Forward. Thank you. The chair recognizes the gentleman from louisiana, doctor cassidy, for five minutes. Effect in arizona. Would you disagree with the table, which im looking straight at. Would you acknowledge, indeed its only one state specific, indeed if we were to look at maine we would see an increase in mortality after Medicaid Expansion. I will happily look to you looking at the table. As you know, as a clinician, you never want to take the conclusions too far. One study or two study. Were in an environment people are looking at one or two studies. I accept it. So i appreciate your clarification. Secondly, i will point out, you were careful in the testimony to say that medicaid prevents people from having financial occur res. You didnt make the claim it improves health. As we both know, the national what is it the National Bureau of Economic Research found in the oregon study, im quoting from the conclusions, the randomized control study show that medication coverage generated no significant improvement and measured physical Health Outcome in the first two years. But reduced financial strain. So also made clear that the best study from nber shown Medicaid Expansion didnt improve Health Outcomes. Lastly i will say , by the way, i enjoyed everybodys testimony. I dont mean to challenge. I just want to point it out. You seem to suggest in your testimony that the choices is die cot mous. Everybody somebody is uninsured or on medicaid. Ill quote another study by a big backer of obamacare who point out that 60 of the children that go ton a public Insurance Program actually formally had private insurance, but the expansion of the public insurance crowded out, if you will, the private insurance. Its not the employer or the family paying the bill, its now a taxpayer paying the bill. Thats 60 . Any comments upon that . Again, its not you know where im going. Well, i do have to begin by commenting on your characterization of the first study. First of all, were there, as you know, demonstrated positive effect on depression. So its important. I dont think it shows it did not improve outcome. I think it didnt show that it improved outcomes, and i think those are actually quite different. But we take the we really cant claim a benefit unless a benefit was shown. I completely with you agree. We cant that doesnt equate with the absence of benefit. It simply means we were unable to show a benefit. Since you are careful, im going ask we are being equally careful in the regard. The literature on crowd out which used to be a very hotly debated topic and faded from view for some time has great complexity about what you count as the e number rate en aerodemon nateer. We know low and moderate income families, the income fluctuates and gain different sources of coverage. The pref lens of private coverage. I have a minute left. Im sorry. My sense could be i adopt think we can state on the basis of the study that 60 of the children would have private coverage if they didnt have maybe. I will say that they have 400,000 observation. And its one respected and to two a big backer of obamacare. T not like something hes trying to trash himself. If theres a philosophical difference if a state is going to manage care and cap at a time payment to the Insurance Plan. There any difference in fact that the federal government gives a set amount of money to the state . Which in turn gives a set amount of money to the Insurance Plan . Is there any kind of difference in that. Yes, a plan organizes and finance the delivery of care. A state organizes the policy environment for that finance and delivery. There, again, i think they have different effects. But if you give 100 to the state to care for somebody, and the state give 90s to the burns plan. 100 of the cost were there capitation and who wrote the bill. I would agree its not the same. Thats not how i see the program. Okay. It may be an issue of perception. I yield back. The chair thank the gentleman. Did you want to respond to the remarks regarding reforms . I apologize if she had to leave. I want to give you an opportunity to respond quickly, please. Thank you, mr. Chairman. I appreciate the opportunity. In my testimony, i referred to the florida reform pilot. The facts, clear. The florida reform pilot outperformed in 64 percent the cases. It higher level of patient sphoox. Perhaps the best validation of how this approach of pay centered pro patient protaxpayer is working the fact that the Obama Administration approved the waiver. T a proven bipartisan approach that saves money, improves health, and produces more satisfied patients. And i would be happy to provide further information to the congresswoman. The chair thanks the gentleman. The chair recognize the gentlelady from the virgin islands. Thank you, mr. Chairman. Thank you for the hearing, welcome to our panelists. Doctor, my first question is about medicaid flexibility, i think your testimony and the answers you have given demonstrates the flexibility and innovation and not only possible but happening in different states across the country and improving access. And actually in some of the cases you sited improving outcomes as well. And ill improved outcomes is what were looking to achieve here. Im sure that you are familiar with the 2002 report on equal treatment. A report that demonstrated bias in the health care. Study more recent study since dpon straited the same it relates the cardiac care and other medical conditions. We know that racial and ethnic minority make up at least 68 of the nonelderly medicaid enroll lee. Its providers and even when there were providers, some of them needed ancillary services were not available in the neighborhood because how medicaid was paid for before the Affordable Care act. So, to you think the factors have some impact and import on weather even with medicaid being available and access to health care being available, dont those factors were not even we havent even talked about the sober determinacy of health that are not changing in those communities. Well, i appreciate the question and the observation. Im struck by how frequently i hear people repeat the phrase that medicaid is aa lousy broken because people on it and they fill in the blank. They are poorer, and sicker and disproportionately nonwhite. As you indicated, theres a strong Evidence Base in all of those areas that help outcomes or worse regardless source of coverage. And very rarely do people make an effort to actually control for it. And [inaudible conversations] income level and education level. We know, for example, that lower income americans are less likely to use health care services, whether they have private or public coverage because they are left on average, they are left comfortable with the system,less able to navigate it. And providers seeking payment are less likely to locate in the places where they live to indict the Medicaid Program for the outcome seems to be a bit odd. I agree. When they are addressed, and the socioeconomic addressed and foreign, racial, and ethnic communities and Rural Communities and some of the reforms you cited in a different states are more widely adopted. I think well see those changes. Were seeing changes where those things are happening. They are making a difference in improved care for vulnerable patients for whom medicaid has been the lifeline. The Affordable Care act recognized we need to make medicaid a stronger safety net. Along with safe changes, is already beginning to make a difference. The republican recommended reforms really are not designed, as i see it. Im i was a practicing family physician. I think they run the risk of reducing access to care and leaving some of the most vulnerable out of the Health Care System entirely. Let me see if i can fit in one other question. It includes a provision that will provide primary care services. What impact on access of pry care care do you believe the policy will have . And what other steps can we take to improve access to these Important Services for our most vulnerable . . Well, higher payment is certainly a positive, although its temporary nature, i think is going to limit the behavioral response on the part of physicians. Its unlikely they are going to fundamentally change where they practice or how they practice for an incentive that will last a short period. I think its important to think of it as a step, an imperfect step in broader efforts to reorient system spending toward primary care, and in of i. T. Is not going achieve. Its two years, probably, because we have reduce the cost of the bill. We have to reduce the cost of the bill because we could not score the me venges, the savings prevention, which is something we still need to do. Thank you, mr. Chairman. The chair thank the gent the lady. And recognizes the gentlelady from North Carolina. Thank you, mr. Chairman, thank you to the panelists today. I want to talk about the North Carolina programs that are moving forward. Im very proud of the work theyre doing in North Carolina, you know, over over the last decade from less thanked billion annually a decade ago to more than 14 billion annually as of 2012. North carolina spends more per person on medicaid they than any of the seven state enables. Recognizing North Carolinas medicate failure, the governor proposed reform outlined in the state partnership for healthy North Carolina. And i commend him for his work, and also North Carolina human health and Human Services chairwoman for the work she has done. I echo the words of representative burt jones in North Carolina calling it a winwinwin situation celebration because it benefits the patients, the Health Care Providers, and the taxpayers of our state. With that, i want to expand a little bit on the florida issue because North Carolina is looking at florida, and i have a question for you in relation to some of the discussion that has already gone on. Is it not true that floridas medicaid reform demonstration was approved eight years ago but only last month did the state receive final approval to go forward with the state reforms . Is that part of the situation that were talking about . Thank you for the question, congresswoman. Florida started a reform pilot in five connecticuts. Counties. They covered 300,000 moms, individuals, and kids and ssi. And two years ago, the legislature voted and the governor committed a waiver to expand the reform pilot to all 67 counties. It was expansion . Correct. Great. Okay. Basically, you know, obviously were talking about tough times here. Scarce resources, drastically growing enrollment levels, states need to know they with move forward with the reform. I know, thats part of the discussion that we have been having today. Unfortunately, they are currently forced to live under the maybe or wait and see approval flail Agency Process that takes years to find out whether or not they can be approved. From your perspective, what can be done to improve by the cms . Im sure its a broad answer. Thank you are the question. I think first and foremost states need predictability. You have in the state plan and administrative filing. You have predictability. There are et is time frames if the federal government doesnt act and deemed approved what happens with a whatever there is no time limit. And therefore, cms can drag the feet. In the case of kansas, cms approved the waiver two days before implementation began. What were seeing is states are playing a game of chicken with the federal court federal government hoping that cms will act or ore theres a wasted effort. I knew i was do you want to explain on that at all . Is there anything you would like to add to that . Ic that i think this is one of the things that has bipartisan or nonpartisan issue. Which is how can you improve the innovations that are happening in the state faster so you can get more people. People can study the result to say it does it work or not work . I think thats one thing that people can come together to look at. How do you speed up the process and allow more innovation at the state level without having the barriers. Coping that in mind, right now with medicare enrollment at over 70 million, one in four americans expect to become a medicaid beneficiary as a result of the aca. Do you believe there are measures in place to ensure proper eligibility okay its after week being back in North Carolina. I cant speak today. Eligibility vertification. I think its actually even before the Affordable Care act the trend has been going in the opposite direction with presumptivetive eligibility, those things move in the opposite direction. I think with the massive complexity of the Health Care Law. I think its important there are some stronger eligibility processes in place. Not only for medicaid but the exchange side as well. Thank you so much. Is there anything you would like to add. No. Great, thank you. I yield back the reminder of my time. And recognize the gentleman from florida. Thank you, mr. Chairman, thank you for holding the hearing. I thank the panel for the testimony. Mr. Bragton, the current law the a reform system to increase outcome and reduce costs typically dont see most of the savings. How can we transform