Transcripts For CSPAN2 Childrens Health Insurance Program 20170317

Part in a discussion about the Childrens Health Insurance Program. The program is up for reauthorization in congress this year. This is 40 minutes. Starting the panel, we have the president and ceo of the Childrens Hospital association, the president of the American Action for him and a former director we were joking about the cbo scores and withstanding criticism and so forth and we also have the former director of the Medicaid Services and bill, the favorite of reporters everywhere, the Bipartisan Policy Center very helpful and also a former director of the Senate Budget committee thank you. Thank you for coming. We appreciate everyone being here today. When we planned the conference we thought we would be a little further along in the discussion of the Childrens Health Insurance Program reauthorization. We thought there would be conversations going along. There have been a few private conversations but not as we might have expected all those many months ago. When you think of Childrens Health coverage what are some of the key aspects that you are thing in about and i will let anyone jump in. Im happy to start. So the key part is about 6 million kids give or take and it is an important program. That being said, we want to focus on the big context which is we have over 30 million kids in the medicaid main program so we think of it as a kind of 15 solution, but the lions share is in the main Medicaid Program that is now tied up in the repeal and replace campaign so thats how we think of the broad picture on the public side. Anyone else want to jump in . I thought this is the year we would figure out what we wanted. They had a sort of weird family glitch and the kids were stranded here and we had a program that needed to be reauthorized and i thought that would get reformed and with a sort of integrate better into the landscape. I lived a life of delusion and now what we are going to do is to see how this American Healthcare act plays out. I think there are a lot of issues. I think a little bit about where weve come from since it was created in 1997 and its been a remarkable success working together to cover kids. Just this past year we reached the point where 95 of children in the United States have Health Insurance coverage. That is marked progress from where we were just a years ago and since that time when it was implemented you could see the progress accelerating and then as well its very Compelling Research on the outcomes for the kids that have medicaid coverage. The children who were served go on to be healthier adults. They are more likely to stay in school and go to college, they have higher earnings and so clearly, a lot of return on investment from covering those kids. The challenge even though it isnt a hot issue right now, medicaid is, and the healthcare act cut 800 billion over ten years as we saw last week and the likelihood that has an effect on children is high because children represent almost half of all beneficiaries of the Medicaid Program so i would say even though it is not front and center right now, childrens coverage certainly is. This particular program came into existence out of the 1997 balanced budget agreement in the negotiations that we had, and i want to emphasize the fact it was a bipartisan agreement and it has remained bipartisan so even in this situation we are the language right now with the Affordable Care act, i think that this particular Program Still has the ability to be bipartisan and will continue to do so which will be an advantage when we have the expansion of the reauthorization expires this year. Some people are concerned that the republican bill would make the reauthorization more expensive, so could someone walk us through that . [laughter] the issue is they put this socalled stairstep into the main Medicare Program and this reveals that and so many of the states can put them back in the programs and that would make it more for the state and federal budget. I have seen no evidence among republicans that they somehow want to reverse that and keep them in the program so i think that is true in the mechanics of the repeal part and when they get to the reauthorization any higher price tag is bad news. Absolutely makes i it makes t much more challenging. In terms of the budget, one thing i want to try to clarify its debt it is a block grant entitlements so that Congress Must tim reauthorized as a fixed number so while there might be the introduction of changes in the Affordable Care act they would have to change that. In other words if the dollar didnt go up and its a fiscally conservative mood it does mean that there will be less dollars for children that are eligible for that is the complication. The interaction is there is a maintenance effort and if you dont give the states the money they need to step back and think about what they want from this program to get it right. I wont speak to the budget elements but from the problematic standpoint, the movement of the kids into the Medicaid Program is a simplification that need it easier for families to know which program their children qualified for and i also would say what went with it is greater affordability and benefit standards for kids, so under the American Healthcare act we would lose that at the same time we have to grapple with the budget mechanics that are described. They would say you can charge the premiums and copays and things you cant always do in medicaid and they would have an attraction to those. Whether that is a good Health Policy or not said that drives a little bit of this. One other issue we will be dealing with is the fact that the healthcare law, obamacare data provide states with a 23 percentage point increase in their federal funding match and that was continued in the last authorization in 2015. There are some conservatives that have said they are concerned about that and want to scale it back. What does that mean and how do you expect the congress to address that . We wanted a 40 year reauthorization in 2015 as many of you will recall and to some degree we thought that was offset by getting a higher rate as was pointed out. Getting to the reauthorization makes it a political process to get reauthorized and i do think that 23 might be harder to keep. Its not that expensive of a program so plus or minus 