[inaudible conversations] would call the subcommitteeee back toward her and thank everyone for their forbearance. Weve concluded with number Opening Statements. It sure would remind members pursuant to committee was on the Opening Statements will be made part of the record. We do want to thank our witnesses for being here today. Taking time to testify before the subcommittee on this important issue, each witnessss will have the opportunity to give an Opening Statement followed by questions from members. Again, previously mentioned today well hear from mr. Michael holmes, chief by qu executive officer precarious Health Services, the associate commissioner for Medicaid Services from health and Human Services commission in the partner in the hill. And ppreciate you being here today. Mr. Holmes come you are not recognized for five minutes for an Opening Statement, please. Thank you, chairman burgers, Ranking Member green, members om the subcommittee. Rankin the federally qualified Community Health centerof the s providing medical and Behavioral Health care in nine locations to more than 12,000 patients in rural minnesota. On behalf of more than 1400 Community Health Center Organization nationwide. The longstanding bipartisan support you are consistently showing for Community Health centers. Since 1979, they provided Health Care Access to patients and communities who would otherwise go without. The service area covers more than 8300 square miles in many of our patients travel 50 miles or more to access care. In fewer than 600 people. We are the only game in town. Much Larger National story. Americas Community Health centers also known as fdic and the underserved communities and populations. Health centers represent the nations largest primary care network providing highquality care to more than 25 million patients. Rsse a record of success would not be possible without the ongoing support of congress to name here today to urge you to continue to support extending investments in the Health Center program and specifically the communitybl Health Centers fund which provides enormous value to patients, communities, the Health System and the taxpayer. Success is reflected in the core requirements every Health Center must meet. Each Health Center must be open to all. Must serve our population and they must offer comprehensive ranges of primary Care Services and governed by a consumer majority board which worksrve ma closely to develop responses to community needs. In 2010 congress created a dedicated the investment Health Centers. The fund directed resources and operational expansions in Capital Investment in Health Centers. D as a result of this investment, sites are added in more than 1100 communities. 1100 communities. Health centers are serving approximately 6 million additional people and expanded services by the dental care. Health center allowed us to add new access in minnesota and helped us expand dental services from three other communities and to significantly expand our coordination services. In 2015, congress extended the Community Health funds for two additional years alongside chip and a number of other programs. D without extension nearing its Expiration Date or strongly urge you to renew these investmentsal and to do so for at least five years so customers like mine can continue to provide reliable access to our patients. Without action by the end of the fiscal year, they face major disruption than care. Hhs is estimated that shouldld congress not act by september 30th would be to the closure of 2000 Health Center sites, over 50,000 jobs and more importantly a loss of access to care for some 9 million patients. In conjunction with my testimony today, the minnesota delegation has given me a letter noting support for Health Centers and the impact on minnesotas chcs. And the impact on minnesota chcs. In my written testimony i highlighted several of the programs which fall under the subcommittees jurisdiction. Key workforce programs are set to expire on the same timeline is the Health Centers fun. The National Health Service Corps which provides scholarships and loan repayment to clinicians willing to work in underserved areas is a key tool as we recruit and the Medicaid Program is extremely important to Health Centers and those we serve inch every state the programs work hand in hand to rush the promise of coverage into health care. E half of patients are covered by medicaid. A tomb of a time of rapid change in our Health System. Health centers help in that change, ensuring every american in need has place to go for hign quality care. That purpose is made into reality every day for 25 million patients because of the support of congress and that supportit begins here in this subcommittee immigrant urge you to continue that support by continuing these program and appreciate the opportunity to testify and thank you for making healther ins an ongoing priority. Thank you. The Committee Thanks you fore your touch. Miss snyder. Good morning, chairman burgess, Ranking Member green and distinguished members of the subcommittee on health. Thank you for for opportunity to provide time on the Childrens Health Insurance Program. Im jamie midder. I serve as the director of the mid okayed and chip programs for the state of texas. This morning id like to provide insight into how chip has worked for the state of texas in response to the subcommittees injuries concerning the reauthorization legislation. The texas health and Human Services commission implemented the states chip program in 1998. The program serves approximately 380,000 children. Since implementation the state has seen a notable reduction in the overall rate of up insured children below 200 of the0 federal Poverty Level from 18 in 1998 to 6 in 2015 chip statute allows state thursday operate chips as a Medicaid Expansion program as a separate state program or the combination of the two. Texas has historically operated chip as a separate program, which has afforded texas the freedom to design a system at lines with the philosophy in whsuring accountability in management of public funds and like the Medicaid Program, which offers an extensive monday program for children, chipg regulations offer the states to tailor the package to meet thehe unique needs. This aloud chip to fungs as a Nimble Program able to respond to exchanges the fiscalout and the evolving needs of beneficiaries. Since the onset of the program, texas has delivered Chip Services through a managementro care model. The state currently contracts with 17 managed Care Organizations delivering services to chip members statewide. The managed care Delivery System offers additional advantages as ncis or innocent viees through a risk based medicaid regulations make it difficult for states to implement costil effective effective cost sharing mechanisms for the full range of medicate bush rid. In con tsa chip offers states greater flexibility to design programs in which families retain a measure of responsibility for the cost or their childs care. Most families in chip pay an annual enrollment fee and all families in chip make copayments for office visits, prescription medications, inpatient hospital care, and nonemergent care provedded in an emergency room setting. Chips is a critical part of thex Health Care Safety net . Texas. Offering a Healthcare Benefit to children who do not qualify for the Medicaid Program. S texas overall experience is that chips simply works. It provides reliable medical and dental benefits to the covered population at a rate of 156 per member per month, and is 67 less on a per member basis than the cost of coverage for the states medicaid population. The state requests quality data offer evidence of the efficacy of the program, and 90 increase in children receiving recommended vaccines in the first two years of life for measurement years 2011 through 2015. A decision to not reauthorize the chip program would result in a loss of over 1 billion in funding annually to the state of texas, and a corresponding loss of healthcare coverage for more than 380,000 children. If funding for the program is not extended beyond september 2017, it is estimatede that the state will exhaust remaining resources bybywith t february 2018. As such, texas would be faced with a prospect of dismantling the chip program and as mandated by the aca the state would be expected to continue adherence to maintenance of effort requirements at a lower medicate federal matching rate for over 250,000 children now served under the state residents Medicaid Program. States Medicaid Program. Through the budget area planning process texas as humid funding for fiscal years 2018 and 2019 at the enhanced federal matching rate should congress elect not to move forward in reauthorizing chips the state of texas will bo longer be able to administer the program which has a proven record of success stemming from adherence to the principle of permanent responsibility, flexibility, and innovation aimedded a enhancing outcomes for beneficiaries. Chair thanks you for your tim. Miss mann youre recognized for five minutes for an openingmorn statement. Good morning, chairman burgess and Ranking Member green. And distinguished members of the subcommittee. Im pleased to be here this morning. Cindy