the system to incentivize states and low them to a greater share of the savings . Thank you for the question, congressman. I think this is really a key factor that Holding States back from innovating. States get to keep only about 40 cent of every dollar they save, or in the case of expansion, 10 cents out of every dollar they save. What i think would be a better approach to promote innovation is having shared savings. One of the things that private medicaid plans do they share the savings that coordinated care contributes with providers. So providers have an incentive to save money as well as the plan. It should be the same with the federal government to states. Why not allow the states to keep one out of every three or one out of every two federal dollars they save. For the panels what off medicaid and on to private insurance. What are the challenges the beneficiaries face . I would say, first of all, prioritizing the population. Not everyone on medicaid is treated the same. I think thats for a benefit to the beneficiary. The higher up the income scale, the more access you likely have to private insurance. It should be encouraged. I would agree that medicaid reliance on private plans makes that transition easier when it occurs. And states are currently making significant efforts to try to assure smooth transitions between medicaid and the exchange. Unfortunately the biggest barrier to transitioning smoothly the jobs most people move in to when they move off medicaid dont offer insurance. And the absence of that, theres nothing to transition to. I would agree with both responses. I think that you its very important to look at four individuals on medicaid. Many of them on medicaid for a short am of time. The private plans are prohibited from marketing to them or reaching out and making them aware of the options available. And states need to be more creative to create transition products that arent quite medicaid private plans but arent quite private insurance to give People Protection to not only catastrophic coverage but Preventive Services. Is it a good idea to provide diversity of plan [inaudible] to consumers . Thank you. Yes, and i think that the most strong evidence of that is consumers voting with the feet. When you give them a i Diverse Group of plans with meaning differences ownership to 80 pick a plan different than the one defaulted in to. I see advantages to plan choice. In less populace area of the country. It doesnt mean anything. The real challenge is finding providers and having different administrative structures doesnt provide any value. Unfettered choice or unstructured choices can be very hostile, actually to consumer or private industry knows very well how to structure choices in ways that help people make choices and not but in general certainly choice is a key component of the drive to quality. I would agree with with the panelist and say though that slight difference a choice of the same product across without any differentiation is kind of choice with no choice. Youre not really choosing anything different. I think there needs to be some sort of i did fors indication or ability to offer different plans with additional benefits, et. Cetera in order to really have what choices. Thank you. One last question, if i may, mr. Chairman, mr. Bragton, they the administration seems focused on expanded medicaid issues. How many people are medicaid eligible and are not enrolled . Shouldnt we focus on getting care to those groups before we focus on expanding medicaid . Also the expansion of patients will increase the patient load on the medicaid system. Ha has there been an influx in doctors taking medicaid . I dont think so. What will the patient surge do to the system . I think there absolutely they are real challenges to access for individuals. A card is not access. We need look at can you actually provide access to care. I would point out that with the question of there are many out there i know children, many children eligible but not enrolled in the Program Raises the question what is it that keeps them out . Its obviously eligible. They would qualify. Do they as pointed out having a card may not be the type of care that best suits them. Thank you very much. I yield back. Recognize the gentleman from virginia. Thank you, mr. Chairman. I appreciate it greatly. Mr. Bragton, i was looking at your written testimony on pages 7 and 8 you go through a process. You want to refer to. You probably know it like the back of your hand, some of the Medicaid Programs that rely on private programs are going to be hit with the tax inside of obamacare. Could you explain that to us more fully than just one or two paragraph response might give to the American People . Sure. One of the new funding mechanisms for the the Affordable Care act is the new tax on private plans, which falls on those private medicaid plans as well. So you have a perverse dynamic the federal government on one hand taxes itself and at the same time taxing at a states to raise revenue. States need to come up with the money or cut services for individuals to pay the taxes. Explain how that works. I was not here when the bill was passed. I was under the improtects it was on the wealthier people and on plans that were private plans. Is it because some states have or work with privatetype plans to provide the coverage for their citizens . This is not the tax on cat lack plans. Okay. This is a different tax that essentially a premium tax for plan private plan, private health plans. But those private plans within medicaid are including within the tax. And that tax over the next decade is going to raise costs from 37 to 42 million for those private medicaid plans only. The number in your report said Something Like one fifth of the money raised by the new tax included in the obamacare plan is actually a tax that we pay correct. Okay. I appreciate that. Virginia is looking at the lot of thing before they do the reform. They set up a special committee. Among those im going go to a specific question instead of reciting the Different Things that virginia is looking for. Although i think those are good. One of them is valuebased purchasing. I like that idea they are looking at. I think we need to do it in an efficient way that it saves money and provides greater flex tobility the state flps has to be a balance. You dont want to a copay to the value pricing that keeps people from using services that may need. I would ask all of you from your experience, you know, where have states been able to use that successfully . And where has it been not successful . Just go down the table. I think its key for states to look at valuebased purchasing not only innovative things working directly with providers. How do you get better care for the individuals . There are great stamps examples of states to do that providing in the Medicaid Program. So you have in private plans they pay if the medicaid patient no shows. Or in some states the plan itself coordinates travel to make sure the patient can get to the doctor. They also add benefits to attract patients. So, for example, adding dental benefits, all within that same fixed price. But really creating taking medicaid like a floor and building on top of it. Which i think is really key. So you to also look at are individuals getting healthier . Thats what we want the safety net to do. Take somebody poor and sick and make them healthier so they have a hope of a better life. Ultimately the valuebase should look at if its improving health. Absolutely. Senates use flexibility to payment rates to promote plans that can demonstrate higher value through standard measures of quality, and measures of access. Theres also Movement Toward what is known as value based insurance design which is a specific form designed to make it less expensive for people to get maipt nebs drug maintenance drugs for a chronic condition. Its theres a center at the university of michigan that is helping states and private payers in that area to get very active areas. Obviously not easy answers. Thank you. I think it has been said is great and what it shows is that medicaid has seen kind of the failure of its past in trying to find ways to be more innovative. And in doing things in a more efficient way. I would caution, like, in the state of virginia. The reforms should take place, and the results how should come through before deciding to add another expansion population to that making further the complexity of what reform is attended to achieve. Particularly in the light of the that the fact i do appreciate that. I also appreciate the fact you are concerned about rural district. I have a rural district. I like the idea of having multiple plans, if folks cant get there, it doesnt do us any good. I appreciate your testimony this afternoon. And with that, mr. Chairman, i yield back. That concludes the questions from the members. Thank you very much. Very informative testimony today. There will be questions that members have that will be submitted to you in writing. We ask that you please respond promptly to those questions. I remind members they have ten Business Days to submit questions for the record, and members should submit their questions by the close of business on monday, july 22nd. Without objection, the committee is adjourned. In a few moments, president obama announcing his plan for delivering Government Service more efficiently. In fifteen minutes, house g. O. P. Leaders talk about student Loan Interest rates. After that more about student loan rates when a meeting between House Minority web and university of maryland students. Several live events to tell you about tomorrow on the companion network, cspan 3. The Senate Judiciary committee will consider the fbi director. After i took office, i did. , and our chief information officer, steve, are working with their teams to innovate and apply the best technology to help solve some of our biggest challenges. From creating jobs to reducing Health Care Costs, to keeping our nation secure. We are the first to confess that progress has not always come quick. And major challenges still remain. But we have made huge soil and Water Assessment tool more efficient and transparent and accountable than ever before. We have done it by focusing on three areas. First, we have found ways to deliver the services that citizens expect in smarter, faster, and better ways. So, for example, until recently, when a Natural Disaster struck, teams from fema had to rely exclusively on inperson inspections to figure out which families needed help. Now they analyze satellite and aerial imagery and get assistance to those areas that need it most more quickly. After hurricane sandy, most folks were able to sign up for assistance using femas mobile and app. S. Fema agents went door to door in some areas with ipads helping areas those without power sign up without leaving their homes. So making sure that were delivering the Services Better, faster, more efficient. Second, we have identified new ways to reduce waste and save taxpayers money. For example, by working to get rid of overlapping it systems we have identified more than 2. 5 billion in savings across the federal government. Thats just the beginning. I have proposed and signed in to law the elimination of dozen of federal programs and cut even more that were dop cantive, not work or no longer needed. Saving billions of dollars a year. And the basic principle is simple. Taxpayers deserve the biggest bang for the buck. Especially the time when budgets are tight, and we have to do a lot more with less. Now anyone can visit white house. Gov to see your taxpayer receipt. Its a literal receipt that tell you how and where your tax dollars are being spent. Finally, for the first time in history, we have opened up huge amount of Government Data to the American People. And put it on the internet for free. At data. Gov you can search through and download more than 75,000 data sensors. Data on everything what different hospitals charge for different procedure, to credit card complaints with to be weather and climate measure. What is happening is entrepreneurs and Business Owners are now using that data, the peoples data to be create jobs and solve problem the government cant solve by itself or cant do efficiently. Theres a company, for example, that used open Government Data on General Energy trends and weather to help families save more than 300 million on the energy bills. Theres another Company Called itriage founded by two emergency room doctors that is using freely downloadable data about Health Care Providers from the department of health and Human Services to help more than 9 Million People find the closest theres and hospitals that meet their needs. And the lie goes list goes on. The companies have hired hundreds of people, and still hiring. Millions of people have already used these applications that were created as a consequence of releasing the data tap. So we have made some Good Progress on all fronts. But now we need to do more. So today i met with all of my cabinet, including a number of new cabinet members, some of whom who have private ebbs the record extraordinary private sector