23 isnt that big of deal. Even though it isnt much money from a federal perspective i think from the state perspective they budgeted a year ago and theres a lot of uncertainty about whether it will hold or not said that creates a challenge for the state thats trying to plan its program. This is the former director the budgetary outlook inherited from last year is one in which left on autopilot at the budget goes to running trillion dollar deficits and presumably that is a daunting fiscal outlook and there is no money and so number one come in the same way im sure they see the idea of the Expansion Program as 23 percentage points, i get that, but if there is very little money it is hard to defend providing a more generous match. I think you have to face up to that and what would w why wouldt of this program. I would expect first of all we have to get to the reauthorization quickly and i would debate the Affordable Care act i think we need to move quickly on the reauthorization. And when he thought there was some sense that the 23 would face down as the Affordable Care act came up so now i do think that given the fiscal issues i think the likelihood of that 23 remaining is questionable and if there is any sense in this it is not eliminated overnight. So they will be facing lower spending over time and they will be facing changes in chip. Did they put the money into childrens coverage or did they provide for other investments and other things . Money is fungible. State budgets have been tied. Theres been a little bit of sunrise on the landscape in the past few years and so in effect that subsidizes other parts and it is and walked away. So they are going to have a problem that weve already budgeted for so it is a challenge no doubt about it. Some states did reinvest through other states and if you look at the money you know its temporary and others will want to make an investment with it. The states that did best of the dollar which had closed its program several years ago and reopened it in part because the federal match was about 100 in their case. But its interesting to see what happens without that if the 23 is not continued. And it did bring the funding pretty high up so there were several states that are not putting any money into the program in their own. One question i have about how this gets done and has so much attention focused on the American Healthcare act the committees of jurisdiction are focused on that and some of the committees have to deal with the reauthorization. Do you think this gets left to the end as an afterthought and do you think that it might get wrapped up in some of the trading that might be happening on the larger healthcare field . This is something we should be reauthorizing now. We did 2015 early in the year because the state budget started to kick in so they needed to kind of know where the money was sitting. We now see the september bucket and i think the issue is the current debate is taking the air out of the room on things like chip so unless you are up within 30 days people dont get their attention focused on it and the idea is we work on something that is supposed to expire in september and now it is naturally resonant. There were very popular bipartisan topics and so we dont really expect that its not going to go forward. The devil is in the details and what that is and what the changes might be. I agree that it should be done now and i think the congressman earlier said there is a lot on the platter that has to be done today as we hit the debt limit for the scheduling of that. We are running on a continuing resolution through april 28. I would argue that giving the states budgets in the way they are formulated for this might be something our organization has put out a proposal to extend for four years and i would say when we come up with a continuing resolution in april that might be an opportunity for the extension for some certainty Going Forward in the next year to resolve all these other major debates that we have going on. Another way that it could play out a less profitable way would be to fold it into some subsequent legislation on medicaid, the administration and congress talked about having a race track strategy and coming back with policy proposals on medicaid later in the year. That does raise the possibility and i would be really concerned to see if traded off against medicaid particularly since 90 of the children covered by both programs are in medicaid and theres a lot i think we would like to see happen for those children and to continue to see strong benefits have been the underpinning of coverage for those kids and so i worry about a scenario in which we have to think about both at the same time and trade one off against the other. What do you think about the idea and is this something that advocacy groups talked about or thought about and would that be something the organization would support . We are in favor so if we tied it into that it would be terrific in that point of view. I would say when we raised chip almost everyone looks at us and says what are you worried about it is going to get authorized, so quit worrying about it. I think for the most part theres been less advocacy today and more on medicaid just because that came square into the crosshairs of the budget process and the larger goal. That said, i would echo the comments around it being used as a political football with 6 million kids and to the degree that it gets bogged down or tied up as a vehicle for onesided negotiating with the other would be tragic if it got held up and we lost coverage. With respect i dont see them ending up because it is a partisan Popular Program and they will not let someone like that because then they couldnt pretend to not pass it. I dont think that will work. I think in the end one way or another theres going to be a flatout oneyear extension in the moment of weve got to do something and then the right thing to do would be to get the leadership house so why dont we come being the folks outside thats going to surround the healthcare act and all that why dont we just say okay we are going to do this in 2018. What do we need to get done and that strikes me as a productive strategy that will allow them to tailor to whatever happens on the larger front. And i think you do nee need the administration for the leadership in the environment and