Transcripts For CSPAN2 Alliance For Health Policy Discussion On The Future Of Medicaid And The... 20170711

This is 90 minutes. Hello, everybody. Welcome to todays briefing on understanding whats next for medicaid. Im sarah, the president of the alliance for Health Policy. Its a pleasure to be with you today. For those of you that are not familiar with the alliance, we are a Nonpartisan Organization dedicated to advancing learning and dialogue on Critical Health policy issues. To say hello as well to those of us watching on cspan this afternoon, and to those that are joining us on twitter using the hash tag whats next for medicaid. Collaborating with these Melinda Abrams at the Commonwealth Fund, and we think the fund for their partnership and organizing todays briefing. Since medicaid was created alongside the Medicare Program in 1965, it has grown into one of the most farreaching Health Programs in our country both in terms of the number of people it serves as well as their health and life circumstances and the cost of the program. Its run by the 50 states and territories within federal guidelines and is financed by the state and federal governme government. While medicaid policy has national implications, it of course also has major implications for states and their citizens as well. And as we know, major changes to the Medicaid Program has been at the forefront of recent Health Policy discussions, and are included in the legislative proposals in the house and senate and so today we are going to talk about what those proposals are, how they would work and what they would mean in practice based on our best evidence and projections. I just want to make a special note because while it is easy for medicaid policy to get very wanted very fast as the old kind of saying goes if youve seen one Medicaid Program youve seen one Medicaid Program. This has been an issue in a National Conversation and it does hit home for many people so that speaks to the need for continued respectful dialogue on the different perspectives that are brought to the Medicaid Program and that is what the alliance for Health Policy is all about and what this briefing is all about and we are just really pleased to have a turkic panel here today to help us with this discussion. Let me go ahead and introduce the panel and then i will turn it over to melinda. Cindy mann is joining us today. Shes a partner and has been a deputy administrator of the centers for medicaid and Medicare Services and directed the center for Medicaid Services at cms as well. Next to my left is josh archambault, a senior fellow at the foundation for Government Accountability and prior to joining the foundation he served as the director of the center for Health Care Solutions and a Program Manager for the initiative at the Pioneer Institute and also served as the legislative director for scott brown and the Massachusetts State Senate and astate senate r legislative aide for then governor mitt romney. I already introduced melinda. So next melinda is right is chuck duart. And he worked at the university of nevada as the nevada medicaid administrator for the planning and evaluation at the department of health and Human Services as well as a special adviser in the office of the secretary, so welcome to the panel. Melinda has a couple of quick opening remarks and then we will turn it over to cindy. Thank you. Good afternoon everyone. Welcome and many thanks to the alliance for Health Policy and to the panelists for joining us. Ive been asked to briefly frame the conversation. As mentioned, medicaid has taken center stage as we have a number of proposals to repeal the Affordable Care act as introduced. These proposals dont just change the expansion, the recent expansion of the Medicaid Program, but actually addressed the underlying traditional Medicaid Program. So, it is timely to say whats next for medicaid. Before we discuss the implications and here are the range of data and perspectives, it is good to be reminded of some of the basics. Next slide. Thank you. So, the ones that are being projected by the way are not as good as the ones in your folder. So if you want to pull out your folder and then you can see some of the members. Just to be reminded it is a federal and state program. There are federal standards but states have banned enormous amount of discretion on the design and the administration of the program and it currently covers more than 74 Million People and it can be roughly four groups, infants and children, people of all ages with disabilities, low income seniors, elderly and then other adults. Children represent the largest group. In terms of what it covers medicaid covers a broad range of services to meet its very diverse population. It can be covered but its important to stress medicaid covers nearly half of all births. 40 of all children. There is a comprehensive benefit for children that is particularly important for children with disabilities. Medicaid covers longterm care including both nursing home care and communitybased Longterm Services and support. Currently, more than half of the longterm care covered by medicaid is an home and communitybased is being done in the home and in the community but its enabling seniors and people with disabilities to continue to live independently. The fund has for a number of years the Commonwealth Fund has supported research to examine the implications and the effect of medicaid on people. So that is what is in this next slide is some data from some of my colleagues off of our National Survey on our biannual survey, and essentially what it shows is that people with medicaid are less likely than those with private funds or the uninsured to skip Necessary Services or medications due to costs. Other analyses look at how medicaid beneficiaries, satisfaction with their care and that they rate the care actually fairly highly. But its not just Commonwealth Fund data. There was recently a paper in the new england journal of medicine by ben summers and gave it a look back at an overview of the implications and the effect of the Medicaid Program and basically showed those with medicaid that have access to care are more likely to have the detection for the medication regimen. Its not overly appreciated they may have some coverage. So, moving on, another area that we tend to look at is not just the implication for the people and state economies but also the providers. Most doctors reported no decline in the ability to provide quality care since the