuate so much between month to month. They may be eligible medicaid eligible at one point and then chip eligible at another point. On a Going Forward basis, is there are there better ways for us to make sure that people dont have to constantly reapply and we can streamline and people would all fall within these and dont have to spend their time as they bounce from one Program Qualification to another . There is an option for states of making the medicaid or the chip program for children, you will be continuously eligible for a 12month period. So even though your income may fluctuate and you may drop down to medicaid or go up to being not eligible for the program, that 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. That would be wonderful if that was sort of part will you keep that as an optional basis on reauthorization . If we really truliy wanted t address that concern, it wouldnt be optional. In virginia we have a version of that. It does say that if your income goes up, you have to report that. But youre absolutely right. Peoples its a lot of Seasonal Workers here. Theres a lot of people who get extra jobs over christmas and their income changes. We have School Teachers with children on chip. So its a constantly moving target and fluctuating environment for families. To expect families every time somebody works a few more hours to report that and ask an el eligibility worker to figure out if that makes a change or not is really not the smart way to have this coverage. There could be a look back after a year, but this bouncing between income levels is really i think important. Absolutely. And in states with a benefit package between chip and medicaid are very different, that alone can cause problems. You may lose a provider. You may still be eligible for coverage and medicaid, but perhaps your provider isnt a medicaid provider. I think weve heard from senator scott and others that in terms of plain old business, making sure that child, making sure caleb goes to School Healthy and its going to make him a better student. I think thats what hopefully you look at the long road, the long picture and does it make sense that we have programs where families could potentially bounce back and forth almost month to month. Talk to me a little bit about the importance of out reach and particularly Rural Outreach since there are so many communities. I know weve got online signups. But the truth is, many families may not feel comfortable doing online or going to a library and putting very important data into a computer without an outreach worker. Talk about outreach and more specific lie Rural Outreach. Certainly. As you know very well, we the state we employed a few outreach workers and we do try to position them around the commonwealth, but another thing that we do in virginia is we use some of our chip admin dollars to help support a project for the Virginia Health Care Foundation of which youre the founding chairman. And that project, they also get a federal grant to do the same. And so their reach is more extensive across the commonwealth in trying to help families. And we do still, even in this day and age, we still get a healthy proportion of our applications on paper. Even though the form is not particularly friendly, i mean, 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 you know, 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 from an eligibility working to help complete that form or to follow it through. Thats where the outreach worker, they will meet you at mcdonalds. They will meet you at their home. They will meet you at your home. They will find a way to sit with you and a time and a place that works for you and help you through that process, help you understand the questions and get the 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, we are still a bur okay ras see. Without that hand holding, without that 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. Thank all of you. Thank you for your continued great work in the commonwealth. Senator bennett. [ inaudible question ] if we can have just the people in this room. Well have to see what happens when others come. Thats very nice. Thank you. Senator warner briefly talked about outreach. His george, how did you fine out about chip coverage . When caleb was born he was qualified for medicaid and it was pretty much a seamless program over in North Carolina. At least it felt like to me. And i guess executive director schwartz, can you talk about and i know, im not sure you can talk about this country wide, but im really curious what kind of outreach is 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 billboards or anything like that, ive never i dont recall seeing anything talking about chip in my state. Is it a more targeted through the medicaid population . Theres some children qualify for this in my state that wouldnt qualify under medicaid. As with all things, chip and medicaid, it definitely varies from state to state. There are 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 ad buys are the things that you and i would notice. We do here have heard quite a bit in medicaid about people wanting that personal touch when signing up. Many people who have been theyre very nervous in submitting an application. They want to make sure everything is correct, and so that last touch with an outreach worker really gives them piece of mind that theyve done everything to ensure that the enrollment goes through properly. That would be a similar role as to the navigators and the aca . Very similar. Which by the way i would point out theyve just cut the budget 40 for navigators and aca and the advertising budget by 90 . Which is a real problem. Could you address, could the two of you address what impact would cuts to the Medicaid Program have on your work . Assuming that there was success which we hope there wont