man n and i work of matters of public coverage the medicaid and Childrens Health Insurance Program and as floated prior to joining them i served as a director of the center for medicaid and Chip Services at sms, responsible for federal policy, federal oversight of medicaid and chip, and supporting state implement take of programs. And a focus today on the testimony of roll on chip the providing affordable coverage for children, the issues facing congress on the expiration of the funding and want to note strong support of the comments by mr. Holmes in terms of the incredibly important value and critical function of federally quality Health Centers. With 20 years of experience with the chip program hard to believe its 20 years ben know what has made the program success. And what has put it in jeopardy. Chip works when it has robusthe and Stable Funding, and when ito has a strong Medicaid Program with which to partner and covering children. Lets took for the chips history on financing. When the program was first started, it was at the funding was apple for states just ramping up their program but very quickly by 2002 some states ban to she shortfalls in funding and we say a mismatch between allotment and state needs in terms of coverage of children. That was not unexpected in some respectes. Congress didnt know how many state wood pick thin chip program. But it gives us an example of what happens when you have misinch in fund. Georgia frozen rowlingment from march of july to 2002 and only lift the freeze after Congress Passed a supplemental budget. Florida frozen enrollment and for five month and 44,000 chip children were placed on a waiting list. When it was reauthorized in 2009 there was strong support from the congress to avoid those kind of shortfallsfalls and enrollme. Chip provided amp funding and revamped the estimator distributele dollar, built in adjustors and build in con con contingency funding. That formula has been handy maintained. Beyond extending the basic program funding, Congress Also needs to consider the issues that have been raised so far, the 23 porch increase in the match rate and the maintenance of effort provision, both of which were in the Affordable Care act. As my colleague from texas noted the enhanced fund are for the chip program is integrated into state budgets and helping a number of states to adopt or machine for program improvement. We must recognize the enhanced funding goes hand in hand with the maintenance of effort provision. Without that provision millions of children will be at risk of losing coverage or paying much higher costs for that coverage. Chip made affordable coverage available to million oses children but given the market place changes, uncertainties of the future of subsidies and cost sharing reductions and the uncertainty in the Medicaid Program. Its essential to protect not just the funding but childrens eligible for coverage and i suggest its unlikely we would continue the moe requirement without the stable coverage for children. Let me circle back to my point about chip working because of the foundation of medicaid. Medicaid is the much Larger Program covering 37 millionds gk children. The two programs depend on each other. Kids go back and forth between the two programs all the time as family circumstances change, but even more fundamentally is medicaid supports chip by covering so many children with the greatest healthcare needs. Lowest income children, children in poor health, kids in foster care, kid width disables. Chip was not designed to do that heavy lifting. Doesnt they the finance or benefit structure to do that. Tit chip is a critical part of the care but cant do the job alone. Congress has much to be proud of. Medicaid and chip have brought in the uncovered rate down. Its a historic low and a great achievement but with sweepingip changes to medicaid and now area in during and chip reauthorization outstanding much is at stake nor nations children. Thank you for your time and support. Chair thanks all of our witnessed for their testimony today and appreciates your being here. And your being flexible with us as this hearing was rescheduled a couple of times. I now want to go to vicechairman of the committee, mr. Guthrie, five minutes for his questions. Thank you very much. With get into my questions we have had some comments from colleagues and others on medicaid and the way the ahca death with medicaid. Medicaid is a program that is growing rapidly and could implode in so what we decided to do when we very carefully sat down and walked through the ahca is how to move forward. N this principle way of moving fur theres a block grant option the bill but the principal way was on a approach to medicaid that in the 1990s was bipartisan. Matter of fact every sitting member of the senate who was in the senate in the 1990s on the dem crack site, signed a letter to president clinton supporting an option of going to per capita allotment, some being key Ranking Members and leadership on the other side. Medicaid over the next ten years under the proposal will grow, not cut, will grow by 20 . So i want to make sure the record reflects more than some of the rhetoric we have heard. First, miss snyder in addition to basic medical benefits texas Chain Program includes Behavioral Health services,wi vision examples and corrective lensing, hearing examples and hearing aids, physical occupational and Speech Therapy and durable medical equipment. Theres also a limited dentallo benefit, and your testimony youu seem to contrast this with medicaids extensive let prescriptive medical benefit for children ill believe every member of thisee wants to ensure low income children have adequate access to health care but sounded like you might have some ideas on the way medicaid could better serve children. Any ideas you would like to share with us . Thank you, vicechairman. Absolutely we are a fundamental believer in texas in both the medicaid and chip program. Think as as is evidenced by my testimony we enjoy the flexibility that the chipp Program Offers to states in designing a benefit that actually is responsive to the population that serves under the chip program, which is a population of children that dont qualify for medicaid. Certainly in texas were looking at opportunities to infuse elements of personal responsibility into programs such as medicaid, which clearly we have done so with chip but we do realize the populations served are different and want to be cog cognizant of those determine u differences in terms of at the population when we consider cost sharing opportunity, benefit limitations and so forth. Thank you. And mr. Holmes, also, the reliance on Community Health centers is very, very important to us in our Health Safety net and in 2015 we extended the Community Health center fund for two additional years. In your testimony you crawl on us to do a longer term basis for at least five years. Maybe some of the reasons for that is selfevident. Would you like to describe what is better for you in a longer extension over a twoyear extension . The things you can do differently or more efficiently. Thank you, mr. Vicechairman. Two years is a shooter period of time for safety net providers to go interest the work force and recruit new providers. One of the more Difficult Conversations in the safety net provider has when theyre trying to bring in new physicians, new dentists, is to have that discussion about if the lead time to recruit these providers is one to two years, to say we hope to have a job for you in two years, it really limits our ability to have realistic conversations with new providerred that we need to help serve our patients. Two years is a short planning cycle for any Small Business tol try to address changes in the environment, and certainly the healthcare environment is changing rapidly, and a longer planning cycle just would make us more effective in how we deliver care to our patients. An thank you. Also, every Health Center must meet cite criteria and how does an applicant demonstrate the need for Health Services and i have a 30second time left. There are 19 basic requirements to fund to be eligible to receive Healthcare Center funding. Other one each one of those areas must be defined and documented, in a competitive Grant Application which occurs every three years at the current time. What you do is critical so we appreciate your efforts. I yield back. Its critical for us to Show Congress that we do what we say were doing, and that we are who we say we are, and without that, i think it doesnt we want to have a process that is transparent for all organizations to say, this is what we do, this is who we serve, and this is how we care for our patients. Thank you. Chair thanks the gentlemen recognize the a gentleman from texas,mer green. Id like consent to place into the record letters from a number of associations and encouraging a fiveyear extension on funding for the Childrens Healthcare program. Without 0, ox, so ordered one thing that is important is chip its linked tied, chip kid receive medicaid benefits. Twothirds of the chip kids receive he more comprehensive medicaid benefit package because states have recognized how important coverage is for children. Thats why im disturbed by what the