Medicaid Expansion. So the implications of the various proposals. So to look at the multiple levels whether it is on the state economies and providers. This looks at a recent analysis looking at the American Health care act on hospital finances and what we see is that for all hospitals particularly in expansion states can participate and increase in the uncompensated care so that as a treatment or a service for which there is no injured for and the patients are unable to pay so it is about 78 over the next ten years. It is about 114 million. In the long expansion states expect about a 10 increase in uncompensated care again over the next ten years. They look at it by state, the safety net hospitals. There is a lot of analysis for you to turn to. Another analysis that we released yesterday is looking at the implications of the Better Care Reconciliation Act on the bill on state economies and particularly on jobs. As it shows on the slide if it were to become lost we anticipate about 1. 46 million jobs would be lost as well and is the business output and so not just looking at this at the National Level but the state level and here is my plug for some of the new fact sheets that we have pulled together that are in the back for kentucky and california but theres one for all 50 states. I only covered two pieces, which is the hospital component and the jobs component, because two of our speakers will look at the implications for federal dollars to the state that will be cindy and ben Richards Will look at a subset of the population of people with opioid addictions. With that, i will echo the comment about how we look forward to seeing a variety of perspectives and having the data and evidence guide this conversation. Thank you. Thanks, melinda. We are going to go right down the line. Cindy, josh, chuck and richard. Then we will have time for qanda discussion and again for those of you just joining us, you can use the hash tag whats next for medicaid. Cindy, go ahead. Its great to be here with everybody. Im going to open up with a little bit of an overview, short overview of the changes in the senate bill with respect to the Medicaid Program and then focus my remarks on the provision and its implications for states and the programs and the people that the program serves. I just want to state my appreciation for the support of the Commonwealth Foundation for the support of the modeling work. We have looked at statebystate impacts at both the house bill and the senate bill and i will draw on both of those analysis as i go through my presentation this morning. There is a variety of different positions in the Better Care Reconciliation Act but here are some of the key changes. Like the house passed version of the bill nobody quite knows if you are supposed to announce the initials or say them out loud. But it converts medicaid essentially to a Funding Program with a fundamental change and as it is identified in the basic structure of the program it really goes beyond any changes with respect to the Medicaid Program s said it would convert starting in 2020 instead of a program where that financing is shared by the government, the federal government share would be limited by a per capita cap that goes up to the aggregate and i will explain that would go into effect in 2020. The bill also offers the states instead of the per capita Block Grant Program for the limited population it generally applies to virtually all spending in all people in the program. The key point is that its not just the expansion program. Its pretty much walltowall in the Medicaid Program. The other big change in the bill is that it would phase out and ultimately eliminate the enhanced federal funding that the Affordable Care act did make available for states to expand coverage to lowincome adults. And you will see in the slide that it phases out at the beginning of 2021 and it has a threeyear drawdown of the rate in 2020. It would be as 90 of it goes to 85 and goes to the rate. Theres also some provisions in the bill that would provide extra funding for the state did not take up the option to do an expansion. The expansion states continue to experience orwell experience with is scheduled to go into effect. It is a special feature of the program that provides funding on a matched basis to help provide financing to hospitals for the uninsured individuals. They cut spending on the theory that we would have more coverage and fed up with the less uncompensated care and to what the senate bill would do is restore those cuts. After the enhanced match goes away those are some of the major things. I need to get going on this. If you go to the next slide, if briefly shows you what the reductions are. If you go to the next slide. It shows the reductions that have been identified. Overall coming at you are probably familiar with the score it says the bill would produce a loss of 772 billion over ten years for the Medicaid Program and of course very importantly, by 2026, cbo predicts that 50 Million People covered by medicaid would lose that coverage and would no longer have that coverage. Go to the next slide. I want to talk a little bit about how the cap works. Im not going to spend a lot of time explaining this. Its a wonderful diagram but hopefully we can have some time during qanda. The bottom line is that it is a per capita cap. Its understanding the impact to the states Medicaid Program. What was the spending in their early years the state has kind of walked into that spending in perpetuity except for the adjustment is different trend rates the bill picks to bring the cats foreword yearbyyear until 2025. All groups go down which is a much lower trend rate. That builds up to an aggregate cap and that is what the state is going to be guided by in terms of its spending so if the state spending goes over the calf and starts to drive down the dollars it will have to pay back. There will be a clawback in the following years and all of the dollars actually spent over the b. Financed by the state. So a very different notion all costs are shared by the state and federal government and if you go to the next slide. This looks at how the trend rates calmed hair. I wont go through the details on this but let me say the trend rates are designed intentionally to save the government dollars. So they are paid at a rate that is intentionally below what the states are expected to spend over the next ten years and that is one of the ways that the bill achieves some of the savings. This one an you