be, but if there was success in cutting the Medicaid Program as has been proposed a couple ever different times in the context of an aca replacements, 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 were that have 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, choices that would reduce eligibility levels in medicaid, they would also 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 admin straight ors. Absolutely. And i would add that medicaid obviously takes care of the lower income children. It also frequently takes care of the sicker children. Waivers, disability waivers, et cetera oftentimes a chip a child may well be in the chip income range or even the private insurance income rarcnge, but given medical expenses and the state of their disability they become eligible for medicaid. If medicaid is curtailed, if enrollment is, you know, has to be rolled back because of funding, for those children were to become eligible for the chip 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 from coverage under the chip program. That would be my assumption, yes. Thats the way that i think its been looked at is that 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 end up in an emergency room uninsured in the most expensive care possible which all those costs are passed on to us. Thank you very much. The ever gracious michael bennett. Thank you, mr. Chairman. To add to that, let me say words that have not been said in the senate before. My questions have been asked. And ive spent but not everyone has asked them. Thats true. Thats a habit im trying to have us break. But i ive spent the morning in the Health Committee where were trying to work on a bipartisan solution to our Health Care Issue, so i apologize to this very able panel. Your testimony was excellent. Its really critical that we reauthorize this program. Chip has provided low cost Health Insurance for about 90,000 kids who did not qualify for medicaid in colorado but are still unable to afford private Health Insurance. Colorados working families benefited by chip for increasing coverage for kids and driving to an alltime low. On both sides of the aisle everyone in this room can agree our children need to be covered whether its through chip or medicaid which covers over 400,000 children in my state of colorado. Chip also covers about 600 pregnant women in colorado and for these women they have peace of mind knowing they will have a provider to go to for maternity care. Without reauthorization as these witnesses have so ably stated, the chip program, colorado may stop enrolling new children as of october 1st. They would have to move forward with Emergency Planning that would be a disaster for us. So mr. Chairman, all i would like to do is with your permission submit for the record a letter from the colorado chip coalition which includes over 70 organizations asking for reauthorization of the program. That is ordered. Thank you to the panel. Thank you senator bennet. At this point ms. Delman. Thank you very much senator for your leadership and the chairmans leadership. This is an issue that has traditionally been bipartisan. Im hopeful well be able to continue with the long Term Extension in a bipartisan way and do what children and families across michigan and across the country are counting on us to do. We know that 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. Ms. George, thank you for speaking for your family and your experiences. I can tell you right now the good news is that 97 of our children can go to the doctor. Thats a very big deal. The highest ever because of changes that we have made through 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 as you have been talking about the sense of urgency, were about to see that health care go away. And we dont need a short Term Extension. What we need is to fully fund the program and give states and more importantly families the peace of mind of knowing they can continue to take their child to the doctor and give them the certainty 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 share one story before asking questions. I talked to so many people in michigan. So many families that are so glad that they have the opportunity to not worry in the middle of the night whats going to happen if the kids are going to get sick but have the confidence to give them the care they need. One of my constituents jan wrote me a letter saying from the time my daughter suzie was young we knew she was going to need extra help, she was diagnosed in second grade with adhd and we proceeded to try a medical solution to her attention problems. As she got older she was diagnosed being bipolar and required a different approach to control her mood swings. Without having access to Quality Health care, we would have been lost. And thanks to my child and michigan chip program with a premium of only 10 a month we were able to afford the help she so desperately needed. Shes now a High School Graduate with the goal of attending Community College and we are so grateful that we have 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 suzie. And i want to thank you again ms. George for coming today. I want to take a moment because my questions on the cost of prescription drugs were ably asked and answered by senator widens question because that is such an important part of health care today and who run health care. Theres another piece that the senator 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 we have been working on this for some time together. Theres a Broad Coalition of organizations supporting this. Theres so many that i its hard to know who to thank but i want to thank the march of dimes in particular for incredible advocacy on this. 