house has been doing, passing trump cair and what the senate are poised to do next week. The conversation about childrens coverage is something that this committee should have before passing legislation, capping and blocking granting coverage for 37 million children. This morning i read theen 3 million children lose coverage under the house bill and senate cuts to medicaid are even deeper. Every one child losing monk our country even one child losing coverage i unsea acceptable. We do can better for our children. Chip, w miss mann can you start off we they ever important concepts to have in rethundershowerring chip and i strongly support. What do people mean why they say chip stands on the shoulders of medicaid and can you discuss the history of chip and how it worked with Medicaid Program to bring us to the highest rate of coverage of children in our history. Thank you. Or id be glad to address that question. Chip was established to extend coverage to children who otherwise wouldnt be eligible for medicaid and states could cover those children either in medicaid or in separate chip programs. So, the idea that chip sits on top of medicaid is in fact exactly how its designed by congress and how its operated in the program, and why chip needs that support is thathi medicaid really does, as i noted much of the heavy lifting. Io beth in terms of numbers medicaid covers 37 million children, chip covers over 8 million children. And medicaid covers the children who are the poorest, often in the poorest halve, foster care kids, kid with disables. Those children, when whenro they any child, when they get a disability, get a chronic illness, they often have to turn to medicaid even if theyre otherwise eligible for the chip program. Its not necessarily designed to be that robust a benefit package. They work hand in hand, and atil the same time, what chip has done is really helped modernize the Medicaid Program over the years. When chip was started it got a lot of Energy Around childrens coverage and people started to look at not just how t design the new chip program but what to do to improve the Medicaid Program. So simplified applications, made it easier for families to enroll. A lot to do with the success and the uninsured rate we have seen. So the two really are sidebyside in and complement each other and are needed for the continue you of health care for children. Let me ask you a questioned following up on my colleague from kentucky. Anything to say about the flexibility in medicaid and between states . Different states with different Medicaid Programs. A great deal of flexibility in medicaid. Often you hear from members of congress and others, its such a complex program, inert glaus of 46 jurisdictions that admire and it theres quite a about of differences among them because of the flexibility accord to the states. States have flexibility to organize their plan. They see design their pavemente system, design their Care Management system. The area where medicaid iske clear, however, is on he benefit protection for children. Its actually 50 years, almost to the day, where congress adopted the early periodic screening and diagnosis jim Treatment Program a to make sure that all kid inside medicaid get friend for hearing and delays and the requirement is they get treated. Im almost out of time. The texas received 1115 waive bipartisan we supported and there is flexibility in state,s. Before i was elect to the congress i served 20 years never state legislature and i watched what how we were funding medicaid back then, and my concern is that the flexibility we also vote this federal money and texas our match is twothirds fed, onethird state, and louisiana gets a little bit better than that some day well get to that level. We also need to have guidelines for what we know that funding will go through i want flexibility and make sure its paid for health care for people, including children. Chairman recognizes mr. Walden. I want to thank our witness fours your testimony. We appreciate what you do in our states and communities communit. Mr. Holmes in your testimony you say that men of your patients travel over 50 miles, often over secondary roads to access care in your Health Center and often youre the only provider. In addition to isolation and distance what other challenges we should know not care and delivery that are unique to rural areas and the district would step from the Atlantic Ocean to ohio, and so its bigger than nearly every state east of me miss is river so im used to pretty remote rural, extreme remote, whatever the furthest out remote nomenclature. Delivery of care in the service area thats almost the size of new jersey is challenging because were in small communities. Two of our Health Center sites attached to critical access hospitals and those hospitals are small, 14 beds and 16 beds, attached longterm care units. We have to be able to recruit providers to see these patients. Were in a frontier area, and its long distances between sites. If were not there, no one else is there. Next level of care for our system, for our health Delivery System, is 40 to 50 miles away to an entry point. When we look at rural areas, its where we have our agriculture, our forest products, our mining. We cant relocate those jobs to urban areas. We have to deliver care to the people that are working in those industries, and it presents challenges of distance and time and access. Reimbursement methodols that come to fqacs help to subsidize or offset infrastructure costs. I could be much moremy economically efficient if i had all of my patients and all of my providers in a single site, but i cant because i cant have patients traveling 60, 70, 80 miles. Im thinking about the Christian County i have in fossil, oregon. Its 90. 2 miles to the dalle, oregon, 39 miles away. Physician beyond that and no hospital in this three county reason. Talk about telemedicine and what role it can play. I understand the recruitment issue and some comes back to the state because they wouldnt board certification. I have had provider said we can wait six months to a year to get somebody here and meanwhile they go somewhere else. Were not as bad as some. Not as good as others. Can you talk about telemedicine . And then i had an amendment before it became law and then expired on bonus payment for home health care. Its more expensive to gout and back 90 miles to take care of somebody in a remote area. Perhaps you could dress address those things. We have a common Electronic Medical record program. Some clinics are midlevel provider sites only, staffed be Nurse Practitioners on physician assistants. I they have issues or questions about care of a patient, they can route that chart to one of our physicians in one of our other sites for assistance in care delivery. We have some telemedicine capabilities. We have telemental Health Services with the university of minnesota duluth where we can have patients access some psychiatric and psychology care, and we do have some telederm setups, but part of the problem with telemedicine is that in rural areas theres not a significant infrastructure for highspeed justicer so we cant do home monitoring because in many places theres not even a cell service, cell phone signal. So we have patients coming into the sites, which is the closest access point they can, and well work with the patient there, whether its with direct handson care or through some telemedicine. Thats helpful. We have jurisdiction over spectrum and broadband, its a big effort to get access. We had hearing on getting access town served areas first with the federal support and then underserved after that and how we map that and figure out where the areas are. Thank you for your work and your testimony today. I yield back. Chair thanks the gentleman. Chair recognizes the gentleman from new jersey, the Ranking Member of the full committee. Five minute tore questions. Thank you, mr. Chairman. I believe deeply in the chipan program and want to see a full fiveyear extension of current chip policy. However, also believe deeply ini the Medicaid Program and i knowo a lot of our success with the chip program is due in partt because of bills so seamlessly on the Medicaid Program in its current form and as virtually every stakeholder agrees the trump cair bill passed by the house would decimate coverage tb for 23 minimum people, 3mileanhour children ask the senates bill doubles down get kids and its a fact the proposals are bad for kidded. With that in mind, miss mann, want to ask you, first, why is the current full fiveyear extension of the chip program with the maintenance of effort and the socalled 22 bump in payment for states so critical now more than ever . Thank you. I have the pediatricses and nga all off recommended a five, year extension. Macpac with 23 p. M. Pound and attendance effort. It goes back to the point mr. Holmes made about Health Center funding. The twoyear cycles are not sufficient for states to be able to really do the kind of planning and improvements that make sense for kids, and i also think the other side of that is to look at what is going on broadly in the Health Care Marketplace right out in. If chip were to end, more abruptly, then children will be at risk of not having coverage, or if they