experience. It delivers a smarter with for innovative and Accountable Government for its citizens. Were going dont continue to adopt good idea for the private sector. I asked the director of office of management and budget to leave it up. She was part of a team at omb that presided over three years of budget surpluses in the 1990s after Philanthropy Work at the Gates Foundation and the Walmart Foundation she has come back to help us move the effort forward. Shes not the only one. We have welcomed a new class of president ial innovation fellows. I would love for the press to meet some of these folk. They are extraordinary. These are earn manies are americans with vast Technology Expertise who volunteered to serve their country in the private sector. So, for example, scott woo helped found a company that helps recent grads turn their good ideas in to Good Business ideas. Clare used to manage Product Design for everything from mobile phones to video games. They founded an innovative shopping site that adapts to the taste as you brows. So they and 40 other fellows are taking this private sector expertise and bringing it in to the government. These are things in the pipeline right now. Currently one our government has this complicated language with complicated requirements that most people dont understand, we are working to make them simpler so it is easier for more Small Businesses throughout the country and this will help save taxpayer money in the process. Recently we relaunched health care. Gov come up beginning october 1. Americans can log on and comparisonshop. Because he will finally be part of a new pool with americans, insurers will actually want to compete for your business. We worked really hard to make these marketplaces userfriendly. When the prototype joins the marketplace and came in at 21 pages, we rejected it and said lets do better, its not three pages long. By the way, and that is an application that you have to fill out for private insurance. Lasser i also asked congress for the authority to reorganize and we are doing a lot of this work administratively. But unfortunately there is still a bunch of rules and a lot of legislation that has poorly designed some of our agencies and force people to engage in this hoop jumping so what we have asked to clean this up and consolidate. We have this authority to redesign the federal government, the executive branch, to deliver Services Better just like every Business Owner keeping pace with the times. Currently we do not have that capacity. Particularly at a time when congress is they want more attention to government and they give a lot of lip service to them. We are operating under severe fiscal constraints we hope that we can deliver this on the functions of the American People are looking for and we should all want a government that is more responsive to the American People. America is full of talented and dedicated Public Servants who are working very hard everyday to uphold the publics trust. Those of us who believe we have a responsibility with some level of basic security, to make sure that everyone gets a fair shot at success from the entrepreneurs who want to start a business to the workers who work in our business. We also have a responsibility to make sure that Government Works as well. That is why i am glad that we have people like scott and aaron and so many other talented men and women who have signed up to tackle these challenges and we are so proud that sylvia will be heading this up. I will be asking more people around the country and entrepreneurs and visionaries to signup for sign up for service. We have to have the brightest minds to help us solve our business challenges. It is a reminder that in this democracy we, the people, we recognize that the government belongs to us and it is up to each of us and every one of us to make it work better. We cannot just stand on the sidelines. We all have at Stake Government success. We have a stake in that. Because government is us. We are doing things right and we are tracking whether or not that saves lives for folks in the past of a tornado. We are delivering effective data on Health Care Choices that will save lives and reduce cost. We have the potential to do so much better right now. We will need the help of private sector and notforprofit and most what we want to make sure that we are empowering some of the folks that are sitting here today, making sure that they can deliver upon the 21st century government at the American People would like. Thank you so much from everyone. Keep up the good work. [applause] house gop leaders called on president obama and Senate Democrats to reduce student Loan Interest rates and rates on new subsidized stafford loans doubled after congress failed to reach an agreement by july 1 deadline. This is 10 minutes. [inaudible conversations] [inaudible conversations] [inaudible conversations] in afternoon trade today marks one week the senate has taken action to protect students all across this country. Although the Democrat Senate has been known for months that on july 1, many Student Loans, federal Student Loans would double, they have been more involved in internal bickering rather than addressing the issue. The students are surrounded with us today, they are all suffering because of this. One example is a woman from eastern washington, she is working at a local mcdonalds drive through in washington to help pay for rising tuition at Washington State university. When she heard that her federal loans may be doubling, shes an aspiring economist, maybe a public servant, she was not sure she could finish school. Unfortunately, that is repeated among so many students across this country. As a first in my family to graduate from college and graduate school. Paying off some students myself and i can tell you firsthand how very difficult it is at times to pay those tuition rates. And its not fair that the democrats who run washington to stand in students waiting. About 20 Million Students are called and 50 of them have to take out Student Loans. When harry reid tells us that he is not looking for a compromise, i would encourage him to think about haley and the College Students and the others across the country. As members of congress, we are here to make life easier for students who want to get an education and find a job. Instead we see the opposite. We see fighting internally and i urge congress to put students first and not washington politics. Republicans have talked about the Interest Rates doubling. To make college more affordable, including students and right here behind me. Senate democrats and the white house have let these students down. And frankly i think that they deserve better. It is time for the president to lead entering the democrat leaders together and develop a solution. The house has done its job. Isnt now time for the senate to do its job. It is very close to what the president offered in his budget earlier this year. The failure to lead on Student Loans is part of the president s larger issue, and that is the failure to lead on the biggest issues facing the country. Jobs and economy. Every american deserves better than the new normal slow Economic Growth and wages. I would like to be very direct. Need to stop these rates from being doubled. The students across america get hurt. I dont care about republicans or democrats, but we need a fighting chance for the future. Do not stop the ability for a compromise. Do not punish them for his in action. My colleagues have pointed out the problem at july 1, behind us now, the Interest Rates on stafford Student Loans have doubled. The house passed legislation to keep that from happening. They have made adjustments to the treasury to get politicians out of the business of setting these Interest Rates every year. The white house has proposed a similar solution. A Bipartisan Group of senators in the senate has proposed a similar solution. Yet there is no action is a Senate Majority leader. It is time for Senate Democrats to step up and take action and give these students be assured he and the relief that they need. We will now take a couple of questions. Thank you to we are talking to Senate Majority leader harry reid. What makes you think that your statement would allow them to come together based on these criticisms . The house has done its job. The fact is that we are going to pay the price. When they see the Interest Rate on their loans doubling especially. It is time for them to act. When you have a Bipartisan Group in the senate and a solution that was not far off from our solution, and was shut down by the majority leader, you begin to wonder whether they are looking for a solution. Do think what has happened there was a coup . Welcome i think that the situation is a tenuous one. One of the most respected institutions in the country as their military. I think the military on behalf of the citizens have done what they needed to do in terms of replacing elected president. But anything further, i think will have to wait for consultations with the administration on how we would move ahead. I have made it clear that i will make it clear again that the house does not intend to take up the senate bill. The house house is going to do its own job developing an immigration bill. But its very clear from everything that i have seen and read that the American People expect that we will have Strong Border security in place before we begin the process of legalizing and pitching our Legal Immigration system. We will have a conversation with our members on wednesday on how we would move ahead. We have a broken immigration system. We have undocumented workers here in record numbers. We just cannot turn a blind eye to this problem and think that it will go away. It is time for congress to act. I believe the house has its job to do and we will do it. Thank you. More now on the cost of college and a meeting with steny hoyer and students from the university of maryland. This is one hour. Thank you for being here today. First thing i thought we could do, i know that you just introduced yourselves, but i would like everyone to go ahead and speak again. Hello, hello there. The lady with the money. [laughter] and has been wonderful. You have done a great job here at the university. Let me start by telling you that before your parents were born, i was a student here. It depends upon how late you parents your parents had doing in their lives. I started in 1957. And i am still alive. How about that, geez. That is the good news. The good news is that my first semester cost me 86 for 15 credits. While. Is not incredible . We concentrated with the seem focused. In any event, when i was a student, you got a no questions asked. I was a commuting student. This is just the cost. It was incredible. And i think how it works at state colleges. They were open and they were very affordable. We still have state colleges and they are very affordable. But they have gotten a lot more expensive. More expensive than even when i went to school. It is very important that we keep College Affordable. It is very important that we do so for america. Because you when you will make a difference for america. And if we dont make sure that the best and brightest can get into school, and can afford school, yes, i was talking about this transition. When i practiced law, i did not care a great day. And i took out is called a National Defense education act alone. September of 1957, i was listening to my radio in my dodge tube. The russians launched a vehicle called sputnik. It is launching the globe. America was shocked that we were not first part of this. Dwight eisenhower, the president of the United States, he said that that is not exit well. We need to make sure that our young people can get into school. That is why it is called the defense education act and it was perceived to be part of her national security. We need to make sure the young people could get into school. I was looking to be a file clerk. I was only taking 11 or 12 credits per semester and then going to work. The debate that is going on in washington today is about how we make College Affordable to our best and brightest. How to make sure that they dont graduate from school so that they cant take a job and the teachers. Caring and 85,000dollar were 95,000dollar debt load, they are thinking, how can i earn enough money. We have tried to work on not by limiting the income. But we just had a debate and i would like to talk to you about it. I wanted to talk about her situation. Because we talk about the abstract, the policy that we try to adopt his discreet as individuals and they affect people personally. It is hard to think in those terms. So i thank you for being here to discuss this with a little bit. As you know, were having a debate in washington as to how we structure the various loans that we have. Whether we cast them at this time. All sorts of different alternatives. And obviously, consumers have the lowest Interest Rates. Which is why a lot of his own homes. Because we have financed them. Because they kept going down. We wanted to hear from you. The first thing we will do is to go around. I have sort of introduced sarah. But