might want to lk at your booklet. This shows the data by state impact of the caps. This is just the calf, not the expansion, so part of the 772 billion. And what you see here is the federal dollars but i also want to point out that there will be a state loss of dollars and if the state says im just going to spend to the calf im going to spend that which qualifies for the federal match which is what most states do now under federal wall they can spend all their money on healthcare if they want to but they generally say i will spend what i can spend a qualifies for a match. If they only spend what qualifies for the match, the state spending will also decrease. So the total impact to the Medicaid Program is bigger than the impact o impact of affordabt and its also the reduction in state dollars. The state doesnt have to reduce the dollars it can simply expand without getting a match. But on the assumption that a state will keep beyond the cap to avoid the clawback and spending the federal dollars you see the total cut into the other thing i would point out on the graph is because the trend rate top asenap 2025, you see a very significant jump between 2025 and 2026 because of the change in the trend rate so it gives you a sense of how they will grow over time. They will become even deeper after about 2026 period. One of the things that we have modeled his the lack of certainty. One thing that we know is healthcare cuts are difficult to predict that the other thing is the trend rates are difficult so when we have done these analyses, we have taken the projections of the trend rate to say i think that it will be 3. 7. I think it will be 2. 4 the next period of times and it is a good projection as anyone might make. What we are showing us over the last period of time these trend rates go up and down so it matters a lot with the Congress Pics but whichever trend rate we need to understand it is not set in stone. It will fluctuate. What if the trend rate isnt exactly what it projects, its just a little lower. 3. 2. And what you see is if of change between 2020 to 2026 about 267 billion. It would jump to almost 400 billion just because the trend rate didnt turn out to be exactly what the ceo thought that it would be. So to close, but as one of the most important points we want to make about the fundamental change in financing of the cab is that yes, it produces significant federal dollars for the Medicaid Program but also produces a great deal of uncertainty in all of the risk of uncertainty over the trend rates. Thank you so much for the alliance. I want to start with a pole. Raise your hand if you think based on the Media Coverage at the end of the budget window we will be spending less money on medicaid. Raise your hand if you think we are spending more money at the end of the budget window. A couple people. Okay. Im just saying the absolute dollar amount you are spending today versus the future. So, i think what we have found around the country is th use tha coverage used this language around cut. Massive severe cuts. We want to slow the rate of growth yet we have a proposal on the table for the program does down the rate of growth, and the sky is falling. There is a lot to unpack. Anybody that is talking about changes in the bill also has to talk about the status quo from the standpoint of the Medicaid Expansion puts the ablebodied adult that is a part of expansion population against the traditional medicaid population so they put extra money towards the medicaid population to get the states to expand. The challenge is i have to balance my budget every year which by the way, they do, unlike here in washington. They have to find 1 dollar of savings to determine where they are going to try to take the 1 dollar of savings they have a few different options. I will tell you first and foremost when it comes to medicaid that comes out of the traditional medicaid population. Because the blues less fertile dollars if they do so. If it doesnt come out there, then it comes out of education spending. Public safety infrastructure. We cannot spend the same dollar twice. Second, as far as the status quo is concerned we cannot assume that federally we could sustain the spending that we have. If you look at the gao, cao, any of the three parts historically when they look at the social medicare and medicaid, they are going to eat the federal budget allies over the next 50 years. To assume we cant do anything with reform i think its naive and its going to hurt people more in the long run. The concern we have these i dont think the program in general has lived up to the promises that we have made before making new promises to the expansion population. The current openended structure leads to some pretty terrible state behavior. The new york budget director for a long time had this statement saying if it moves and medicaid can pay for it and then put it in medicaid so we can pay for things Like Services and if not, to appreciate it if we cannot pay it off. At the heart of what that is is to say we are going to try to pull down as many federal dollars as possible. The focus is not about program integrity, coordination of care, health outcomes, and as im sure many of you are aware there has been some questionable outcomes on medicaid. So, if we have a program that is estimated to deliver about 20 to 40 cents of value for anybody, why would we just defend the status quo and why would we not be open to trying something new . From the state perspective we look at those when it comes to medicaid with the year in the blue, purple and red states alike is additional flexibility. They want and desperately need additional funding on medicaid. It does allow for a lot of flexibility that when you need to balance your budget the average request takes over a year to get approved its not as helpful in the short run so getting the flexibility to grandfather new eligibility changes Going Forward to do more frequent eligibility checks and reinstate the sort of things governors are starting to look at a specialty in light of some of the proposals here Going Forward of what they want to do to move forward. On a per capita proposal president clinton had a proposal in 1995 along the lines and there have been democratic governors in the past. Former governor dafoe patrick talked about the need to bend the cost curve or reduce the rate of increase in medicaid. So i want to make sure that we are having an informed and intelligent discussion about what the actual changes are Going