find coverage theyll have significantly high are out of pocket costs. This is a time of great uncertainty in our healthcare marketplace, small m, and it is really a time, given the bipartisan support for childrens coverage, to give chips five years to be stable and to do the job it needs to do for children. Well, inobviously agree with you, and the importance of an immediate and full extension and also share the same belief about reauthorizing the Community Health center fund. I think we need to do it immediately. But again, when you talk about the Health Center program, lot of our success do is in part to the Medicaid Program which provides 40 of revenue all that cities is jeopardize evidence with to trump cair and yet my colleagues argue that a cap on the Medicaid Program is not but and in fact the administration was testifying on the budget,t the ways and means committee, argue that trump cair was not a cut to medicaid at all. So id like to hear from someone who knows a lot about medicaid and chip. Many have likened the capping of the Medicaid Program to be just like managed care which in medicaid is widespread. Is the cap in medicaid like managed care . Well, ill jump in and an that and im sure ms. Snyder has view on that. Its very unlike managed care. State use managed care largely for their chip programs and for their Medicaid Programs. They set rates, they set rates at regular period of time. They adjust rates based on the acute of the needs of the population that are served. They take into account policy changes, healthcare cost changes and theyre constantly reexamining their rates just in the cap in the bill, is it is set based on spending from years back, moved forward, adjusted by a National Trend rate that is not related to the actual needs and cost of serving people in that state. And it doesnt adjust based on acute of the need, and doesnt offon the Health Care Costs atwhat happen to benefits and provide ever revenue. State havent three major levers to do significant reductions in enrollment, provider payment rates and benefits. Likely with the kinds of changes proposed, all three will bepo relied on by states but if you think about going to provider rates, the first place states will turn, we worry about accession for kids. Access for kids. Access is in good shape for kid right now in the medicate program but if we then out the payment rates for provider, lower our payment rates for manage emCare Organizations well have access issue and problems of serving children as well as seeing some children who are on optional kinds of programs, kids with brain injuries and other kinds of hcbs service, home infusion, maybe losing coverage services. There are any winners for the policy regardless of what states have carved out . Is it going to matter. No states are carved out and i think it is just a fact of math that when theres a federal and state partnership to share all costs and the federal government is saying, im pulling out of the partnership and setting my limits at a certain amount and the state is responsible for everything, every state is a loser in that formula. Thank you mr. Chairman. The gentleman from new jersey yields back. Judge from new jersey is recognized in the gentleman from new jersey is recognized. Thank you, and good morning to the distinguished panel. Is it the view of the panel that the current formula for medicaid, which is openended, as i understand it, should continue as it exists permanently without any analysis of the potential modification . I ask the question legitimately and i was one of 20 republicans not to vet for the Healthcare Plan on the floor of the house of representatives. Miss mann, ill start with you. I think the shared commitment, the shared Partnership Around underlying financing of the program is critical and needs to be retained. I think there are always areas of improvement. Theres been years of complaints about how the f map itself how the share is the formula for that. A its quagmire i think thats the up underestimate of the day. As i understand it costs haveo increased relatively significantly in the last decade. Is that accurate. The cost per enrollee in the Medicaid Program have grown much more slowly thanmer alcohol insure krohn or medicaid. Medicare costs have grown because us a covering more people. Others on the panel who would like to address the issue. Id be happy to respond to the question. Very similar to miss mann iy think we can all agree theres always opportunity for improvement when we look at the funding formula for medicaid as it currently stands. As a state i can tell you texas is looking very closely at the implication of the aca and the proposal advanced by the senate, spikily the impreliminary indications for the state of texas and how on the proposed funding formulas would play out for the program versus the funding formula that were now working with. Yes. From a rural standpoint and theo small safety net standpoint its important to recognize at medicaid patients north across all pair type and provider. In the to rural areas theyre a higher level of medicaid population and nursing home paid by medicaid may be 64 d nationally in the Nursing Homes im familiar with, their n medicaid population is 90 . And so theres a disproportionate percentage in some of our communities that rae lie on medicaid, and so anytime we have a change in the system, i worry about unintendedth consequences, and how the rural providers and the rural safety net providers and all safety net providers, adapt to those changes. Regarding Rural America, is this particularly important as it relates to those in Nursing Homes as opposed children and other populations served by medicaid . In the rural areas . We still have a significant nursing home population, longterm care population, and we have a disabled population and a population of moms and kids. Thats true across the country, obviously. There is a disproportionate percentage in Rural America in one of the cohorts you just mentioned. Theres a disproportionate share in the rural areas. We have an aging in rural parts of the country. A lot of the younger people have moved out of the rural areas to urban areas where the jobs are, and so we have a graying of the population in these rural communities, and along with that graying of the population, i think theres greater reliance summon of the programs to help provide care. Thank you. I think that this is an issue that deserves a great deal of attention and im not one who wants to make this a partisan issue. Think that its a very difficult issue, and we have to examine it in my judgment based upon the facts that we want to cover as Many American as possible. We also have a responsibility to the tax paying public with the rising federal debt, and i hope that we can examine these very difficult issues in a bipartisan capacity, moving forward, because i do not think that this is an issue that should be politicized. I yearold back 17 seconds. The gentleman yields back hi 17 seconds. The lady from california is recognized. Thank you very much, mr. Chairman. Chip and the Community Health center fund are creditly important programs for serving children and families in our communities and i do look forward to working with my colleagues to continue their funding in the future, and hopefully far into the future. He however, we all know we cant have a conversation about safety net that chip and Community Health centers provide without including medicaid as their foundation, because medicaid is the foundation of our nations safety net. 41 of children in california are on medicaid and chip. Thats about two in every five kids. I say 41 on medicaid and chip because you cant separate the two. Chip eligible children in california in fact receive services through the medical program. The chip and Community Health Center Programs and the children and families shay serve, will be devastated by the medicaid puts proposed by the trump care bill. The way it looks now is the Trumpcare Bill goes through, billions will be cut from medicaid. Would states be able to continue the same number, cover the same number of people . Would be able to cover the same time of services . Where might they cut and are there examples of difficult choices states have had to make when budgets were squeezed . The Medicaid Program i think certainly has cbo projected the reductions in medicaid funding, 834 billion over ten years, would result in about 14 Million People in the Medicaid Program losing coverage. Ts that will grow over time due tot the impact of the cap and how the caps get tighter and tighter over time just because they of the way the mag works. And the math works so well see necessarilyless of impact to the program beth on the coverage number and also in terms of whether we see limitations on the kind benefits the people are able to access. States will have to look for the first time, i think, really closely at socalled outlier costs people. People who elderly people, children who are in special waiver program. S whose expenditures are so much higher than the cap would be. Every time they enroll somebody in that situation, the state will lose a lot of money under the way the caps are designed. We also see big concerns about access, whether lower payments