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 fiveyear extension of the Pediatric Quality Measures Program which were building off of. I wondered 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 pete yachtic quality measures program is intended to help fill gaps and also to work with users of measures to make sure measures are not some academic exercise but can actually work for in terms of reporting and in 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 corset that cms uses and there are measures related to labor and delivery and prenatal care in both the adult and child corset. Thats obviously a dynamic process and over time measures have been introduced into that and taken out as our understanding increases and i do think its important we talk about value to the beneficiary and to the taxpayer these programs and certainly the av l availability of valid and reliable measures is an important part of that value equation. Thank you. Senator weiden, i want to thank you and the chairman for supporting our effort for the quality of care for moms an babies act last year. It would add to the strength and the quality of whats before us now. I very mooch appreciate what senators are trying to do here. It has been supported in the committee and look forward to working with both my colleagues. Thank you. At this point the also gracious senator karden said it would be fine if senator grassley went. I think senator grassley had a relatively short set of questions. I appreciate everybody appreciates everybody. I think i have a fairly 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 thats called hawkeye, not exactly spelled the same way as hawkeye football team. Its healthy and well kids in. By hawki. It provides up to 302 of fpl. Because of this Program Children can receive life saving vaccines, medicines, doctor visits, 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 to dr. Schwartz i want to ask you about the 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 ive introduced that with senator bennet who already has 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 of specialized pediatric doctors 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 Integrity but make caring for these children more streamlined . Its my understanding that the ace kids act has evolved over a number of months or perhaps maybe longer than a year in terms of its scope and size. We have not looked at it recently. Its something we would be very willing to do. Both at the staff level and 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 without looking at it without the bill i ask about . I think the population of kids that its my understanding that the ace kids act focus on children who are extremely sick and tend to have quite a number of hospitalizations. Its a very small population, needs specialized care and need care outside of their community and maybe in another state. That does create potential challenges for states who are very scrupulous in Program Integrity and knowledgeable about the providers in their state. 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. Any advice you can give about the bill but also any consideration you can give without even the legislation of enhancing that would be very much appreciated. I thank you and thank senator carter. Thank you senator grassley. Thank you mr. Chairman. Everybody is thanking everyone else. I heard your Opening Statement and i identify with it and thank you for your leadership on the chip program. I just really want to underscore how important it is for us to timely reauthorize the chip program. Theres 143,000 marylanders covered under the chip program. In this fiscal year it costs about 275 million. Now 275 million the total cost of the program, the federal shares about 241 million. The board of public works in maryland just approved a budget cut mid term because budget deficits in our state. There is no conceivable, possible way that the state of maid can fill the gap under the chip program if its not reauthorized in a timely way. If we dont reauthorize in in a timely way theres 143,000 maryland children who are at risk and i wandted to underscor that. I was proud in the reauthorizati reauthorization, the offer to include mandatory dental coverage was included under the chip program. Now, mr. Chairman many have heard me talk about this before. This was as a result of a tragedy that took place in maryland in 2007. Two years before the reauthorization was enacted into law. And it occurred about 7 miles from here. In maryland. A 12yearold who died because he could not get access to dental care. He had an abscessed tooth, needed to find a dentist who would provide about 80 worth of dental wacare and could not be seen. He ended up becoming abscessed and infected into his brain. A couple operations later he lost his life. That motivated the congress to take action. I was pleased that we did. 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 the success of students in our schools. You cant really learn if you have tooth problems and pain. So we have made tremendous advancements in dealing with pediatric dental care as a result of coverage within the Childrens Health Insurance Program. Im proud of the progress that we have made. After we included dental under the chip program we also included pediatric dental under the Affordable Care act. So one might think well, now, if chip is not reauthorized wont we still be protected under the Affordable Care act and the answer is yes, but not to the same extent that we have under the Childrens Health Insurance Program because of the match, cost sharing and the states can put caps, et cetera. So theres a significant difference for oral health for children if we dont timely reauthorize. 