only they can sit down with both sides and thats what we are going to find. You are a part of the Obama Administration so what do you think . Theres a lot to be said for the one year and come back to it later approach. What we have been struggling with in the reauthorization ends if past is the question of what is the role. Its always worked in concert with medicaid and standing on the shoulders of medicaid but now that the marketplaces exist in Congress Never firmly landed on the question of is it better for kids to continue in a the separate program or the marketplace. The changes we are contemplating to both medicaid and the marketplace are fundamental and i think that it would take things textend todo a oneyear e what the landscape looks like for medicaid and the marketplace and come back to the conversation next year. I would make a comment about the marketplace one of the reasons they remained relevant was the managed care product exchanges and Network Adequacy does seem adult centric and robust products for kids whereas the Medicaid Program were kind of pills for that. I dont think we saw as much evolution in the products as we hoped in terms of the pediatric nature of them and whether or not the networks would be well served for kids and that remains an outstanding question as we think about whether or not we can get rid of it and replace it with a broad set of commercials in the private sector or medicaid or whatever they might be. I dont think that children should be brought into this in terms of trading i think they should be protected particularly in this population but i will say there are three other program that authorizations expire this year one of them being the National Health Service Corps that expires and the other one is the maternal infant sand Childrens Home Visitation Program and the Community Health centers. I think that you could almost package the extension of the one year or not with those other programs and move that forward. They bump up the money and the authorization. If it is only a oneyear extension it makes things potentially a little bit tougher. What do you think about that . It can be extended longer than one year for these programs. I guess what i see is in the end they just extend it to pass something that maybe its longer than a year and it may be they think they can do something that is genuinely bipartisan. A lot of that will depend on what the outcome is in the Current Health care debate and how that plays out and concludes or not. We only got two years on the last reauthorization and that was considered to be pretty good so i wouldnt be surprised to see at some point in time we sort out what we need to do but we are not advocating each year for the programs. There was an open question what role would yo did you playn with and now even that is potentially overturned so it does make sense. All the issues on the network affordability and family coverage i think theres a lot to work through that argues for more thought and time. But maybe the typical budget Debbie Downer even when we did the extensions in the past we did try to find a way to offset the cost. This is a strange one because it is built into the baseline that just extending it for three or four years it doesnt score as a cost and i would say that could easily be if we extended this for four years it could be in the 20 billiondollar range so the question even though we talk about this, i do think congress will come a conservative Republican Congress will want to find a way to offset that cost somehow which creates another set of issues as we go forward. Bill is right on that. Theres 30 million kids in medicaid and 6 million so that is one of the things we could try to avoid. You talked about the role of the Administration Just thinking about the administration, we have a new administrator in place as of this week so what would you anticipate coming out, any kind of changes to the program . They already indicated they want to give the states as much flexibility as possible and of course it already does have some flexibility for states that do you expect any changes in the direction . As we saw in the administration the first indication of what their interests are and the secretary released a letter indicating a strong interest in flexibility and a couple of reflections on the letter. One area of flexibility is opioid abuse and that is something that clearly god bipartisan across the administration support. We have started to programs to develop stronger state approaches to Substance Abuse disorder and the administration showed expediting that is the right priority and i thin of prk they are likely to struggle with competing demands and they are strong in figuring out what type of providers they want to find and that is a growing struggle for us and it will remain a challenge but more fundamentally i have a hard time identifying how the addiction will be meaningfully addressed. Medicaid expansion is the strongest area that we have for addressing the National Epidemic of opiate abuse and if that isnt fair or strong i think we have pulled the rug out of some of our National Efforts in addressing the addiction. Another area of flexibility that the administration indicated an interest in is imposing greater premiums and cost sharing with fewer benefit. I think that there is reason to be concerned doing that would create barriers to access and keep people from getting the coverage that they need so those are a few areas of the letter that jumped out at me. Are there studies that indicate what happens when the cost sharing is increased or have you seen from your own experience what happens when those sort of changes are theres quite a bit of research on the cost sharing for the low income population. And it can serve as a barrier. It served for people getting the services and for the perspective of the low income family, it is frequently prompting difficult choices between rent and groceries and paying for health care. They will forgo getting medicine for their childs ear infection because they have to pay the rent or keep decentralizing or deregulating to become more state based if you will then at least for the chronically complex kids and disabled kids and ill children and the number of National Referral centers of pediatrics is fewer than the number of adult centers. We have the sickest kids