to providers locker payments to health plans will narrowans networks, children wont be able to get access to Specialty Care and the kind of services they need in a timely way. So seems to me well be rationing care here. It seems to me we have to make very difficult decisions as to what population the care they need. What youll have even more than you have now always issues at the state level about funding the Medicaid Program. Its a big expend andexpends did tours and i expenditures. There will we a cap between provider in the state. Want to ask you about in California Children receive full epsdt, early and periodic screen, diagnosic and Treatment Services through medical. Can you talk about in the impact of access to services for children and family and talk about differences in in the benefits and resulting health outcomes. Epsdt was designed initially because of concern about low birth weight babies, children growing up, children being going into the armed forces and as young adults and not being in healthy shape. It is really a very sensible benefit fact, that that screening and diagnostic testing and says when a child needs treatment, as recommended by their doctor, they get the treatment that they need, andd that is incredibly Important Service that is available to children, and i think the kind of standard we all want for our children. With reductions in spending, that might be a hollow promise. You might have the promise even fore ssd there but can the chilc find a provider good, get to a dentist, get to the specialist they might need for a particular kind of circumstance. Okay. I see that im out of time and would like to submit my questions for the regard. The gentleman from virginia, mr. Griffin, is recognized for five minutes. Thank you, mr. Chairman. I appreciate it very much. Mr. Holmes you have been talking about the rural issues and i appreciate that because my district is larger than the state of new jersey and you indicate your territory that you cover is about the size of new jersey or a little less than that. One of the things that i have been its been rattling around in any head is that the medicine issue you touched on earlier is that we ought to be able to figure out a way to save money longterm, maybe not initially but longterm by using telemedicine and not only save some money but increase the effectiveness of the care in the rural areas or at least make it more accessible. Example, i have a bill in that deals with making sure that folks by telemedicine talking to the appropriate neurologist, et cetera, can get a quicker response on getting the tpa in the case of a stroke because obviously if youre in a rural area, sometimes you cant get to the hospital where the right doctor has to look at youge currently to give you that medication. But we could speed it up. You mentioned that you all are providing some services for Mental Health. I think thats extremely important because if we can catch that just like with the stroke, instead of having somebody in longterm care, epa can stop a lot of that. Likewise with Mental Health, you catch it early in a regular clinic and what we found wearing doing nat the my district. People are much lower like go to the clinic, if they can just step into the other room and get the Mental Health, even if its by telemedicine because we dont have the football have population to have psychologists or psychiatrists in every one of the communicates. But they also dirks theres to certain stigma, particularfully rural areas to getting mental Health Services. If they can just step into another room in the clinics nobody knows whether theyre getting fir food looked a or getting a Mental Health evaluation. So just some comments than and do you believe there might be some savings there longterm, particularfully rural settings, because we prevent effects from having more serious maladies. I believe there are opportunities for cost savings by integrating Behavior Health into primary care along with medical services. We have a couple of rooms set up in some of our clinics that have the telemethod sin capabilities, the hookup ares for Behavioral Health care. Those patients are schedule routinely. There is no indication that its a specialty Behavioral Health visit for that patient when theyre in the waiting room. Some of the other things do is we have some Behavioral Health specialists from the local agencies to the clinic ands they have office space and exam room space in our other space. So we try to care for the patients in the best way that we can within the local situations, within the local facilities. There are still reimbursement challenges. With telemedicine. The originating facility is not usually a part of the reimbursement methodology so you have to build the infrastructure without having payment for that infrastructure. You have to maintain it. You have to have enough ban division to have interactive bandwidth to have interactive television. Let me spring board. The stark act, if i understand contributely, prevents us from using some facilities in conjunction with a hospital that might be willing to pay for infrastructure because at one time they were worried about collusion and raise thing bills. Today ive got underserved areas, i could use in space in a nursing home longterm care facility and put in some telehealth stuff even itself it was in conjunction with the hospital because in all fairness, only have one hospital in competition if youre talking about somebody having a heart day attack but my folks have to travel 202 minutes to get there. Can we relax that win we can get into underserved areas. Antitrust issues are certainly an issue for medical delivery, especially now when we are seeing the development of large systems of care and yet we have small providers that are trying to deliver services in a Cost Effective way. Small areas dont have the depth of resource to have competitive services. We have to find the best way to deliver that care to our populations, but we have to be at this point careful of antitrust issues and its always something that back of our minds. What youre signature is weit have to figure out the balance. Prefer to have competition but where there is no comp addition, maybe we need to look at giving some flexibility on the antitrust issues to make sure were Getting Services there. Yes, sir, i agree. I yield back, mr. Chairman. Thank you. Now recognize mr. Lujan from new mexico. Thank you, mr. Chairman. Ge miss mann, keep hearing on the news that trumpcare doesnt cut medicaid,est the cbo says thats not true. Look at the quotes from different stakeholder. T Northwestern Academy of speedattic says the u. S. Senate residents healthcare legislation fails to immediate childrens needs. There is too much at stake for those of white house care us to compare to children to be silent. Pediatricians will speak out until we see legislation. The childrens hospitals association, our unified in calling on the senate reject the bill they say at its core the bill is a major step backwards for children and their health. And the American Academy of Family Physicians say that this legislation would have a profoundly negative impact on americans. So, miss mann, can you set the record straight . Is trumpcare a cut for children, family and everyone in the medicate Medicaid Program . Yes. Thats a pretty straightforward answer. So im clear you responded to the question with a resounding yes. Resounding yes. Theres 834 billion taken out of the program. 14 Million People by cbo standards losing coverage. Theres countless other changes that states willing have to make if the cutters are imposed, and if and children will suffer both from the caps from the parents losing coverage the loves the expansion and enormous ramifications to the Medicaid Program, negative. I appreciate that clarification. When i asked that question during our 27hour markup in this committee i was responded to several times that medicaid was in the cult. Al i appreciate the clarification of the reduction, the cut of 834 billion from the Medicaid Program. Miss mann, as we heard today the Childrens Health Insurance Program is an important provider of Health Insurance college for neumann american children. However the Medicaid Program is a primary source of college for low income children, cog four times as men candidates in as chip. In new mexico theres 414,000 kids that reel lie on medicaid and 15,000 dead kid rely on chip. Can you please describe the role that medicaid plays in childrens coverage . Sure. That ratio you have in the new mexico is pretty much what the National Average looks like. It is first of all a much Larger Program, as you noted from your figure. Medicaid just covers so many more children, and it covers infants, covers newborns, kits at school age, covered a lessens. It covers 100 of the States Foster care kids, for example. Any child who has been determined disabled under the Social Security definition, they go into the Medicaid Program. Dope go into the chip program. Covers Early Intervention services for young children, schoolbearingsed healthCare Services, very a program with a lot of different functions and lots of different ways in which it serves the child population. And i think you addressed the next question i