Forward. Whats interesting to note is two things. One, for those that were supportive, there were over 700 billion of reductions in payments in medicare. I dont recall seeing the sky is falling rhetoric around that time. In fact i went on the commonwealth website to look and what i found was karen davis testifying about this as positive and in fact she said more is needed to have a Sustainable Program and she laid out different proposals to do so but i think that its just interesting we have people that want to have it both ways. If the recall in welfare reform in the 1990s, the sky is falling in a freeform as well and what was missing in discussion similarly to what is missing today is that there are two components. There is a tax credit in welfare reform there is the end of the earned incomto bethe earned inc. And there is a robust debate to be had. But in the medicaid space when the state decides to move away from expansion there is a tax credit for those into the non expansion states for people who are not currently qualified there is a tax credit available under the Republican Health care bill that should be part of the conversation we are having looking at what decisions will be made. We are not interested in closing much but i will make a couple comments about the coverage of the losses that we keep hearing about. What we need to understand the process, and it is very arcane and i get why the public does not follow it, but the model off of the 2016 members of a number of assumptions of how many people were going to sign up in the individual market and medicaid. They didnt model off of the updated numbers in 217714 or 15 million lives number that we hear about people losing coverage is not losing technically. Its changes. And theres a couple things ached in there that are just random, for instance they say that 5 million of those are people who lose coverage in states that they thought would expand medicaid. If youre not on medicaid, i dont know how you can lose it. They also make assumptions around the individual mandate that five or 7 Million People will decide from this year to next on medicaid now effectively a free Insurance Program that theyoure just going to stop signing up. I think that there are some reasonable questions to be made about whether that is a safe assumption Going Forward. Thank you for the opportunity to share that as we move forward and i suspect i may be sharing different perspectives on time than others on the panel. Since we talked about the expansion population in medicaid and the per capita iowa to raise a point as well is offered to those that might be watching on cspan. Kim cindy or josh, one of you give that primer overview of that . A lot of people thought old people get medicare and medicaid grew up over the years, congress changed it over the years but there was always a missing group of people and so parents could get coverage, children could get coverage, people with disabilities and the elderly. People should be eligible based on income, not based on family circumstances. So, by filling in the gap, but it meant is the Expansion Group are parents about the level covered before poverty on the average and socalled childless adults, i say socalled because in medicaid language its somebody that is not living with a dependent child under 18 or 19 so i am a parent but in medicaid language its up to 138 of the poverty line. One more question for the 15 million number that was in the score, is it related to that expansion population otheexpanse there other populations covered . There will be some implications because of the reductions that how any given state might address those reductions i think our somewhat speculative. But its the competition. Roughly about 75 of the growth in spending in medicaid is due to enrollment and not due to the underlining health care e costs were other things going on. So, when we are talking about the savings Going Forward is frequently related to the involvement of some sort. I do want to get to it in the qanda for any of the other panelists to share their remar remarks. Good afternoon, everybody. I want to thank the alliance and Commonwealth Fund for having me here. My name is chuck duart and im at the Community Health alliance. By way of background, i wanted to call you a little bit about myself besides running a Community Health center in nevada, i spent 15 years running Medicaid Programs on the front line as an administrator 12 years in nevada and three years in hawaii. Before that iran Community Health centers and start a managed Care Organization and a nonprofit managed care company in hawaii, worked at hospitals and laboratories and a number of other things and im going to start but how many of you folks have ever touched a patient as a professional practitioner i am actually glad to see a lot of hands going up, thats wonderful. One of the things i warned sarah about this im going to wear my heart on my sleeve and one of the things, im going to borrow a line from a friend of mine. She said you can only break head to break hearts because at the end of the decision, this is very important to keep in mind. What happened in nevada being a pivotal state in the discussion and also as a medicaid administrator what i see is a tough decision coming up for medicaid administrators and governors throughout the nation. I run a Nonprofit Organization in nevada as a Community Health center. We have six Health Centers in the county. We have mobile services, medical Nutritional Services and we provide integrated medical Behavioral Healthcare as well as dental, pharmacy and Nutritional Program to the patients. Next slide. We serve about 30,000 a year. 44 of th the march hearing. 100,000 annual patient visits indicate they are of hispanic origin. 95 or below 200 of poverty. Most of them are medicare, dedicated or uninsured. Next slide. What i would also like to do is tell you about nevada and give you a snapshot so the next thing you have to learn how to do is say nevada. If you pronounce it like this, waiters will refuse to serve you and dealers will appeal from the bottom of the deck. What people dont understand about the state is if you think about las vegas, nevada is a frontier state. It has two population items. Las vegas and reno. They are 500,000 miles apart and you can go across the state of the othetheother way and it is f nothing. 