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 we have 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. As you pointed out, pediatric dental is an essential Health Benefit but the way the exchanges cover dental its often not included in a comprehensive package, can be purchased separately but it is in fact much more expensive. We did not find a tremendous number of differences between chip and Exchange Coverage but audiology and dental are the two we found just as you say. I was proud of maryland that all of our carriers included pediatric dental within the prime contracts. We had the separate policy but there are places you had to get a separate policy and had to run into the cost sharings and capping that could be different which causes problems. Do you want to comment . [ inaudible ] microphone. Microphone. Sorry. What occurred to me was that we are always very cognizant when we do outreach for the chip program of highlighting it involves dental care. Thats extremely valuable to parents and i suspect it is for parents who dont have a particularly sick child at this point, it is one of the big 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 point out in closing that one of the side benefits of the chip program and oral health for children is that we have dentists access in communities that didnt have that access before. So its not just coverage, its also the providers are now in communities they werent before as a result of the chip program. Thank you mr. Chairman. Thank you senator. And thank you for again highlighting the importance of dental care. Now, heres where we are in the order. Senators thune is next. Senator cantwell and our friend from delaware if thats all right with colleagues. Thank you mr. Chairman and for holding the hearing for the Childrens Health Insurance Program. I want to thank all our witnesses for joining as well especially ms. George. In my home state of south dakota chip serves more than 50,000 kids in a given month and we run a Combination Program and our state projects if chip expires nearly 12,000 kids will be shifted to medicaid and more than 3,500 can lose coverage all together. We can agree that this program is bipartisan support and critical we Work Together to ensure kids continue to have access to uninterrupted coverage. It sounds this ground has been plowed already but i want it for purposes of my states interest to ask the question of ms. Nablo and the administrators of chip in south dakota talked with us about the importance of maintaining state flexibility to determine benefit structure moving forward. You mentioned that in your testimony as well. From a state perspective, are there other areas where greater flexibility might be needed so that states can best meet the needs of their populations . Well, 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 Substance Use disorder benefits to help address the Opioid Epidemic and added those for children in our chip program and for the pregnant women in our chip waiver so the ability to do that was very helpful. The story in virginia is we started out with a very restrictive program. Had some of the most restrictive policies in the country. For example, we started out with a 12 month forced period of insurance before a child was eligible. That later went to six months and went to four months and we have since abolished it. That is the ability of the state and given where the legislature is and what people learn as they two along with the program about whats needed and as they become more educated about familys needs theres a constant and continual improvement to the program. I think states appreciate the flexibility a great deal. Its one of the most attractive features originally for states taking up this offer in the first place. I think they would be very concerned if that flexibility went away. Okay. Dr. Schwartz, south dakota raised the importance of states continued ability to carry over funds. You raised this issue in the context of how long states will be able to continue to run chip programs and raised operational considerations associated with extending the program. How quickly can states respond to congressional action and i would also i guess direct to ms. Nablo how quickly you would expect virginia to be able to respond . But dr. Schwartz . When mackpack made its recommendations we set ourselves as deadline at the beginning of this congress so you could act quickly to allow states to take the time to plan for the next fiscal year. Obviously many months have elapsed since then. States have held off 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 the clock really is very close to having run out. I think the other point i wanted to make clear is that mackpack has put out these figures noting when states will run out of money and that is not meant to say congress can wait until that deadline to make a decision. Its really important for states to have the certainty right now so they can plan appropriately so that these programs are run in a deliberate and professional manner. Any response . I would say the challenge is not so much how fast can we respond to any changes you would choose to make. The challenge is much more how long can we wait until you tell us with certainty there will be funding and what level it will be. I think for some states were weeks, a few weeks, maybe a couple weeks away before they start having to take proactive measures to start shutting down. For virginia as i said earlier, i have a long todo list in my briefcase today of things that will need to happen and that todo list starts in october for us, beginning to do the training and system changes and all the things that will need to happen. 