had, which was what would the concern be associated if the Senate Passed their bill or the house passed republican repeal bill, otherwise called trumpcare, would pass, and how it would affect chip. I think you eloquently described that. Our nations leading Childrens Health providers a, advocates including the American Academy of pete idea frick, childrens defense fund, family focus, march of dimes have spoken out against the republican repeal bill and wrote in addition to bills initial proposal to Fund Medicaid through per capita caps the republican bill would allow states to choose a black grant mod eviscerate existing protections for children and pregnant women in the Medicaid Program. Comprehensive epsdt benefits would no longer be required for children, allowing states to ration limited dollars by drastically cutting back pediatric services. Mr. Chairman id like to submit the statement for the record. So ordinary. Just as i close, mr. Chairman, i appreciate the conversation about the concerns mr. Holmes with the impact in rural communities. I represent a district that takes eight and a half to drive across. This is critically important. When we talk about concerns to rural Healthcare Facilities the conversations that were taking place about the importance of mental and Behavioral Health probable programs in small clinics. If the bills become law that would eliminate the Affordable Care act, we would see the programs get eliminated if not disappear. And when it comes to getting Broadband Access across mrs. , i certainly agree. Ive sed it once and say it again. Theyve a debate with tsa having phone conversation on an airplane once you board in los angeles, california and can say on the phone until you get to new york we should be able towe have broadband coverage across Rural America and every part of our beautiful country. We once elect trifiled Rural America and lets me a sure sura we connect america with affordable broadband service. The chair can see a downside to you being on the telephone between win albuquerque and new york but nevertheless yourhe comments are appreciated. The carry recognize the gentleman from georgia, mr. Carter. Five minutes for questions, please. Thank you, mr. Chairman. And thank you for being here. A very important program. Very important in my state. And the state of georgia, as chip is the peach care program. Were very proud of it. Its been a very good program, and has benefited many, many recipients. I want to ask you ms. Snyder and then mr. Holmes. I want you to address this. But i know that in my district alone we have got six federally funded Health Centers and they serve over 55,000 patients. Very, very important. One of the things that we require, the federal statute requires, is that states reimburse these federally qualified Health Centers and rural Health Centers using prospective Payment System, and theyre being groups who have said this could be done better and met me quote real quick. The nantz association of medicao directors of medicaid directors said this is state reimbursement System Limited the able to use the full rang of value based purchasing strategy inside this care delivery setting including modeled thatid incorporate financial risk and proevents states from transforming Health Care System across all provider. The direct years of said states need to be allowed to align value based purchasing approaches. How do you foal feel about that. Ou miss snyder. Im happy to answer the question to the degree i can. What i can tell you is that thes state and texas is well aware of the requirement around the prospective Payment System and committed to working with all of our managed care and provider partners the advancement of value based purchasing initiativesment unfortunately i based purchasing b cannot answer specific questions in regard to email burrs little because the stays is in active litigation on the matter. Do tell. I wish i could but i cant. Okay. Well give you a pass. Mr. Holmes . Over the years, payments payment methodologies have changed. Across all provider types. Whether its been a costbase it payment, whether its a discounted fee for service payment, or whether its a prospective Payment Systemay payment. Fqacs are reimbursed under an fqhc prospective payment methodology for both medicare and medicaid. A couple of years agomedicare upat the same timed the payment methodology and its important to note that medicare in that payment methodology update retained the payment per visit methodology. A bundled set of services is reaming burred under the methodology. Were looking at a change tourcn valuebased purchasing. The question that come inside with valuebased purchasing is how to determine value. S we have seen in minnesota, for instance, we have clinical outcome disclosures for outcomes of care for all medical groups, and the medical groups will range from mayo clinic down to the smallest safety net provider, and there aredown t different ratings for optimum care and for dib pettic care or cardiovascular care. But what concerns me about valuebearingsed payments is whether or not that value truly reflects the skill and the care of the provider or if it reflects the Patient Population that provider served. If if was going a valuebased system, i would be i would wonder whether or not the best t value is perceived in the suburban areas where theres high levels of income, theres high levels of poverty, and or low levels of poverty and high education. I think we have to be careful that value does not reflect our Patient Populations but more accurately reflects the care that is delivered by the provider. Okay. Very quickly, have just a few seconds left. De want to ask you, mr. Holme, if your expense yesterday 34b program . Do you that and what is yourus impact on your systems there . We use the 340b program. We have some savings under 340b. In turn we use the savings to pay for some of our care toward colorado nateogy and patient centuries where we can align our patiented in pharmaceutical manufacturer Patient Assistant Program because free is better than discount. Tool to influence reimbursement. What do use the savings for the cannot identify specifically but a certainty were always looking at opportunities maximize savings we are seeing through various means, including speedy we are looking at this closely on this committee of the away like you may so be on that, okay . Thank you mr. Chairman. I yelled back. The time of the gentleman has expired. The chair recognizes the gentleman from florida for questions. Thank you very much, mr. Char witnesses and the role you all have played with your organizations and hitting this historic mark of 95 of americas kids with health coverage. Certainly isnt the time to go backwards. We need your expertise in how we maintain that level, and anyone who cares about making sure kids are on the pathway to success in life really need to focus on this devastating Trumpcare Bill and the most radical change to Health Services for kids under medicaid in the 50 year history. At the same time we do need to reauthorize the Childrens Health Insurance Program, and there are a few portions of it that are vital to maintaining that 95 and upwards coverage rate. One of them is the enhanced 23 . I resent people say that 23 bump in the match did nothing to improve childrens coverage. I can tell you coming from the state of florida, and this happened in many other states last year, we were able to eliminate the fiveyear medicaid chip waiting. For children by using that bump up your it has been a major win for children and families. Florida brockley 17,000 children were not able to come onto the roles. In arizona they were able to lift their enrollment freeze in kid care allowing 30,000 kids tf receive health care coverage. Ms. Mann, how important is it as part of the reauthorization to maintain the 23 match . I think as you know it really has triggered a number of states and the National Academy of state Health Policy did a report talking to chip directors about the impact. But also as ms. Snyder said it really is integrated into state budgets and new kaiser survey of state budgets than by Health Management shows that 26 dates are experienced a terrible time economic but 20 states, 26 dates expensing budget cuts. I think if we pull those dollars out from the chip program we will definitely see repercussions. And as i noted before i think its very much tied to the maintenance of effort speedy that was my next question because i have heard folks say that that maintenance of effort thats been in place for seven or so years and then was extended in a bipartisan way in the macro come some folks say that is limited state flexibility and innovation and should be allowed to expire. But boy, that needs has been vital to the continuity of care. So is that important they go handinhand to 22 . I go handinhand. You could have the maintenance of effort requirement continuing to protect childrens coverage and pull the money out from state bu but i think of the a lt of unhappy states with that arrangement. It really do go hand in hand, and i think even more now than t two years ago in terms of the stability of coverage is just critically important for children. If we didnt do that as part of the reauthorization