please go out and we will introduce everyone i am sarah, i am the assistant Vice President for Financial Aid here the university of maryland. Hello, i am a senior here gridiron from new york. I am from chicago. I am from annapolis, maryland. I am a senior Government Politics major. Hello, my name is patrick rock. Im a politics major. I live in bel air, maryland. Hello, i am a sevenyear hitch to student im a graduate of Maryland College and i am a graduate student at baltimore. All right. That is great. I appreciate your participation. I am lucky enough to have worked with the gentleman. The reason that i have introduced everyone this way is because my friend is here to listen and to learn. Why dont you come up to the table. Okay. This is the Communications Director here. Such a nice guy. All right, actually we have kirsten. Okay. That sounds great. This is my district director and she runs the district job. What tom wants to hear from you, because it makes a difference in the debate, often policy means something to somebody in some circumstances and we want to hear about. [inaudible conversations] come on out. If we dont have enough seats, we will move them up. There you go. All right. Please go ahead. She is making sure that i do the right thing. Okay. [laughter] who would like to be first in telling me what your situation is and why it is important to you . And as you know, we have a bill that freezes for at least a year or maybe even two years, subsidized loans, stafford loans, which we also did last year, and some of you probably know. The rates fluctuate on the market. The president has a market rate that is frozen from the time you take it. But that is the major one. So i know that you have been talking about this and this is important. I could not have completed my education without my loan. I was working so that i can meet some cost myself. I mean come i cant even remember what i claimed. Again, this is not so much for you. I would like to make that point. It is for our country that is so critical to have read some of your resumes. Commerce and come i have a question. And i went to georgetown previously for my masters. While i was there, i encountered the fact that we do not have access to subsidized stafford loans. Im wondering what is the reason behind not. You have to go to grad school for particular career warfield and im wondering why is that not available to us. Well, today the congress made a judgment that getting an undergraduate degree was a priority. The thing is if you have more resources, you could subsidized loans. But that was essentially a shorthand answer. The shorthand answer is that it was the most efficient use of resources to ensure this degree, feeling that graduate degree, while loans are available, they do not subsidized loans on the theory that graduates are going to make more money as they go up the educational ladder. And everyone knows that if you dont graduate high school, the chances of making a decent wage are very substantial. If you graduate from high school, you will do better. Do better, as you point out. But that is the reason and let me just say that i believe, because this is in the best interest of the country that we have to look at Student Loans as a deficit reducer. It ought to be neutral. That is to say that at worst it ought to be neutral. And the reason for that is that we are asking students to subsidize the deficit because we want to encourage you to go to school, we want to make it as secure as possible. It ought to be my generation and her parents generation as well to do so. That is one of the debates, by the way. You cant put into a Student Loans anything that we thought we could. Its freeing up money that we thought was there. I think that that is an excellent point, to the extent that we put capable people in debt. We undermined not only their lives, houses, necessities, children, we diminish our ability to grow this. I think we are putting the is an appearance of these people. You are right. It does make a good point. Thank you, megan. [inaudible question] as you say, it is definitely more difficult. It is important that we do this, as we have in the past. It is largely ahead of the control. [inaudible] we have confidence that we will set aside this much money every single month. We will do the best that we can. We are kind of on the same page. I think that you are right. I think dad this is something that is not retroactive. And tom, lets talk about this. I think that this is all part of this. On july 1 the rates will go up. That is true. But there is no intent [inaudible] yes, sir . Yes, hello. You asked for a more personal opinion and you want to know how it affects us directly. And i am originally from new orleans, louisiana. My father was just diagnosed with multiple sclerosis. Financially, loans, that is pretty much what put me through college. Im the youngest of 12. My parents have with six kids through college and now i have to find a way to make it for myself. It can be hard, typically. Getting out of high school and transitioning. My grades in high school were much better than my grades in college. But i think that the loans themselves, once i graduate college within a year, i will have to make do. Trying to find an apartment or a car, to be able to have a job, having enough money to have an apartment would be difficult having to pay back their Student Loans. So i just wanted to give you that tidbit of my life. Do you have a student loan now . Just come i do. You have a student loan servicemaster. Yes, every semester. If you do not mind saying, what, approximately, do you think at the end of your junior year, so you had two years to go, what do you estimate your debt will be when you graduate . Probably about 3000 3000 a semester . Yes. Youre talking about another 12 then . Yes, pretty much. By the time i graduate, yes. So you can all see how that would affect me. Many students like me, we would rather try to either stay in school, im going to graduate, but i know many try to take an extra year to have enough time to live at a particular level below it. Guest. Good for you. Of you studying . Criminal justice. Okay. Well, this is one of the more affordable that we have when you get a good education. It is affordable, it can be in the eyes of the holder or the thickness of the rocket. Eightysix dollars, i think my first job might be 60 per week. If you put this in the context. Im a psychology major and also a junior. Where you from . Washington dc. For me it is a little bit different. I support the idea and i am also not having the means to commute. I pay about 13,000. So like you said, it is much more affordable and i have taken loans out since my freshman year. To have the idea is a bit scary. My mother has her own loans to pay back things herself. The idea of me having loans any possibly discussing the next year, which could be much harder, to have that idea in mind, if there is going to be the struggle for both my mother and myself once i graduate from college, it is going to be scary and difficult. One of the things that i heard from both of you, i have been in financially for 22 years, you can see how the culture has changed over time. That the decision, even though it is its called a student loan, you are basing this based on your family circumstances. Its a very interesting concept that has to the phones work today. I do not think that people recognize how it is a family issue. You get something that you get called an efc. That is based upon your families salary and does not take into account what you have outside of debt. I definitely suggest this. That is definitely starting help me i have met some great people. But things will get a lot harder for me to be in school. I dont know if i want to go to law school or grad school. It depends on many things. I also work a lot with High Schoolers teaching a class in high school. A lot of times we talk about this and college. The main reasons that some people dont attend university is due student Financial Aid or lack of Financial Aid. Seniors, juniors, others, this could apply to any school in this country. Some dont get enough aid. Slipping down his partner National Defense and not something to keep in mind as we speak about higher education. That is a point that i agree with. You know, i think it is important also to look at this conversation in the context of higher education. By right now we are just talking about the industry. Maryland has done a great job in keeping College Affordable compared to other states in the country. That we are having this site over this and it is not even about the cost of keeping College Affordable. I think that some treat it as a permanent deal. We talked about this about a year ago. We did this like a year ago. People in Congress Want to move on. We want work on unemployment and actually keeping College Affordable. So i do think it is important for students to see a permanent deal. I dont think anybody wants to be at this table a year from now. Yes, that is absolutely correct. And unfortunately we have been doing too many things on a temporary basis. So some give those for medicare and it is called a Sustainable Growth rate. We encourage the development of new products in the ways of creating jobs and making money. The credit is product every year. None of that will be part of that. But i know what this will be two years from now. So i can plan around that. Saying that you absolutely need to do this on a permanent basis. I dont mean political parties, but i think all the people want to do this on a permanent basis. It is not a good solution to do it. You know, the Interest Rate will be 3. 4 . I can talk with my family. And no, guess what i meant i just went up to this or that other percentage and i dont know what its going to be this year. And that is how it spends. Seems to affect the decisions of families. My sister cannot afford her dream school because of an athletic scholarship. My brother doesnt know about what he will do about a scholarship. It can be so upsetting to try to work on this problem. If that is the way that it affects things, we need motivation to do extremely well and many cant afford college and i need to figure out how to pay off my loans. We should be worried about what we are going through. This is not a new problem. The magnitude is, but it is not a new problem. For example, i have a 1500 scholarship out of high school. And i got a 1400dollar scholarship for a university, a big school in pennsylvania. And it required me to get another 1800, 3200 total. So i went to work. I went here. It was affordable. My family gave me zero money for college. Not because they didnt want to, but because they didnt have it. So they came out pretty well in the family contribution. You know, this is not a new problem. Its just that the magnitude of it has gone up so much. It was relatively solvable because it was an alternative. Now that is not the case. Not only because of the academics, but you can see otherwise how it is part of the affordability as well. Yes. Theres a lot of competition. I have 2. 85 and i graduated with high honors. I am sympathetic to kids who couldnt predict what is going to do. But theres no way i couldve done it today. Its hard to get in, as you know. We are talking about the standards and you guys are also smart. Okay. Who else . You guys are participating in looking at this. Not right now, not as they apply to college, but although my older one at the university of richmond, which we believe is far enough away, but close enough that she could come home, we know thats very important. That was in the late 80s. We can see how it has escalated from there. Said that you couldve gone to private university that was an affordable alternative . It was the only alternative, because i could not for the other alternative. That had to be one of the best decisions. My mother is a single mom. When i was applying to school, it was pretty apparent that i would have loans wherever i go. But she kind of asked me how much my loans would be if i choose to go to each college. I ended up applying to all state schools because i knew that i didnt want to have six figures of loans. Ended up going to the university of maryland partially because of the instate tuition and i love my decision. But this kind of educated off the bat to know how much i would have to pay. Sometimes its pretty clear with whom i talk to about the decision they were making. They are keeping up with inflation if nothing else. The debate we are having in washington, however, it is not about increasing mess. You know, in 2009 and 2010, we increased. So sometimes it is just longer than what we go. Replacing 70 to 72 . I was on the labor subcommittee and eroded over this. At the time the other will be implemented in that way. But now it is starting to wither away. This number that we are marking, how much money we have decided to invest in discretionary spending, the Education Bill is projected to decrease. The centers for disease control, pell grants, it is scheduled to be decreased by 25 we are deciding to spend 50 billion so if you take 54 billion and it is a little bit more a little bit less, but