14 of the 17 counties in nevada have about 10 of the population. And, excuse me. If you look at the population in the snapshot, and this is from kaiser, 35 are of income. About two thirds are overweight. One third indicate that they have a Mental Health condition and 10 of diabetes. 13. 8100000 we are seventh in terms of the rate of hiv diagnosis. This one slide tells the story. Hopefully you have this in the handout. There is a slide that shows the change in the rate in nevada between 2013 and 2017. One year after governor brian sandoval, our governor indicated the expansion in 2014 and the Insurance Exchange we saw a drop in the rate within one year from 19 to 11 . Boasting the rate behind texas at that point its changed dramatically with the implementation of the Affordable Care act. I saw a recent statistic that the uninsured rate had dropped from 34 to 19 and that is the slide that it was referring to. Next slide, please. Its backwards. Sorry. Okay. Now we are all right. This shows the impact on the medicaid caseload and this is from the state budget. You can see where the Medicaid Expansion happened in 2014. And between 2014 and november of 2016 caseloads of crown from 630,000. They represent 230,900 of the total population but what is interesting is not only did those two caseloads increase but we fall a pretty substantial increase in the traditional caseload. That happened primarily because of the woodwork that of people becoming aware of medicaid and saying i am eligible for medicaid and so are my kids are my disabled parent or sibling. It is as a result of the Traditional Programs of any cuts that occur, i will talk about that debate, they have to come only from the newly eligible but they are going to have to come from the traditional population. Next slide. And then the next. Okay. Im going to keep rolling. Right there. Stop. Okay. So this is the patient population. You can see before and after the expansion for children and our r practice, 2013 we had 41 and today it is 17 . For medicaid the childrens enrollment went from 58 . For adults, it declined from 78 to 22 and Medicaid Enrollment went up to 43 . Next slide. And this is what i mean about breaking hearts. This is one of those socalled ablebodied individuals and a ia story published by the nevada public radio. At the center for complex care which is a specialized Community Health center for people with complex medical conditions and Behavioral Health problems. She has type two diabetes and here is a quote. They would keep me coming gets me a little bit file and send you my way. She is a beneficiary of the expansion and worked as a loan officer but became too ill to work and lost her insurance. She now has coverage into spending time with her grandson. I go to soccer games and church, i am not edward bed ridden. She is not a unique individual in the situation. Of people that are in the program and the Health Centers who are expansion eligible, a lot of them are disabled, but they dont qualify for ssi. Many of them have chronic conditions. You cant tell me these are all healthy body people that go right to work when theres an opportunity because the struggle already and they do work. Again im wearing my heart on my sleeve but that is important to understand about the population anthat the populationand these t will be affected. The last thing i want to do is give you an idea of what the administrators and governors have to do especially in nevada. The urban institute put out a statistic and thereve been other numbers thrown around in the last two days about the loss of federal revenue to nevada. By 2022 the institute estimates that nevada was 1. 2 billion in medicaid funding that would be a 43 reduction. Now granted this could be an increase in spending but its going to result in people losing coverage. So the other complicated factor is we have a relatively high match rate so the boss is going to be equally significant and we have a high expansion population. We have a chronic Disease Burden and a lot of the folks in the te division of adult health disorders, addiction, hiv infection. We have the frontier counties that are going to be adversely affected by this. We have a rapidly aging population in nevada that this coulis tobe ultimately dependenn Homebased Services or nursing home care and a low tax base. So, what are governors going to have to do . I have four titles that dedicated directors usually a just and viable talk a little but very quickly about some of these because these are the positionpositions of the governd medicaid directors have to make. Eligible to become a Service Utilization payments and divisive little control button called managed care if we cant see it. So, eligibility. You can do things like work requirements, assess limit increases, you can to things like getting more frequent eligibility determinations, all of those things have a nice result of knocking people off the program and that is fine, but the big gun on eligibility is you have to take the whole populations off at once that is the only way to get the cost out of the system. Youve got to get rid of some of the people involved in the Traditional Program and that is where the cuts are going to come or reductions i should say, reductions in spending growth. For services you can look at this picture medications, personal care. Theres cost impacts on the program and its not necessarily wise to cut for services. You can look at utilization management. Those have marginal impacts and you cant be willynilly about it because they are to maintain a criteria when they look at utilization management so you cant just do that. You can look at cutting payments but its still looking at cutting the payment has an impact on access. It doesnt do a lot of people are depressing it a lot and its called managed care and i can say that from my experience of 15 years of running medicaid. Its great. Governors can say i washed my hands up and give it to the managed care programs and be done with it. Thats why they do it. It doesnt save money. And finally, i would like to see again if i am talking to a patient that is going to lose coverage im going to tell them dont worry its not because of cuts, its because of reductions in spending that you lost your coverage, so it is not a problem anymore. Im sorry to wear my heart on my sleeve and not be totally datadriven, but i had to do it. It sounds like a couple of lessons here, language matters, consequences whatever they may be going to happen one way or another. So, we will keep talking about that. But first, we have one last presenter and then we will get into a discussion and q a. Thanks. Im