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 legislature comes to town on january 10th and i guess that would be the first problem they would be have to face is what do we do with that kind of a hole in the budget . And it gross the next year. Its really more a matter of were waiting with baited breath to hear from congress. Thank you. Thank you. We started actually a couple hours ago with that question and now as we move forwards the end im glad you have highlighted that because this is not something were in the traditional washington situation, you have the amendment to the amendment and maybe it happens and maybe it doesnt. Your question again is now highlighted this morning shows this has real consequences if the theres delay and i appreciate you bringing it up as we get wrapping up. Senator cantwell. Thats definitely the line i want to follow as well because im from washington and we like efficiency in our Health Care Delivery system no matter whether it is talking about chip or adults or what have you. I want to say i so appreciate your testimony today. Being here, you really highlighted what this issue is about and its about giving families the ability to take care of the needs of their families. I so appreciate that youre son is here as well. I wondered if we could just i was so touched by your story. Is it okay if we give him a round of applause. [ applause ] i dont think we can ever forget the people who are affected by the program and what it means. I think that when i think about ms. George and her family, i think about the modernization of chip. Our state, we cover children up to 211 and cover up to 312 through chip. And yet we have families at Different Levels and one thing we have seen in new york with the basic chip plan is a front door that allowed families of chip no matter whatever the injury was to then get coverage. It also has driven up costs for everybody, for the state, for the federal government. Its made the program streamlined and efficient. Do you think theres more to do dr. Schwartz in streamlining this program thinking about both children and adult making sure theres coverage and cost savings in the administration side of this . Theres certainly always work to do. I think one of the things that the Commission Recommended was demonstration grants to states to try and think about how to better coordinate different sources of coverage. We know 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 a change in their life circumstances and you lose continuity in care and have gaps in coverage. Theres more work to be done. Were meeting next week and one of the things were taking up is a broader inquiry around medicaid to assess where we are with the streamlining of eligibility enrollment and renewal processes to be able to say what more work needs to be done. Apparently my mike wasnt working so i dont know if everybody heard the question that i asked. I think so. I would agree with dr. Schwartz. Both within the Health Care Arena and also just other federal programs like snap, et cetera. There is a great deal of difficulty, disparity, differences in how t there is a great difference in how you account income etcetera that is extremely confusing for families and difficult to administer. Even if you are successful in the Health Care Arena moving from chip to medicaid or back where your family gets coverage on the exchange the benefits can be very different. The doctors can be very different. The copayments, deductibles can be extremely different. It creates an extremely confusing atmosphere. I think i probably creates cost too. Streamlining that theres a front door and that we do so in the most Cost Effective way considering we are likely getting coverage its just not in a uniform way. I regret that we identified this when we were doing the Affordable Care agent but some of our colleagues thinking more about chip at the time and less about this con fluns that was going to happen. I wish we would have offered innovation to streamline because i think we could have given more certainty to those families. I certainly think well take a look at that now because i think its one of the keys to making this more affordable for everybody. Thank you. Thank you. Oregon has always seen itself in a partnership with Washington State on these efficiencies. I think the point you have made is important because inefficiency wastes money. To our colleagues here the four senators are all democrats. I would just note that our dharm chairman, to maybe none more important than his work on senator kennedy on the Childrens Health program. I look forward to working with the colleagues that are here but with certainly senator hatch to ensure millions of kids including about 18,000 in delaware are receiving Health Insurance coverage under this program. I was actually in the white house with president clinton and Hillary Clinton on the day this was rolled out. This is one that has special meaning for me and the people im privileged to represent. I have a couple of questions. Thank you for being here. Are you from virginia . You work for the governor there . Yes. I do. Tell him a guy that grew up in roanoke sends his best. Chip serves on 18,000 kids in delaware and about 14,000 in maryland are covered. If we allow it to expire at the end of this month many of the children across the country are going to need to become uninsured or maybe under insured. I will ask maybe dr. Schwartz, can you speak whether they would be able to provide for these children if chip expires and how does it compare in terms of pediatrics benefits and Pediatrics Networks to chip . Certainly. Our Analysis Shows if chip funding comes to an end. There are two different scenarios. Separate chip funding 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 Exchange Coverage but for most of them the cost of those cost sharing would be prohibitive and they would become uninsured. For those that do enroll and those that do enroll they would experience a much higher cost sharing than they currently experience under chip. As i noted earlier some differences in benefits, most notably audology were the ones we pointed out. You mentioned the importance of chip for mental Health Services, basic health care to help children live a normal