lets say you take 54 billion from the side nondefense and you put it on the defense side, that means that 54 billion less which is about a half billion dollars in long terms. So that is an adverse impact to keep them not only from decreasing. But if you dont raise them at least with inflation, you increase the volume of inflation. You understand. Youre absolutely right that we need to increase the pell grants. Not for you, but for the country. If we are going to compete, thats what you want to do. It will be because we educate our young people to be the kind of growing economy that we need to create the jobs that we need. For the millions of people that dont go to college, but those who have skills and the will to work hard. Eighty to 90 an hour. By zack . Because you need to put things together in america. But you get my point. This is something we ought to be increasing not decreasing. This includes students who have a lot of ability but not much means and we need to get them in a the car so we can use their times. I think it is kind of interesting. Sheryl sandberg says wayne ford. [laughter] theodosius . Chooses ceo of facebook. She wrote a book about winning and. Well my name is amy and i am an outofstate student here at maryland. Maryland is a magnet for new jersey. It is one of the top five students. What i think is interesting about portability, youre talking about how you could make 86 in like a week or a half. That is when i was working fulltime. After that it was probably 45 then i was making that 20 or 30 a week. Okay. I personally the idea that washington does so much on unpaid internships, it created this gap and people who can afford unpaid interest with washington dc at. That is the way they get so much. And i would usually work tw jobs. Right now my internship, i am making a little bit less than minimum wage per hour that i am working. This is in no way in my tuition from. And my friend graduate with her associate degree and because of that she is able to graduate with less debt. She cannot afford it because of the loans that you have to take out for college. Is four for your is the magic number . Is three years . That is what were talking about in terms of education. That is a lot of Student Loans. A lot of countries have three years of higher education. Then it transitions may be the last year, the thirdyear of law school or medical school. Which adds up to the extent saying that what we need is a larger discussion of how long is enough and what do you need and how much does it cost and there are a lot of big issues that we need to discuss. You put your finger on it. It is a fantastic program. I dont think that we have such a program on the ground. I know you came from new jersey. And i think that we will have to think along those lines where there are some people that can take a first year of college in their junior or senior year because they are gifted and we will take advantage of that, again, to save that money and use a we can have them here. I know an individual who graduated college at 19 years old. Hes particularly gifted and is a math genius. But having said that, think about how much money he saved. Yes, i know he is interested in looking at these programs, figuring out ways that we can cuss costs here at the university level. To get kids out quicker. You know,. I think that we are looking at that as well. We are making sure that we are being supported on the National Level as well. We are accelerating people getting out of school. You grow jobs in every sector. As a result we really do need to focus on this as much as we need to. We ought to be doing this. There is a place to use your talents. What is the timeframe . We might need to wrap up here. Obviously we are here doing the best we can and that is a really good point. And its a little bit like the point i am out. Especially from an economic standpoint, we have an army that is not as diverse as it used to be. When i came to the university of maryland, it was mandatory. We have 4000 male students. That was part of the reason that the costs were deferred in the government participated because it was useful to the country. You make a very good point on looking about. It is not necessarily involved with Student Loans. And sam will tell you that although interns do this, as critically important work, it may not have an essential process to internship your senior year. But i was being exposed and when we they are . 2010 . 2012 . I was over there winter break. We need to think about this. Now, the option is paying interns. What is the problem that. We need simpsonbowles. That doesnt mean we have to agree with every point. So it is the uncertainty that will hit the country. This is just one factor of. Not the big picture as sam says. I want to thank all of you for what you do every day. This is so important. You do so much for what you do in terms of making yourself more able to contribute and participate it really mean that sincerely. I almost walked out of maryland. And going on to my second for what wouldve been my sophomore year, we need this done. Thank you very much. You are all outstanding students. I want to thank you. We are going to help these young people get a good education. We really appreciate all you have done. I appreciate your efforts, sam, helping us to get these kids together. We will take your comments. We have been writing notes and again, a kind it kind of goes into the debate, as i said, helping to resolve this particular view of things and that is the problem with health care. Medicare and medicaid, Health Care Costs are fine. But they are not find and that leaves 50 of the payer Health Care Costs. So we need to deal about. Thank you all. The white house says that immediately cutting aid to egypt is not in the best interest of the u. S. You can watch jay carneys briefing in its entirety online at cspan. Org. Here is some of what he said. What i would say is that we are monitoring the situation and taking the time to make a determination about what happened and we want to label it, if you will, and we will work with without any further assistance. We are talking about the assistance we provide the goes broader and deeper than that. For democracy, a better future. We support the process. Our decision is in regards to the events that have happened recently and how we label them. In accordance with the law in congress. It is one of the things cutting off his aid. I think it would not the best interest in the United States to immediately change our program. And we are reviewing us and we will be consulting with congress about this and about the way forward with regards to this. We think that would not be in our best interest. We talked about this over the weekend with the democratically elected government. The white house is not calling for the return of president Mohammed Morsi. We are calling for the return of the democratic governors. It is for the egyptian people to decide who their leaders are. We are talking about the actions of egypt and the military and removing Mohammed Morsi in regards to the polarization in egypt and the millions of egyptians and im trying to be handed this. Youll get no argument from me if you say that this is not a complicated situation that requires a very careful monitoring. Congress is back from the july 4th recess. With the next washington journal we will talk to the new york congressman whether the house and senate can work out a final emigration bill. And we will discuss the Senate Republican agenda including health care and the economy. And then allocate u. S. Trade policy. Washington journal each morning at 7 00 a. M. Eastern. Now hearing on medicaid would be affected by the new Health Care Law. About 7 Million People are expected to be covered by the program next year. This is a little more than an hourandahalf. [inaudible conversations] with a time of fouroclock having arrived we will call this subcommittee to order. The chair will recognize himself an opening statement. Todays hearing is the third in a series of the current medicaid system ideas for reform. The bills on the march 18 hearing with their most believable says since it from the intent of a crisis and our hearing on june 12 with reform, and spee Energy Commerce Committee Medicaid check up report making medicaid work and the committee reached an idea on the program. Medicaid was designed to protect the most vulnerable americans pregnant women women, blind and disabled and dependent children. Nearly one metaphor was enrolled as an employee in 2012. Making medicaid is the Largest Health care program surpassing medicare. We have an obligation to ensure the Program Provides Quality Health care to beneficiaries with a flexibility and to innovate to better serve this population. Were feeling on both counts only 70 percent of the nations doctors are accepting patients lead to problems of care and scheduling followup visits after seeing a provider. Of medicaid beneficiaries often lack access to primary care and Preventive Services and a twice as likely to visit the emergency room. In some cases, outcomes for medicaid patients are worse than those who have no insurance at all. Regarding flexibility flexibility, instead of encouraging states to have innovative models of care they have locked them into the one size to its old program dictated by washington. The states do try to modernize their program to the individual populations and often spend years waiting for medicare and Medicaid Services to approve their waivers. Before we approve the Medicaid Expansion which would add another 26 million americans to the program, we must first address these issues in the Current Program for garlic forward to hearing from our Witnesses Today about ideas to strengthen this vital safety net. And i welcome all of them to our subcommittee. I yield the balance of my time to the gentleman from louisiana. The current debate over reform of the medicare Medicaid Program brings to mind and i am paraphrasing on the Exchange Even from worst to better. Even if it is important with obamacare and the medicaid component said they would never designed it today as it was 50 years ago to meet high todays needs. It serves a Diverse Group of people pregnant women and kids in now ablebodied adults. If the intent is to take care of the most boyle verbal i raise the issue with the traumatic brain injury child have to compete for limited funds against a healthy adult. Also how much federal money receives her beneficiary. So the five wealthiest dates received twice as much as federal medicaid contributions to the care of their low income residents in those living in the five poorest states. If it is a federal guarantee to have a baseline of coverage why should day disabled recipients in new york received twice as much aid as a disabled person in california . Other problems include quality and access to doctors. There is a recent study that said they have higher costs costs, lunker hospitalization and worse outcomes than the uninsured but yet despite being a highcost program there frequently pays below a physicians cost which denies them access. Medicaid is the illusion of coverage about the power back says. I applaud the chairman for holding this hearing we cannot just add or subtract cash to call it reform we have to be willing to reexamine the effectiveness of the structure. I think all members can agree it should be structured in a way to provide benefit to individuals and the most efficient and effective way. I would also like to add a recently introduced the medicaid accountability act that i hope will be considered and i yield back the balance of my time. Our Medicaid Program has continually underperformer behalf. A set of having medicaid dollars that would direct more attention to improve the outcomes of the existing population we must allow the states to experiment with their program to improve results. The overly bureaucratic waiver process does not allow them to deliver care to the most the honorable. It is passed the time to repeal the minutes provision and release the states on a system that currently fails its participants. Thank you for the extra time we now recognize recognize mr. Waxman for five minutes. I recognize the gentleman from maryland who was filling in for the Ranking Member today. I appreciate you convening this hearing on the Medicaid Program. As you yourself said it is Important Program we view it as a critical safety net to provide Health Care Coverage for those individuals who are shut out of private insurance because it is unaffordable or unavailable or does it cover the benefits that the need. Is important to recognize with the Medicaid Program we dont just talk about a program that is low income families but a program that covers children and adults with disabilities and pays for half the of nearly all services. I represented Health Care Providers as an attorney and a particular those that have services to the elderly and i realize how critical that program is for a lot of the services that are provided most in need. Swiss important to understand the full dimension of the Medicaid Program. We talk about home and communitybased services and adult day care and caregiver respite. In 2011, the Medicaid Program provided Health Care Systems for one out of four or five people and the country including 30 million children that is why we need to make shepard this program is strong or rebuild on the most important elements. To bring this coverage to bear the championed efforts with respect for those that are eligible to get the care wherever they may be all our easiest to receive whether school or a clinic but the coverage for children is really one of the most important aspects of the program. And id like to enter into the record without objection testimony from the American Academy of pediatrics on this issue is why it is so important to the pediatrician and the children as well. Without objection, so ordered. Be Affordable Care act includes an expansion of the Medicaid Program to have more lowincome adults taking it up above the poverty rate. Half of the uninsured stand to benefit from the adjustment going forward. But we do have states across the country that so far declined become partners in this effort to take advantage of the expansion in the result is many lowincome adults that will likely remain uninsured with predictable results and for society. Also look get this through the economic clinton as the economy continues to improve more people still find themselves in need of this Health Care Safety net. Cutting medicaid that is cutting jobs for every dollar spent is good economics. According to one study by the Kaiser Family foundation 1 cover medicaid is 1 and 0. 