traveling across state lines. Its a minimuat the minimum reqh different kind of eligibility that impact care patterns for people that need to travel and g and it is actually thousands of kids when you distill down the percentage across the basis. The Bipartisan Policy Center has done some work recently. We put out a report ensuring other programs and issued if you can believe it it is a Bipartisan Policy Center now and the principles on this came together with an agreement between the two of them with the recommendation that we should take this out of the debate of the broad picture and reauthorize the program and we agreed and said for years for reauthorization. We also sent to extend but to phase it down at that time we thought we were going to have a different outcome on the Affordable Care act so maybe we phased it down to the Historical Rate for the extension in the expansion states. We also set it to maintain the requirement and offset the cost and we were focusing on some of the rebates in the program as a way to pay for this reauthorization so we we issued a report along with the other programs i mentioned in the healthcare Service Corps. I would love for the audience to get involved and welcome any questions anyone has and in the meantime, as the states are looking at a difficult fiscal situation, are there ways that states are innovating and ways to deliver care to try to save has anybody noticed anything interesting in terms of experimentation that we should talk about . I saw incredibly strong interest for the states building stronger Delivery Systems during my time working with the states and it went all across the board he had 2we had 29 states that we focused on maternal and infant health and trying to obtain stronger outcomes which was appropriate. We had states taking on the initiatives and massachusetts was just launching the Accountable Care organizations for the medicaid beneficiaries and things like that and arizona is undertaking new approaches for Behavioral Health and reentry entering the community as well as medical homes for native americans. There is a lot out there right now and i think the concern is if you count federal funding, it really clamps down on a state incentive to invest because you are limiting federal funds, and i think i am concerned the per capita cap in the house bill could discourage rather than encourage it. Are there any questions in the audience, anyone have anything they would like to bring to the panel yesterday i ran an interesting article that indicated intent females born in africa i dont recall where would have a longer lifespan than a similar american baby girl born here. And it was by several years. I wasnt planning on using this so i didnt take notes. Given that this is not fake news, can each of you perhaps respond to what is the most important thing we can be addressing currently not to deprive the african girls of a long life but to expand the hopes for our girls . Thereve been members of studies which show i would say that we overspend in prenatal care and zero to three particularly on wellness and coping and Thriving Skills and the spend a lot of money on hightech intensive care units and imaging so we have more of a fixit culture band aid make it good culture from the beginning and until we start to shift back, we will not see a difference. We have 80 million, thirdlargest in the world, so a big country isnt a European Union nation and we are not spending enough at the broad level. One of the things i worry about in general is the basic insurance model is a oneyear snapshot and these are all issues where early investments have payoffs. There is the incentive to avoid the cost and weve never come to terms with the fact. And the construct of the federal budgeting, we have the end title and so on and spend money taking care of people with the endoflife to allow them to take care of themselves and the fundamental problem is we have to pay for both from at least one generation and there is no money. I dont disagree with either. I think what i would add to that going back to the earlier conversation is i think that there are efforts underway across the country to improve maternal and infant health and there is progress on things like reducing early elective deliveries which doesnt solve all the problems that youve identified that it is a step in the right direction. In the meantime i worry that we are going backwards rather than forward in the house bill and we will risk eroding the benefits of the affordability standards protecting americas kids and we know the coverage that they have now is extending mortality, so concerns the type of outcomes that you are worried about rightfully could become more likely Going Forward. The usual republican type of response would be number one we have to have economic growth, we have to have jobs and work on the big picture, but more importantly since youve been in here this morning the president released the blueprint and exactly what we talked about quite frankly is its going in the wrong direction for where you want to go because it is reintroducing the funding for those programs that deal with Research Prevention and early wellness programs. Those are the wrong programs to be reintroducing in dealing with the issues that you are talking about and im in trouble now with my republican friends for saying that. Mentioning be expiration of a the home visit to suggest that would be considered as well the whole visiting programs have had very promising success to help moms and parents get off to a good start and that is the type of investment we need to continue spirit real love it when people say things that our unexpected. I would advise third dont bother to read it. That is a good point. Is not a budget. Be honest. First of all the press said where it is the of other 3 trillion . Is the 4 trillion activity and it is only for one year. So the way that we talked about it was onethird or onetenth therefore it is 130 if of of budget no aggregate numbers it is not a budget. Key like similar then i do. [laughter] i am seeking asylum. [laughter] this is your opportunity for questions. Last call. We appreciate this it has been a wonderful panel be have interesting views and lots to write and think about Going Forward. [applause] [inaudible conversations]. 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