happy to be here. I really wish i have the social skills. First of all, i am going to focus on medicaid and its role of addressing the emergencies weve been facing over the last few years. Opioids of the flu, you can throw in diabetes and asthma if you like. What im goinbut im going to dn opioids a is the condition of ts broad set of a Public Health threat and how medicaid works to give us the tool to deal with it. Second, by expanding access to preventative interventions and treatments, medicaid is an important part most governors are using to fight the Opioid Epidemic both in terms of addiction itself and in terms of the mortality consequences of addiction. Third, the proposals to repeal the Medicaid Expansion and then shift to the per capita cap will be destructive to the state efforts for the Opioid Epidemic. And im going to show you a little bit of an illustration of the kind of pressures that are put on states under these type of arrangements. And then last, the money that is being proposed, and there is a lot of recognition in various parts of congress that certain kinds of Public Health emergencies are being threatened and he opioids in particular in that none of the proposals ive seen both come nearer providing the kind of money that you need to deal with that problem, and you can imagine that coming down the road example we have recently seen an uptick in methamphetamines that he wants to talk about yet. Next slide please. So, let me start off with some fun facts about opioid use disorders. The first is in 2015 we had over 53,000 people die from overdoses in this country. 61 of those were a little over 33,000 per due to opioid use disorders. The overdose grew at 15 between 2014 and 2015 nationally but this is not a new problem. The Opioid Epidemic has been going on since 1979. Its ground pretty steadily at 9 a year with respect to mortality. And because the Opioid Epidemic disorders concentrated for populations, you see the Medicaid Expansion population being responsible for treating these folks and in the states like maryland that expanded medicaid to roughly two thirds of the people that died due to an opioid overdose were enrolled in medicaid. It turns out about half the people with an opioid disorder abused or used other types of drugs, that amphetamines, alcohol, cocaine among others. And a large number of them suffer from chronic diseases, some of them directly from the opioid use and some of them not so hepatitis, those that are but theres other illnesses such as diabetes and asthma but also tend to accompany the opioid use disorders. So, what that means is the average amount of spending 40 enrolled in medicaid that has been of these disorders is somewhere around 11 to 12,000 nationally. To put that into perspective, treating somebody with a medication is the treatment for a year costs 5500. So that is half of the cost not directly related to trading but disorder that is related to all sorts of other problems they have. Next slide please. So, this is to illustrate the impact there is a drug called mallomalxone. They use in the Medicaid Program and expansion states relative to the non expansion states the tt steeply increasing one of the expansion state, the modestly increasing one is the non expansion state. What we have seen is a coincident in these increases as aggregate data showing between 2013 and 2014 if was a doubling up of the use to reverse overdoses so medicaid is contributing to getting more of the opioid reversal overdose reversal into the right hands at the right time in order to sort of save lives. So, really this graph is a reflection of the reversals that have occurred as a result of making the drugs more available. Next slide, please. Now we are going to do some arithmetic. Its not meant to be a precise estimate of the future but to illustrate the pressures the states will be under a as these were to fight this epidemic. So this is the case in West Virginia. In 2016, West Virginia spent 242 million on Substance Use Disorder Treatment in the non expansion part of medicaid. Its been at about 5. 7 a year for the last ten years and so now if you start to move out of the spending along that trajectory you see that by 2026, you would expect the main part of the non expansion part of the program to stand for about 445 million a year on Substance Use Disorder Treatment. If the grove at by the more generous at the index is being proposed in the Health Reform proposals, you see that we come up with about 368 million of spending. Those dollars will no longer be available. What does that mean . That they will lose 50,000 people will have to look elsewhere for treatment. So just to put that into perspective let me take out that 45 billion proposed in the senate to deal with Substance Abuse problems and i will allocate the way those dollars are allocated West Virginia would get 61 million per year. Right off the bat take out 112 million on the first day and that will continue to grow. That is all i have to say. Eight you for your thoughtful presentation go to the discussion portion and then somebody will come pick that up there are also into makes so that theyd pull this back because it seems like what is coming across the comments so what is the right way to offer coverage . Maybe healthy for have significant chronic conditions but may not qualify based on runbacks disability. What is the best way to finance all of that . So what i am curious about from the panel perspective what is that fundamental issue that needs to be solved like slowing the growth rate in spending and the debate brewing over the advisor report that would reduce the growth rate once that is outside the scope of this briefing about employer sponsored coverage sore we being schizophrenic how we approach this question so when you think is the problem were trying to solve . So we need to decide if medicaid is all the insurance or welfare depending on your answer you would change the structure of it. Is the coal is the goal for people to be on the for a long time . I would the answer no. So that means by a definition the airport . So why cannot they afford insurance . So ultimately so that means by a definition probably not working. That should be deeply in the deeply concerned you. But that is what we need to start. And then to be focused on at. So if you werent snap for food stamps or medicaid. And then that is a whole conversation. To speak as than economists. And looking around the audience like Ronald Reagan but Ronald Reagan had the