do you think we would see the return of waiting lists and moss covered for kids . I think we would. We definitely would see a pullback. One of my great fears andnd its been integrated that way back in the 1990s bill clinton at the democrats fooled around with block grants. I can tell you right now this is very dangerous, the build of our kids to be successful when you move this direction. Im particularly frightened for my home state of florida becauso florida spends about 1880 per child medicaid enrollee, the lowest rate in the country, ms. Mann, if we went to medicaid caps, it appears that that would lock in floridas low spending rate. N but we are a highgrowth state and our needs change over time. What was a cat due to lock in, what would happen to our states ability to take care of kids and elderly and people with disabilities . Florida is a good example of many states experience where they would be whats referred to as relatively low spending state. State. They would be locked into those dollars, modified only by small trend rate over time. If they chose to add benefits, if they chose to put different Care Management into help, kids with asthma, diabetes come to elect to do that as state dollars or by cutting Something Else in the program. In florida theres not a lot of give. Where do we go . Folks in Nursing Homes, they are very expensive. Special needs kids, childrens hospitals . Absolutely. We spend about a third of our dollars in Longterm Services and supports for the elderly, for people with disabilities. Populations will be vying for the limited dollars just to be able to keep steady, never might lose grant. Thank you for helping to explain what is at stake. Take very much. I yelled back. The chair recognizes gentleman from oregon five o minutes for questions, please. Thank you very much, mr. Chairman. I appreciate it. Mr. Holmes, i love to get in a discussion with you on value. You may have some good points there was still a silobased Delivery System in modern medicine, but i point out in the ac there was some risk adjustment to take some of the issue away. In oregon most of our physicians, Nurse Practitioners and medicaid, chip arena now use coordinated Care Organizations. D we get bundled payments. Its not just the root doctor responsible which of the social worker, Mental Health provider and, frankly, to take it upon itself to make sure theyve ultimate success. I wont belabor the point. Thats another discussion. What percentage of your Community Health Centers Budget comes from medicaid . Nationally it is just under 50 . So thats a pretty big number, that plans woodford from our republican colleagues would pretty much a devastating thed funding for Community Healthfu centers because it would be tough to make up that 50 . What would happen to your expansion, you talk about your expansion services, if the republican plants went into effect and youll cut significantly, particularly if if you have any rural areas . Certainly if we have an immediate reduction, it places us in a difficult position. A we have ten different medical and dental delivery sites in nine different communities. Theres no way for us to be able to sustain all of those sites with a significant reduction in resources. That means were faced with which sites to be close, which staff to relay off, how do we reconfigure our providers . And it all effects ask her to care for our patients. Thank you. Ms. Mann, tell us, i guess for all purpose of my, unlike a lot of my republican colleagues huge swaths of rural oregon in my district, and im a little surprise because 25 , no, actually half of the kids inf rural oregon with her healthcare to medicaid. Its so critical to success and help of these communities. Its a key portion that rural hospitals are a key component and portion of Economic Growth in employment in these communities. So im very concerned about howw these reductions in medicaid reimbursement, certainly over the long haul will affect them. Can you talk more about what might happen in rural areas if the Medicaid Expansions rolled k like were talking about . One of the things weve been talking about so far in the series about ways to modernize our system of delivering care, ways to integrate Behavioral Health and physical health, ways to bring in telehealth, changing care practices, expanding our Electronic Health records, those all require investments. And so the first thing that will go will be in those investments. At and states will be scrambling to bring their spending down below the caps that are set by the federal government if the bill passes, just because in the dollars spent that cap will be wholly state dollars. And federal dollars brought down over the b club to back the picture and would harm the state. So we will not seek investment for sure but we will likely see reductions in funding for Community Providers and other specialty providers that allow pr that fragile fabric of access in rural areas to be able to work. Thank you. Ms. Snyder, you talked about a reduction in uninsured rate forn kids, 16 to six in Texas Pacific what will happen to that uninsured rate in texas it some of the Republican Health care plans go through as currently envisioned, what you go up or down . N so what i can tell you is the chip program code in texas proceeds the advent of the aca for the Senate Proposal that was advanced yesterday. The chip program in texas its highly successful. As an agent that has resulted in a reduction in the percentage of thed what about the medicaid whatb peace . Is the medicaid reversal for texas is cut as proposed, isat your childrens uninsured rate going to go up or down . So we are right now look at the implications of the legislation thats been proposed on that, the house side as well as the proposal that was advanced yesterday to determine how that is going to impact the state. What i will tell you at the state speeding you are not sure quite get . Were still looking into that. I appreciate that and thats a good answer given where you all are coming from. I feel sorry for a lot of the providers. I know rural hospitals and your state and many states that did that to the expansion are facing some pretty tough times. I think theres some middle ground here to be quite honest with you. I, too, am in favor of making sure that medicaid is put on a budget, but a budget that is realistic and doesnt result in tens of uninsured children. Children that we should not be balancing the budget of thiscing country on. I worry about that but i look for to work with my republican colleagues to fix this system overall and i will yield back. The chair thanks to gentleman. The chair recognizes the lady from california, ms. Eshoo, five minutes for questions please. Thank you, mr. Chairman, and thank you to the witnesses. I just want to start out by speaking about what is racing through me, throughout this hearing. And that is that ive lived my life my children. I think everyone here has as well. We are talking about something that couldnt be more sacred, our children, my children, your children, the children of our nation. And i really am overwhelmingly sad by whats happening. I cant believe that this is taking place in our country. Some sort of conflation thats going on here today. Rt its important for us obviously to reauthorize the chip program and the other, and with all of, everything that should be a part of it. But to have the evisceration of medicaid as of the top issue, top line headline of today, thats going on in the congress, what are we doing . Children need patriots in the congress. I dont know whats happened to the republican party. I dont recognize it. Republicans that are in my district dont support any of this. And a strong chip program depends on a strong medicaid dep program. Ram so theres like a pretend thing going on here. Chip this, chip that, chip chip chip. What about the chipping away at or the destruction of medicaid . Does anyone here think that were going to be able to care for, provide what our children need in our country if we rip away 834 billion out of medicaid for tax cuts . That we are taking care of them . I mean, there are myths that are swimming around, a myth that 23 bump in the aca did nothing to improve childrens coverage. Since the enactment of the enhanced 23 bump and the matching payments for chip, the states have used those additional dollars to improve the care and expand coverage for kids in our country. Theres a myth that chip is the primary insurer of lowincome children in the united states. Medicaid is the primary insurerr of low income children in thee united states. So yes, chip is important, but lets not let all these myths creep and around it. Thithis is a shameful thing thas taking place in our country. It really is a shameful thing, and its hurtful. What is going to happen to children that are disabled . Does anyone examine their conscience on that . So id like to go to ms. Mann and ask you to expand on the issue of disabled children. It is one thing for children to get a basic care that we all provided for our children, but this is, i think these families that had to, that have disabled children are among the most courageous people in our country in what they need to deal with. They get up earlier in the morning because i have a lot of things to do for that child. It costs more money, more doctors, more complications in their lives, more complexities. And they try to balance their affections, too, because the other little ones may end up feeling that this one other child is getting more attention from the parents. This is what takes place in peoples lives every single day across our country. And were sitting here in some insulated airconditioned green painted room as if this one thing that we are going to reauthorize, and we should, he is just going to take care of everything, and that anyone who is involved in it and vote for it has absolution. They dont, in my view. They dont come in my view. So ms. Mann, what did you say a few words about disabled children and his programs that are knitted together . Yes, certainly. Thank you for your comments. Some medicaid has many different eligibility pathways and theres many different definitions of what is a disabled child. There is a category that is to be determined disabled by the Social Security administration, the state then, you could automatically get medicaid and that circumstance about 1. 