live. Could you describe for us the role chip plays in treating Mental Health conditions as well as combatting the Opioid Epidemics . Chip has alms coverways cove well, i take that back. It was designed over the state Employee Health plan. It has brought it much closer to the medicaid package of benefits. We dont cover Residential Care in chip but its become a very robust child centered benefit package. A big part of that initiative is to add addiction treatments that are evidence based and are recognized by National Associations as being effective to both medicaid and to chip and to our pregnant women coverage in both of those as well. We have just done that. Most of those benefits became effective april 1. We have seen significant growth. All right. Thanks so much. Thank you. Senator brown. Thank you. First thank you to the witnesses. I would like to submit two letters from Medicaid Services and one from the ohio without objection so order. Thank you. I would add ohio has more Free Standing childrens hospitals than any state in the country and i know that when my friend, the senator from oregon was in ohio he met some of the people that work in some of these hospitals. I would like to ask each of you about the importance of extending chip funding for more than two years. Secretary price testified. I asked him the question of longer extension. I suggested eight years. He concurred and said eight years could make sense. They suggested we extend funding through 2022. Explain briefly why they recommend a five year extension whether it relates to medicaid or the Exchange Market and volatility of the coverage and really a notion that its important to secure the gains in coverage that chip has brought and to put kids in a place where coverage will be available while all of these other problems are sorted out. We have had quite long extensions of chip in the past. The first one was for ten years from 2009 to 2013 and so certainly theres a track record thank you. Thank you for coming today. I understand your son caleb is here. He has his eagle scout. Im an eagle scout. I appreciate that. I know the work he will do to become an eagle talk to me about what it means for a young man like caleb . Probably the biggest thing is knowing that he is covered. We had insurance lapse a couple of months ago because of changes employers. He was effected by that because he had chip. Just that peace of mind knowing no matter what happens to you or your loved ones 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 tremendous. Thats why it is so important for us. Good luck. Let me know what his court of honor is in x number of years. I sure will. It is a lower cost and to improve outcomes we are embarrassingly awful but chip has helped us be more than marginally better. They tell me its difficult to whether the future is uncertain. Talk about what certainty means in terms of stability, in terms of running a department in terms of making this all work especially in terms of innovation. Well, when youre looking at we have come expreemly close to the wire this time. What does it mean for the future . If theres a one year extension or twoyear extension, what it is saying is we are going to be back here two year frs now up against the wire again. So the question you have to ask yourself is what kind of investment are you going to make . How much outreach are you going do when it may not be there two years from now. There is a future in chip call add Health Services initiative where states that have sufficient admin funding can help support other programs like poison control centers. I understand theres one state thats using funding to help supply opioid, the kids that help somebody immediately recover 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 of the paperwork done . It needs to be more than two years. Ill take anything at this point. Of course, but i dont want you to have to come in here. Absolutely five years or longer would be a very well thing for states. I would continue. I know senator widen will continue, at least many of us we will continue to advocate for at least five years. Thank you all. Thank you senator brown. I want to wrap up with a couple of thoughts picking up on senator browns really thoughtful case for how important longTerm Extension is. 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. I didnt just kind of magically show up in america and everybody said hey, we are going to cut the rate of uninsured kids in america. It happened because two very strong willed United States senators, late senator kennedy and the chairman of this committee knowledged they will have plenty of differences on plenty of issues. Both said we have got to do right by kids. We have 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 kennedy and stepping up, step up. Youll hear a lot this fall about how there are all kinds of priorities on the senate calend calendar. We need to make sure chip is way up that priority list, doesnt put us in a situation ms. Nablo describes. It starts to happen pretty darn soon if it doesnt get the attention that its deserving. Now, the last point i want to make is im sure well have discussion about cost. 