6 cut from the states economy in which that occurs. Of loss of dollars means activity across the country which means you move states in exactly the wrong direction. In terms of economic recovery states in the federal government need to focus on creating jobs or incentivizing Economic Growth not just cutting the most colorful programs like medicaid slightly the Expansion Program under the Affordable Care act is not only something that makes sense for a vulnerable population to and across the country but in state economies as well and in the poorhouse to hearing how we can push for Quality Health care for all of our citizens and with that i yield back. In and wielding to the vice chair for five minutes. Thank you for yielding. As we meet here today to discuss medicaid and recognize it was created to care for some of the most needy in the nation however reality because of weak oversight and chronic over paving a lack of coordination of benefits, the ability of medicaid to provide Health Care Coverage is further threatened by the Affordable Care act in the drastic east region of the program to nearly 72 million americans in 2014. It currently consumes a quarter of the states budgets passing expenditures of Emergency Services said ministates darfur stooge drop reimbursement payments to face budget shortfalls. I and Stephen Furst and coverage does not guarantee access. The creates barriers to care and services because medicaid pays less for Comparable Service their private and jurors or even medicare itself making providers than applying made is hard but and as a sign of the problems and then instead we sat here in this very room with the health in 2008 and talked about this very problem. It was the day that Lehman Brothers collapse we are headed to a crisis. But we heard if you want to do Health Care Reform on the cheap, you just provide but it is the critical that why bridges that we provide the coverage anybody will tell you the ability to meet the cost of providing the care is critical for a hospital, clinic, doctors office. If you can meet that your doors will quickly be closed. As we sit here, we never ask ourselves is the best we can do medicaid . Would we be better to reform the program before we expand it . But those questions were never answered. I submit today we need to get back to basics and ask what was it created to do and is a doing the best it can under the circumstances . We know the fiscal problems problems, how long will america tolerate without fixing them for future generations . It is time not just to reform medicaid reviewed the entire system measure can see from the events the problems of the Affordable Care act for beginning to bell and reach Critical Mass m this subcommittee has of its power to take in its issue. I yield the balance of my time is too bad we now recognize the Ranking Member for his opening statement. The queue. The hearing today is called making medicaid work for the most vulnerable. That is a good topic but i do want to talk about what the republicans have proposed. They have proposed making medicaid and block grants to the states are told this is the amount you get, and no more, wellesz you dont have to do anything, no requirements, do the best you can and if you can afford to do you have been doing then you do less, that isnt to you. But so is a fact they are proposing to shift their responsibilities of the state in the cost and avoid the federal responsibilities. Block grants or per capita grants or increases in premiums and copays do not reduce Health Care Cost the simply shift the cost on to the beneficiaries providers and states and they make it less likely people can access care when they need it. Are the things we can do to improve the program . One thing is to make a federal program as a federal Medicaid Program guaranteed they ghembs rate that the medicare providers get paid. I dont think that is something we will hear from the majority part d. I think this is a good hearing to have but i am interested to hear from mr. Alan weil with the states can do to make the program innovative and effective thing cover low income beneficiaries they can afford the programs right now. Think about the state can do today. I believe he will tell us they continue to in advance of programs by implementing innovations such as the multi player collaboration or access to Higher Quality and lower cost developmental and others for the prevention of chronic disease. Multiple studies have shown that medicaid enrollees have comparable access to care as those with private coverage and much more reliable access from those that are uninsured. The republicans forget that before medicaid come these people were uninsured. They didnt have access to any care. Under that program the beneficiaries king can access the floor cost sharing in make a very poor people may have to come up with more money out of pocket . They cannot afford it. Not only does is ensure equal access to care and operates with efficiency and medicaid cost is four times lower than the average private plan. And there are other proposals that i think we will streamline for a provider reinforcement time line to ultimately increase the participation the state program and one of the things i am very proud of this is for a couple years we will require that preventative them primarycare the providers are paid the same. That wasnt a permanent change although made sense but just a couple of years and hopes that people would try to keep in place because it makes a lot of sense. We cannot afford to pay everyone the medicare rates than the least pay for those with whom you like to have access the most with primary and preventive care. The Affordable Care act can stand the Medicaid Program and it is a good thing to do it and i am proud of the Affordable Care act a think private is to stop complaining and make the law work but if republicans dont have anything to offer but to shift the cost to people who cannot afford to pay them and thereby 89 them the services they need. I yield back by time. That completes the Opening Statements. We have one panel today and i will ask them to take their seats at the table and i will introduce them at this time. First, nina owcharenko, director for Center Health policy studies from the heritage foundation. Second, alan weil executive director of the National Academy for state and Health Policy. But to find a nation for government accountability. Figure for coming today. You each have five minutes to submit your written testimony and so at this time we will recognize you for your opening statement. Thank you for having me today. It has the reagan will noted it challenges faiur program are not new. There unaffordable and raised serious concerns if we could meet the needs of those of the program today especially the most notable. Serving a very low Diverse Group, the Affordable Care act expanded eligibility to all individuals and with traditional eligibility is based on income alone. I see three major challenges facing it in the future with democratic and structural and fiscal. With the addition of the new Medicaid Expansion, the cdc 2011 projected that nearly 80 Million People will be on medicare by 2021. With enrollment alone children will remain the largest category of wood is worth noting that as a result the ablebodied adults will be a very close and. But only 16 total it was for the age and the disabled. This competing trend continues medicaid will be more diverse and complex to a banister. Structural challenges, payment rates are one of the key indicators for participation in medicaid. It has already been noted today in the annual report it is noted well vary by state on average there twothirds that of medicare in 2006 published survey found 21 percent of physicians reported favor not excepting you patience while only four reported not taking privately insured patients in 3 percent said no new medicare patient although at the Affordable Care act provided for primarycare physician in has been noted it is temporary and several states every indicated it is unlikely they can maintain this new rates. Therefore access and quality issues will remain a challenge for beneficiaries in the future. Physical challenges coming entitlements including security and medicare and medicaid with the spending crisis these three programs represent the federal budget in willis or paul tax revenue by 2021 federal and state spending alone is projected to reach millions of dollars by 20201. For a state that has to operate under real budget the fiscal situation is no better when the contributions are included it is the largest budget item representing 24 and the recent one negative recent fiscal reports the between receipts and expenditures, he feels he can stretch out with the government plays a retirees. Although the challenges can only make it work look worse there are a few basic principles with the key challenges facing medicaid. Number one meet current obligations instead of expanding attention should be sure to know that is meeting the needs of populations should be prioritized based on need and return medicaid to a safety net not the first option of coverage but those who cannot obtain it on there alone careful attention and should be giving on negative giving a transition to those who can go into private market. Number three, efforts to shift from feeforservice accelerated the war should be done and empowering patients with more choices to spur competition including insurers will help to develop better quality care at a lower cost. To ensure sustainability similar to other entitlement reforms budgeting at the state and federal level should have a predictable and sustainable path and taxpayers alike. In conclusion it is encouraging to see efforts of the house and senate to address the serious challenges. With federal and state policy makers meaningful change will ensure the most vulnerable are not left behind. Thank you. I now recognize mr. Alan weil for his opening statement. Members of the committee i appreciate your opportunity to appear before you today im executive tractor for state Health Policy and nonprofit and Nonpartisan Organization to promote excellence the state Health Policy and practice in my own experience includes and that characteristic remains true today unambiguous evidence demonstrates success in to relieve the Financial Burdens associated with the care. My testimony is a report from the field where i report on a dynamic and devolving to meet the needs of the population to transforming of those around the country. For example, medicaid is one way to promote the use of developmental screening methods to identify children who benefit from Early Services than those that receive a screening have grown in nationwide children with Public Health insurance are more likely to receive critical develop the screenings than those with private Health Insurance and in 2000 the Surgeon General called that the silent epidemic and Medicaid Programs are pursuing efforts to ameliorate the crisis and year earlier intervention in medical practices not just a dental Office Maryland among others has innovative programs to increase access to dental care. In now the states spending more than onethird of their budget to meet peoples needs more effectively. With the eligibility a moment louisiana will streamlined process for applicants and those seeking to renew coverage. Oklahoma launch the first online realtime in roman system but some of the most exciting work this out works with other public and private programs. All the states rely on managed care to deliver some of the enrollees in twothirds received the store all of the benefits and states are increasingly relying on managed care programs for more complex populations like children with special health care and people of all ages. Medicaid is a leader. 