misery index which had to do with inflation and if you look at cbo and those index rates of medicaid are keeping up with the increase of Health Care Inflation for girl so to say those dollars will grow but that seems very misleading so i think the problem is money. So people are pour and even when they work they dont have enough money for Health Insurance in the budget is tight and in order to pay for poor people you need those budget dollars with real resources. I am not as smart as richard but calling medicaid a Welfare Program is an interesting concept because that has a connotation of cash assistance and medicaid does not provide cash assistance but a service. There are no dollars given to that beneficiary and protect them from financial bankruptcy. And also to put a roof over their head i get 2,000 people per month that come in and a lot of these are expansion populations. So you were talking about the economy of a household where they do not contribute to the economy of the household but that provided say protection and a safety net the root word of economics i think it means home. So the whole root of economics has to do with the sanctity and the protection of the home. It was bastardized by the english and became something totally different so i dont consider that a Welfare Program metal. I just want to add it isnt just about porter but the program that is also there because of their illness it is harder for them to work and get the care that they need. What problem are we trying to solve . Good question. As josh noted earlier sold per person medicaid has been well below commercial insurance. But medicaid spending has increased and covers a lot more people. And as chuck had talked about and did not know there were always available so what problem are we solving . This seems to be why they grow them of medicaid dollars. Sova josh has proposed that they should never go to private insurance. And i dont mean to be delivered but it isnt really that medicaid problems role to solve poverty that medicaid is a very Diverse Program that onethird is for what Long Term Care is for the Medicare Beneficiaries and we have pregnant women and permanently disabled and those cost of the Medicaid Program and the diversity of the population and and finally just to focus on how to cover very poor people, lets look at the tax credits under the senate bill. So at the poverty line for a single individual what belsen dollars per month. Not to spell lot spend on health care but food and rent and utilities and transportation and every single lead including health care. You can get the subsidy under the senate bill and fewer of 50 percent of poverty or o . Eddy would get a subsidy to help the premium it is pretty modest. There will be very many low income who cannot afford that. But assuming they could looking at the deductibles and arizona in particular and what the premiums are in the marketplace and what that would require so as a percent of income for that subsidy will consume between 76 and 90 percent of the total income if youre 100 percent. New route for rent or anybody else. And the tax subsidies do not just cut it. So now lets get into the question of hot part of the challenge starting from your gins in 1965 for those who were receiving cash assistance, is that in response frankly as a failure to address the problem in other ways of the functioning insurance system that could be affordable for people of any income . The short answer is yes there is a lot of work to do that is what i spend 50 percent of my day job but to return to one thing anybody that criticizes the reform has to defend the status quo. So lets not pretend we can keep doing what were doing. We can. So i appreciate the passion but this is deeply personal to me i have had family members of medicaid. You have three choices to come up with a reform now to make it sustainable or defend the status quo that over the traditional population or kick the can down the road. Which do you choose . That is what were talking about so theres a lot of snipes in the media may not here to defend the Republican Health care bill however talk about reform, if we want to keep any sort of promises we have to change it. Also bomb last point for us to defend medicate medicaid is a great coronation of care i space talk to directors and governors they are so frustrated with people going to the emergency room on medicaid. Because we know that is not the best way to get your care but yet it is a persistent problem proposal for them to say it is a great Silver Bullet is not true. There is a lot of ways to fix it but if you put them back since 2000 i dont think anybody would have exceeded the percapita cap. The growth rate for the elderly is what the project three growth rate is. So at least lets understand that dynamic Going Forward in what we think that status quo is. I would argue absolutely not. I with the National Employment law project i would ask of little bit more about home care in support of first beyond your three suggestions there is revenue in not giving the tax breaks to the wealthy. Going into Longterm Services with medicaid as the primary funder and as the look at the aging population of demographics we have never seen before this legislation will harm the Current System and our future one in even greater ways with the percapita caps will not adjust for higher cost for the oldest old population of 85 and older and also the job losses particularly in addition to 1. 5 million projected in the specifics of those it the work force meeting that Community Catalyst between 300 and 700,000 and that is just the time we need even more home care workers to meet that demand. Also 1. 