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 ton the basis of the of 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 generous kind of way. We heard testimony about what it really means to be able to afford these skyrocketing medication prices. I noticed your excellent was well, you know, we probably could figure out a way to do this you said as a mom 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. We either get there for kids like caleb and ensure we can afford medications and you spend a modest amount of money or you basically say we are not going to do it. Well pay and pay and pay some more in the years ahead as a result of that shortsighted thinking. So we have got a lot to do to talk about how we cant afford not to do this. We have got a lot to do to make sure it gets up the priority list. We have a lot do to show it didnt just come about by accident. It came about by extraordinary and 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 tried to specialize in health care since the days when i was director back home in oregon. It has been one ot best hearings. Its because the three of you laid the case out so well. You could see the interest, the great interest on both sides of the aisle. We are walking out of here today knowing that the job will 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. He wants senators to meet with him to talk through their ideas and suggestions and he believes we are confident. We can get a meaningful and bipartisan solution. He would like to make clear that for any that have written questions for the record he suggest they be submitted by the close of business on september 14th and with that the Senate Finance committee is adjourned. This was urgent business because they describe how the consequences kick in very quickly, how you end up waetsing money that would go to children instead. I see it as my job working with the chairman who is an extraordinary on this over the years to make sure that we are going to gate lot on the agenda. I will be telling colleagues this cannot get short tripped. This has got to be way up the priority list. My background is working with the elderly. Over the years with respect to children i touched on it probably in a more garbled way that it ended up costing more and the costs kick in pretty quickly. You know, the costs that you learn and get caught up in various kinds of challenges. But it would be to not make this a top priority. You heard them say 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. I want to have a chance to talk to the chairman about it. I am trying to convey the urgency. I think the chairman and staff have worked very closely with my staff and i. Im very appreciative partnership. I really do see, nobody could ever replace senator kennedy. I joked with the chairman about that. Senator kennedy is the Gold Standard in terms of public service. I will do everything i can to step up in every way possible and be the chairmans partner. [ inaudible question ] i am a very strong supporter of strengthening medicaid. I will have to talk to the chairman. There is a stabilization as well. There has been talk of attaching that to if it needs sort of a rider. What you speculate about that . Other than as the author of the state waiver, the state innovation i have made it very clear what this program is about. 1332 is about giviing states th chance to do better, not an opportunity to do worse. And so anybody who tries to turn this into a program where they can roll back, you know, fundamental concerns will have to rollover me, number one. Number two i think they would be violating the letter and spirit of 1332. The other area i would like to mention is what has been particularly attractive to the states over the last few months is reinsurance. The two states that have gone forward recently have used the existing provisions in the law that i wrote. They use the existing provisions in section 1332 to get the reInsurance Programs off the ground. As i understand it minnesota officials deal that implemented came out of this room under existing law they would be lowering premiums. And some of those ideas around 1332 were very pro proce proceedural. It was really born in my bipartisan bill. It was equally divided between democrats. So im always open to new ideas and good ideas. One of the things i have honed in on is that if a governor can give us specifics about process aspects of 1332 that they feel have caused them problems i want to hear about them. I think we want to come back to the fact that what the states have been most interested in will be reinsuranced. The two examples both were done in existing law. Are you going to push for a five year reauthorization or are you open to maybe like a four year or three year . I will talk to the chairman about it but i want the longest possible extension and the most generous funding. Does that mean two years is off the table . Let me have a chance to work with the chairman. I have stated my colleagues. Even when senator brown nobody is going to have trouble with my preferences. [ inaudible question ] zb zb i want to most generous founding possible. [ inaudible question ] i will talk to the chairman about it. I have already made it clear to my colleague that is we feel strongly about health extenders. I dont want to front run the chairman. Are you just starting to talk about it . We have been talking about it quite some time. How are things leaning . I think he is clear that she a strong supporter of chip. Theres just a lot on the plate. Thats where we are. I am very encouraged about my talks with you. Thank you. Cspan, where history unfolds daily. In 1979 cspan was created by americas Cable Television services and is brought to you today by your cable or satellite provider. During thursdays washington journal we are launching our 50 capitals tour. Join us at 7 00 a. M. Eastern to learn more about our plan to visit every u. S. State capital, the 50 capitals tour, celebrating 25 years of the cspan bus program. Yesterday the u. N. Security Council Unanimously approved new sanctions against north korea that impose a ban on all natural gas imports. This morning the House Foreign Affairs committee is holding a hearing with government officials to discuss sanctions and other options. Well take you there live within the hour at 10 00 a. M. Eastern here on cspan3. Next, a look at the state of u. S. South korea relations in light of north Koreas Nuclear threat. The main speaker is south koreas Foreign Affairs speaker. He spoke for about 30 minutes