29 states have launched one or more programs of the childrens Health Insurance to promote medical holmes. In 18 of those they Work Together to support. The whole model is the extent that integrates physical health, Behavioral Health to meet the needs of the most complex populations but fees but in 2006 from massachusetts reform to its Health Care System it took a blended approach to Smoking Cessation services did in massachusetts smoking dropped a 26 in two years with significant hess savings as benefit. The programs are pursuing know new models to encourage them to coordinate care as they accept the initial risk and accountability. The structure of these programs is the state is as colorado, oregon, the states take the approach to meet their own needs. 25 states have received support to develop further comprehensive multi payer payment and Delivery System reform welfare funding to the state innovation models. They will pursue with the provocation held that a but it is not just medicaid but medicare and five it appears. Medicaid is surely complex but a very demands dynamic and open to improvement if a thing we have created a fundamentally as a lookout at the experience of the states and what is going i see a program that works for americas most vulnerable. Thank you, mr. Chairman. I now recognize mr. Tarren bragdon for his opening statement. Thank you mr. Chairman. The foundation of gao weird naples, florida, a thinktank but but it is the fast growing item concerning what a 4 per credit it is projected to double over the next decade. Given these cost projections their failing the american taxpayer but more importantly but the inability to personalize care keep too Many Americans pour in sick and rob them of health hope of a better life. It is not a safety net but it is a tight rope the patients are falling up every day. Because of the Affordable Care act, many states are debating whether or not they should broken their old medicated system. The reels is to make when states have flexibility Truly Patient centered care can be a reality. And one of the doctors are giving the power to choose with several competing brands in the scare from its approach ignored the individual concerns but where patients have a robust choice such as florida, kansas to the vienna, patients are a priority. In florida patients can choose from 13 different private plans and 301 customize benefit packages. And it features but to have the incentive to improve health. This and theyre also constantly but 70 or 85 to proactively a livein automatically being signed into one. It promotes a Better Health a come but they all or outperformed outcome in 94 had improved since 2008. When this reform goes statewide of florida period taxpayers will spend 1 billion with a billion over five years and 150 million in the first year. Protest when it includes details of other strategies that states have embraced including integrated work to promote specialty plans. But following the rules and regulations can make it difficult for the states to innovate including the waiver process. New taxes on private medicaid plans with caution to this day. Luckily the committee is exploring ways that congress will make the state reform easier to grant additional flexibility. Many are detailed in my testimony including allowing waivers to become incorporated into the state plan and to provide claytor but with the efficiency in the hope of a better life. Access to quality care is still the new Health Care Law proposes the largest expansion of medicaid in history. The expansion that is clearly built on a framework that is already failing to meet current obligations and helping our most vulnerable citizen. Mr. Bragton, if your testimony, you note that states should be cautious in opting in to Medicaid Expansion. At this point, the majority of states are not expanded or still undecided. What are some considerations you would raise with states that are still deliberating the decision to exdemand 2014 . Thank you for the question. When you look at states that have expanded medicaid in the past, two states that have most closely replicated the expansion of the Affordable Care act are maine and arizona. And the reality of those states higher per person cost, and many people enrolling than originally projected. What happened as the safety net was stretched further and further, the states proposed and cut sfs to the most vulnerable. Arizona stopped covering heart and lung transplants. Maine proposed Cutting Service to folks folks with brain injury and stopped paying the hospital all together. What happened as states expanded most vulnerable tends to be higher cost as mentioned. The services are cut back on the individuals first. I think the primary caution you have to give the long view what the future of medicaid will look like versus the short view. I think the temptation in bump of federal dollars to state has a tempting offer. It has a short team clinton. Looking at the implications of the federal level, understanding our country cannot serve survive on the in your testimony, you mentioned some of the reforms that states some of the innovation states are pursuing. From your experience, what are some of the barriers that states face in pursuing new innovative delivery models such as those outlined in your testimony. I think one of the things mentioned by many folks here is the lack of flexibility the the federal level. Too many times the states have to figure out which loops to jump through. Even if they we think they are making progress under current law. Imagine what they can do without having the contract of all the federal requirements on there. I think it would be the best distribution for the state and the federal government enable them to. Each of you highlighted the value of manage care and increased care coordination in the Medicaid Program that mover us away from the pay for flaw den if given one opportunity what would be an important policy reform pursue for medicaid if each of you would respond. I think expanding without having to do so many waivers on the populations could be included. I would argue that the states know best when trying to develop and deliver care to the most vol herbal which they think are suited for the manage care approach. I would note its not scru good enough to have one managed care plan. What you want is insures competing against each oh. Making sure theres competitiioe choice to choose will alleviate concern a plan most suited for the most vulnerable. The Rapid Movement of states in the medicaid population makes it hard for me to see there a major federal barrier to rely on manage the care. The primary area that remains a challenge is a integration with the medicare program. We have demonstrations going on designed to entable between medicare and medicate. I think have to see how that evolve, but thats, to me, is the population that fashions the largest barriers if the boothe. I think there are a few Different Things. One, looking a the the robust Competition Among private plans. As the rans build on to have that you can provide more comp hennive care that hold medicaid doesnt. Kansas add a dental benefit when they moved to private plans. Ged services so individuals could get the best safety net which is a good paying job. Florida shows how when you give people choice, and choice counseling which i think is an important component so patient unthe difference among the private plans, i think lastly theres a debate over mandatory versus voluntary private care. When you look how patients vote with the feet, patient appreciate having robust choices of several different private plans. In kansas native american are given a choice whether to choose from one of the three different private plan or opting back to old medicaid out of 4,000 only twelve stayed in. Louisiana o. 3 voluntarily choose it versus five different private plan. Thank you. The chair recognizes the Ranking Member. Five minute for questioning. Thank you. We thank our panelists today. It was mentioned challenge to the Medicaid Program, and i didnt hear that necessarily formed an indictment of the program overall. It justice laid out what some of the challenges are i want to get maybe your reaction to the challenge. Whether you think the Medicaid Program can handle it. The first is the demographic challenge coming out particularly the baby boomer generation, and the implication it has for the Medicaid Program. And the notion of competition within the diversity of the pool of beneficiary covered bit Medicaid Program. These are realities we have to deal with. My sense is an expanded Medicaid Program we are trying make better every day is going to be best equipped to handle that challenge. She spoke of structure challenges, for example, related to payment rates, did acknowledge that in 2013 and 2014 thats an attempt made to achieve 100 parity. And spoke of the phis cam challenges ahead of us with entitlement program, as i offer refer to them earned benefit programs in some instance. We your testimony suggested that in some ways medicaid is on the cutting edge with respect to innovation not only to improve care. Particularly care one might put under the heading of sort of Public Health when you look at children developmental screening with the Medicaid Program cousin is really cutting edge ahead of both the commercial arena, and potentially the medicare there. The dental care for children and Patient Center medical home among many examples you gave, these are things particularly the last one i mentioned that can improve efficient sincerity and save costs over the long run. Its really because of aca were going it see some opportunities for that. So can you address these challenges that demographic strurm, fiscal, and other challenge you see. And why it may be best equipped to handle . Thank you for the question. The demographic challenges are real. They effect medicare as well as medicaid. We cant ignore the reality that we have aging and they will increase the average cost per person. But i think against that backdrop its worthing noting despite aging population of medicaid nursing home census have stayed flat despite the aging of the population a that are our use of grows and some leading states have really shown us how to not just prevent people from going in a nursing home in the first place, but help them come home even after they have been resident for some time. Washington state is a leader in that regard. With respect to your question about expansion. I think we need to be careful about whey heard the repeated use of the determine abled bodied adult if somehow they dont need Health Insurance. It they are not sick, the good news is they wont cost us any money. We shouldnt be worried about providing them with coverage. Everyone gets sick sometimes more than others. Or may have chronic conditions untreated that getting them early care will actually reduce the overall cost. We know theres growing prevalence particularly among the target. The issue here is going to move the population to a system where there is someone responsible for managing their care. Sate and federal government responsible for paying and usually a private plan. And i should note most states offer their medicaid enroll lee a choice of plans. A private plan that is interested in maintaining health or do we leave them the alternative only alternative im aware of they are uninsured. No one is accountable for improving results. And similarly, i will ready admit they are below commercial and some in some instance below medicare rates. But again, i think we have to ask compared to what . These are people who otherwise would be uninsured. There would be no payment source for them. There missiondriven providers and oh providers that have a they are going to subsidize care for some in order serve others and medicaid helps alleviate the burden. Doesnt completely eliminate. These are challenges, but my experience is that States Observe them, look ahead, and are doing what they can to tackle them, the design of the Current Program. Thank you very much. I yield back. The chair chank the gentleman and recognize the vice chairman. I thank the chairman for the ranking mission. Let me ask you we mentioned several times in the Opening Statements and i believe in your testimony about provider rate, and how that effects access for medicaid patient. So provider reimbursement rates. Medicaid is a shared, federal, and state responsibility. So how can the federal government ensure provider rates are set at levels that will open courage pamption participation. I think one of the point you have to contract with the fiscal challenges. So if you have viewedder payment issues. You are not paying providers enough. The easy solution is pay them more. To pay them more you have to pay for that. The states decide maryland many instant theyre not willing to spend the money. They wouldnt have had the federal government come in for the temp temporary boost. Did the federal government continue to provide the level