5 million job losses by 2026 can you recount for the potential losses when it is cut by 35 . The analysis is done by George Washington university it is up on the web site and it does project out through 2026. I will go back to my previous life as an administrator. One of the things i am most proud of the nevada is the expenditures between nursing and Community Services over a decade. It took a decade by establishing programs by personal Care Attendant Services to make sure there were funded adequately not only in urban centers are rural communities. So i am very proud of that. So your point despondently dont disagree with joshed with josh and the percentage of gdp but we have to find a way to make them more affordable with that aging population with the second highest growth rate they will end up for longterm care. And we have to find a way to make that more affordable. It is revenue. From much does it cost . I worked with blue cross and blue shield it cost me at 30 years old in premiums 5 a month for coverage and i could have continued paying those premiums. If we charge just 5 a month as part of the Medicare Program we could afford in the long run a payment for those services for individuals. Not everybody but a modicum of services that could be income adjusted for adequate longterm Care Services so revenue could be a solution to that problem looking at the growing elderly population. Really have 12 minutes left so to make a note the issue of Longterm Services is a huge issue with reports coming out on that issue and that we plan to look bad in the future separate from this discussion. But talking about adults and Older Americans mentioning the statistics how many children are covered, where the intersections in with those changes thats our proposed and how it should be implicated. I appreciate the question because it is often overlooked medicated such a significant player to get their coverage through the Medicaid Program so the chip Program Stands on the shoulders a little over 8 million children are covered 37 million through medicaid both cover healthy children but medicaid covers the lions share with Greater Health care needs. So to be enormously successful with bipartisan support that helps with continuity of coverage to make sure the uninjured rate has plummeted for children over the last 10 years now below 5 but it functions because medicaid sits beneath that. And covering children of Higher Health care needs so you need both to complement each other to maintain the coverage and the outcomes we have seen. We also have a question about pregnant women and the block grant option so what is the option for the states to do the block grant . And that is non disabled adults to explain the proposal what that is and what does that mean and what incentive does that put in place to do a better job with maternity outcomes . In terms of incentives to do a better job i will quickly take up the point that i dont think there is a Medicaid Program in the country that is just running on autopilot. It is incredibly dynamic and it is a very focused effort will of better integration of care and coordination of care and avoid being emergency room costs. Lots of Energy Around that so i dont think any of this discussion around the bill of the criticisms but there ought to be no change your there is a change. In terms of the block grant proposal that is more narrowly drawn so it is maurer detailed and largely be for pregnant women and very low income parents without the expansion population. And cannot bear the amount of money that you got based on the numbers of people that you enroll. The big financing difference in the other thing with the senate bill with the growth is the lower trend rate. So based on enrollment even as much as those percapita caps why would a state want to do that . It does give the states more flexibility and reduce requirements in terms of what services are covered but also has a feature added is hidden to drive down those federal block grant powers so may also have an attraction for that reason. So to describe what is in the senate bill the final version of what comes out of it as people are reading a the media would is currently debated as the final version is a moving target. That is a great point. So we have time for one more question. And then the only u. S. The rhetorical question are you better off now than you were four years ago . That is a great way to proceed what is wrong with the Health Care System and in particular the changes of the of aca that is those between going into medicaid the of private insurance in those going out of those coverages it makes their lives better in the continuation of coverage. The way of the Affordable Care act way implement the affordable cataract so it isnt that is not continuing to be an issue so of simplification of the enrollment process that those paperwork barriers as long as they are eligible. And that goes to the issues raised talked about. So if youre really trying to get the individuals to change the trajectory so then to be connected to a continuous period of time. So that is also good for the gold and to bring that down. So it just there is like trying to get people off of medicaid is an impossible depending on how you view that. And long term . We have a few minutes left so now to have a robust discussion so want to close by asking the panel and that is salvi will have time for. We will start with richard. I also want to issue what i think his day correction but then that suggest that there is an to skip over the fact and diabetes is probably the most expensive and those are the places they have the biggest effect but for meet there is flexibility so i do think some of the of problems with that underpayment in certain areas to control supply and i do think the advantage of managed care allows greater flexibility at the Delivery System into the Medicaid Program. In to fix medicaid and the whole system looking at those that already operating in the united states. So i think Bernie Sanders said the. Sold to have a single parent system. I would hope the conversation about medicaid and could fix all above problems to take a critical eye if they are a real robust policymaker we could see if there is a better way to do it instead. In to see if that solves all the problems. I suppose where i waved my one and so i will talk about that medicaid is not perfect no program is perfect so what seems clear to meet so cutting off expansion funding so to get coverage for the first time with consistent regular care arbitrarily with those contributions to have this much and not more will solve the Health Care Problems to guarantee the federal government building that tackles any of those health care cost. Please allow your blue evaluation forms. Thanks to the panelists. [applause] [inaudible conversations] the neck to be any absolute monarchy with corruption to get you in so much trouble. Talking about her time in prison after challenging the saudi government ban on women drivers. Spec we wanted to change this going on. And for the right to drive. But that is for more civil acts of disobedience. We are capable to do that the of civil disobedience. Ben house and senate are back this week. What is in of a 2018 version . That National Health authorization act late last month is the annual defense policy bill