of reimbursement. I think thats the pro, with i have medicaid in the longterm. Is it sustainable from a if i call standpoint . Who is responsible for paying the increased rate . The federal government and the federal tax payers are paying them. And the past 2015 . Is will go back to the states. As they said many states saying they dont think its its doubtful theyll be able to keep and sustain the level. The challenge will be states back here in washington saying we need more federal dollar and dont want them temporary. We want them permit permanent. The federal government have to find the money if they go down the road. The federal government doesnt have the money to be continuing that type of spending. We have seen that movie before. The stimulus in february of 2009 provided an 18month bump up. As it was about to run out in august of 2010, i recall, we have to have an emergency meeting of congress in the middle of the august recess, one of the few times thats happened except for war. The purpose was topaz a supplementty stimulus bill toking ament the medicaid rate. For the record, i voted gent it both times. Let me ask you a question, were looking a the the states that agree with it and some that have not. The Supreme Court in the wisdom said that you could not make acceptance of the standard medicaid regular medicaid con ting yent states actually have some leeway there. The deadlines for the exchanges since this expansion of medicaid of not set in federal statute but rather a court directive, there are no dates, there are no drop debt states for the states. Wobtd be the state be well advised to see what happens and a few other state before they jump in to this. I think the complexity we see the Health Care Law facing i think it would be wise for states to think for the longterm and see how it plays out. I think it will be an annual debate moving forward as well. Theres no penalty for a state that says not now. Thats correct. And they can revisit in subsequent legislative session in the future. Thats correct. Let me you know, when you get back to the getting the providers to get tack back to the system. I can remember in texas in the early 1990s, there was a mistake said, look, well cover your first 100,000 in medical liability claims for medicaid patients if you agree to see a certain number. That program didnt last very long. I presume it was a costrelated factor. It seems when something along the lines to encourage providers to come back to the system would make a great deal of sense in their flexibility built to the Medicaid Expansion that would allow at a times states to do that . Im not familiar with any at this time. The other panelists may know more. Let me ask you a question. The center for medicaid and Medicaid Innovation and the use of what did you describe the multipayer systems . Can you provide us a refer for that . I would be interested in what the data was they used to make that determination. How much money was forwarded in those grants. Do you have that Information Available if not today could you name available to us . Yes, i would be happy. Thats public information. Were quite early in the cooperative agreements but the states that were awarded them what they intend to do with the funds thats all public. Its available from cms. Thank you i appreciate it making available. My experience with them is not that great. It seems to be a bureaucracy that not even a bureaucrat can love. Thank you, mr. Chairman, i yield back. The chair thanks the gentleman. Recognize the distinguished Ranking Member five minutes for questions. I commend you for holding this important hearing today. Medicaid is a Critical Program that provides Health Insurance to the most vulnerable in our society. Many states, include l my own state of michigan are currently deciding whether to extend the Medicaid Program under the Affordable Care act. I believe activity the right thing to do. Its going to expand health care to millions of americanss who displaitly need it. These questions for one out of three children. Is that correct, yes or no . Yes, sir. Now, children and their parent account for 75 of the medicaid enroll lee . Is that correct, yes or no . Yes. And this population account for 34 of the pend spending of the program. Is that correct . Yes. What area where medicaid has been innovative is the area of developmental screening for children. Which helps promote Early Detection and prevention of had health care problems. How many states require medicaid providers to perform developmental screenings on children as part of routine exams. I believe the number is fourteen; is that right . That sound right. They are not; however, required to this . Thats right. Repeatedly we have seen the National Percentage of children receiving developmental screenings rise from 19. 5 in twoafn 30. 8 in 2012; is that correct . Yes, sir. This is a great improvement. I believe it helped increase the number of children that undergo the screening tests. Is it correct that a child with Public Health insurance is now more likely to receive a developmental screening that a child with private Health Insurance . Yes or no. Yes. Successfully implementing innovative programs that are seeing positive results. Isnt that so . Yes, it is. Which are describe in your testimony of lead to positive Health Outcomes and are models for other states to follow; is that right or wrong . Yes, it is. Finally recent study of new england journal of medicine cited the do you agree with the conclusion of the study that expanding medicaid will lead to lower rates within the states that do it . Yes or no . I believe the strongest evidence that it will reduce mortality. I thank you for this. I believe medicaid brings real Health Benefits to our vulnerable population and states currently coming up with new innovate strategies to improve access to care. As states across the nation including my own state of michigan are or not i hope they will look how the program is working to improve Health Outcomes for million of americans. States should consider the financial benefit for expending medicaid as well. Michigan alone can save 1 billion over the next ten years if they choose to expand medicaid, which i hope they do. I hope they will continue to exam this bipartisan matter. You have been help to feel us. Thank you, mr. Chairman i yield back one minute and fifteen seconds. Recognize the gentleman from georgia. Mr. Chairman, thank you. Let me i want to address the first question to much has been said that the Medicaid Waiver Program offers states all the flexibility they need to improve and reform their programs the existing waiver program. Adds you know, this administration is a strong supporter of the medicaid population expansion. You said up to 138 for the federal populous. May there be an opportunity for the administration to intentionally withhold waiver determination at the state does not get with the program and expand . I cant exec late. We know its long and cumbersome. You dont know when theres no time limit how long a process may take or the complexity of the whatever. We also need to recognize that the waiver is dictated by the statute. Theres only certain things that can be waived and so to the point that you want to do something above and beyond what the statute allows you to, that still is a limitation. Yeah. Mr. Chairman, we have seen this administration continually use almost cohearsive methods to aid implementation of the law. Allowing medicaid waivers as the only process that to innovate seemses to offer an situation right for abuse. This is why we need to repeal the medicaid and chip paint then of provision and give states a chance to truly innovate. Continuing along that line, the maintenance in obamacare have not only been costly, but they have been a barrier to reform. Thats why i introduced hr1472. The state flexibility act to repeal medicaid and provisions in the president s electric law. Repeal the maintenance. These difficult fiscal times, states often must make cuts to other nonmandated programs. Such as education. Because they dont have the flexibility to prove their existing Medicaid Programs. In other words, get rid of people that are on the rolls that shouldnt be there. That maybe two or three years ago these people were ebl eligible. Now they are making 75,000 and frozen on the program. Would you please explain to the panel how these provisions increase cost to both the state and the federal government and actually hamper Patient Outcome . I would say that the maintenance of the takes a tool off out of the toolbox that states have to work the budget within the mean and budget to provide the care to what they feel are the most vulnerable and most needy. Again, getting back to the flexibility for the states, i think the closer the policy makers are to what is going on on the ground at the state level, the better our suited in deciding who should get the care, where the adaptation can be. Where we can scale back or policy should be . Im thinking if they didnt have the paint then of provision and able to clean up the roles, if you will, maybe some of the states would be willing to expand. Because they wouldnt be throwing money at people that really dont need it. Will you care to comment on that as well . Thank you. I think that youre touching on an important point. When you look how states can customize the Medicaid Programs. You need Different Solutions for different population and you need a dynamic duel kit, if you will. In florida, for example, the average single mother on welfare receiving medicaid is on the program for five months. And so for those individuals also about creating some sort of [inaudible] what happeneds now is you on are medicaid. You may be in a private plan you like. Theres no ability to keep the private program once you go off the program. Theres no ability to even be aware of what is available to the people. I have thirty seconds left. I want to make the comment. I thought about this three and a half years ago, right here when we were in the minority on this side and the bill was being developed and the Medicaid Expansion up to 138 of the federal populace level. Where would the people get the care if they were not eligible for medicaid . Get it on the exchange, and the provision that goes to them would be all federal dollars. They wouldnt be state dollars. So its really a game of moving the hat around to see where it is. Clearly that was a setup. So there would be less federal cost and more burden on the back of the state. And i yield back. The chair thanks the jentd lman. Thank you very much. This is a very important topic. There are so many exciting innovations going on all across the country when it come many ed candidate. Thats the lifeline for family and seniors and children and disabled. I wanted to i think its very important that we share an understand what is happening. In these innovations. We do this on a regular basis for those that are interested in the Childrens Health care caucus i cochair with republican congressman dave ricker from Washington State. We educate staffers across capitol hill, other policy makers, members, and we have another of our medicaid matters for kids sessions this friday here in the building at 12 00. I would like to thank the Political Capital campaign for children all the Childrens Hospital az cross the country. The pediatricians and Family Foundation for helping to organize the important medicaid educational session. The one on friday is un one of the mo exciting innovation i know in florida in my hometown Saint Josephs hospital is the complex chronic complex clinic for children. Its been running for twelve years now. It provides continuous comprehensive and coordinated care for the most medically needed children in our community. If the clinic was organized after years and years of a watching children cycle through the Emergency Rooms without a real focus on their Ongoing Health care needs. The hospitals desperately wanted someone to provide them with a the car nateed clare. The cliej came together and serves over 1,000 children in the that bay area with a great team of pediatricians, nurses, sworkers, social workers and many others the families in my area love this clinic. We appreciate the fact it saves 6,000 per year in costs alone. Some National Studies say we are saving closer to 10,000 a year. Thats one of the innovations that im excited about. Name another one where things are going right under medicaid. The important federal state partnership. I think some of the most exciting work is in the area of Patient Center homes where what were trying to do is take a Health Care System not just in medicaid but in the system at large that primarily send the resources to the most expensive setting for care for hospital for institutional care. And build out, as you described in the scenario you described, build out an infrastructure of the kind of care people need at the better touch. Its closer to the community. Its less expensive. Its less open so thetic. Its more continuous. Ands i think some of the best innovation going on now are about bringing in Mental Health in to how we think about delivering health care