9 million children around then country who fit in that category. Based on that medical necessity standard that we talked about before, they get the care thatre they need and to get the kind of care that really is not otherwise available in the commercial markets. Some of them get special waiver service, respite care for that caregiver who as you say is going 20 hours a day in terms of taking care of their child. They will get a wheelchair refitted as they age and as they grow. So very important program, and then theres other kids within other categories of the Medicaid Program. And maybe foster care kids are low income kids. They may not have a disbelief that meets that level of disability but gets them into the category of disabled but they are kids with very significant healthcare needs and they have their needs met very strongly by the Medicaid Program which is i think why you see the statements from organizations like family voices, parents of kids with special health care needs. Time has expired. The chair recognizes the gentleman from texas, mr. Barton, five minutes for questions please. Thank you, mr. Chairman. I apologize. Apologiz after votes i took a group of members and staffers out to the hospital to see matt michael, one of the individuals who were shot in the incident last week at the Congressional Republican baseball practice, so a little bit late getting back. I think its obvious how is he doing . Give us a report. Hes up and dont violate hipaa. Come on, this is federal hes doing very well, diane. [laughing] i can go into detailss i apparently, but he is excited and hopefully hell be out of the hospital within a week. Can the chairman invoke hipaa . Im not a doctor. I can just type what i saw, okay . I saw a breathing, happy young man who was wearing the cap of his employer, which im not going to publicize it, but they still a lot of chicken and there headquartered in arkansas. Ken at [laughing] now, to the purpose of this hearing, mr. Chairman, we want to talk about chip reauthorization and Community Health centers. Ization i think the last chip reauthorization, i was one of the chief cosponsors of, so we are obviously for chip and the Community Health centers. My Family Foundation how bought a building in my hometown and donated it to the hope clinic which is a Community Health center ellis county, and the barton annex is providing services for low income citizens in texas, and is doing very, very well. So we are strong supporters of the Community Health centers and schip. I have two questions and ive been asked to ask our distinguished panel, this one is for ms. Snyder and mr. Holmes. This Committee Earlier this year passed a bill to charge millionaires, people who have won the lottery, a little bit more if, in fact, they have come into some extra money. To put it into perspective, this policy change would mean millionaire medicaid beneficiaries would only pay approximately 70 more dollars each month. That would save apparently seven, several billion dollars. Wed you support making millionaires on medicare to pay their fair share to help pay to extend the schip and health sc . Center funds . That was supposed to have been asked by mr. Walden but he is not here to ask it. Congressman barton, im happy to answer the question. As i mentioned in my testimony earlier in some of my responses and over the course of the hearing, in texas where very much in support of personal responsibility and infusing a level of personal responsibility into the programs that we administer. Certainly this i think is a good example of an opportunity to induce that person responsible into one of our programs in that is commensurate. Ultimately we hope with thewhole earnings that each of thoseth te individuals lucky enough to be a beneficiary of a lottery winning, they will draw down as income. So we would support a measure such as that and would support that it ultimately reflects the earnings in a way that hold individuals accountable. Mr. Holmes . Certainly the expenditures of the federal government are important to its people. Its also important to wear those expenditures are directedr we have, things that we need to do as far as defense. We also need to look at the care of our most vulnerable populations. And in order to do that we need money. That money is coming from theays taxpayers, and we have to make sure that it is a fair system and that it is a system that has good return. I will say from a Health Center perspective, we are concerned about the return on investment that the taxpayer is making in Health Centers, and that we use those dollars wisely to lessen the burden on the taxpayer, and that we show a return for those dollars in the savings in the Medicaid Programs and the medicare programs and throughout all of our Patient Population. My time is expired, mr. Chairman. I will submit the other question for the record. I do want to say that we are working on a bipartisan basis. Have a bill called the ace kids act, and we had in the last congress with over 200 cosponsors. Ms. Castor who just left, mr. Green, i think everybody in the room right now who is a member was a cosponsor in the last congress, and hopefully will be in this congress. We will reintroduce that very quickly. But its a bill for the special Needs Children that have complex medical conditions to create a medical home so that they care can be coordinated with medicaih across state lines that its a voluntary Optional Program for the states to participate in but if they choose to participate, but apparently is a piece of legislation that will make the care much better also save money for the taxpayers. And we hope to reproduce that bill in the very, very near future and we have a commitment to have hearing on and hopefully will have a commitment to move the bill. I yield back. The gentleman yield back. The chair recognizes the gentlelady from colorado ms. Degette five minutes for questions please. F thank you very much, mr. Cha. Weve been talking a lot today about a lease on the side of the aisle our concerns about what t this Trumpcare Bill would do to medicaid. And how it would interface with the chip program. Because chip is something that weve all agreed is important for the children of this country but it really does ride on the foundation of medicaid and wantn to talk a little bit about that. The 840 billion cut to medicaid and converting the program into a percapita cap under trumpca trumpcare, it would then be combined with president trumps budget, which cuts chip funding by 3. 4 billion by eliminating this socalled 23. Bob. So medicaid covers 37 million children and nearly 9 million additional covered under chip. Im trying to figure out what would happen if both and the budget cuts to chip went through. Ms. Mann, can you discuss from your knowledge of this proposed medicaid cuts and the chip proposal under the trump budget would affect children in the states . Certainly. Thank you for your question. The house provision around setting caps for the program without a fundamentally change the commitment the federal government makes to parents, pregnant women, to elderly who are served by that Medicaid Program. They would force states to have to significantly reduce their spending in order to stay within the caps unless theyre going to spend only their state only dollars. Uld sp and so the kinds of things thatt states would end up doing no doubt reluctantly would be things that would reduce access to care, things that would potentially look at some of the specialized programs for kids with brain injury and special health care needs, pull out funding around childrens schoolbased services and Early Intervention care. A number of different ramifications we think that would have your in addition it would pull out the funding for the expansion population, and often talks about the socalled childless adults and expansion population, isis oco because i would be a childless adult. My children are grown. Im not a childless adult that many of those individuals covered under the expansion our parents, and shall do better with the parents are healthy. Those cuts in the budget cuts id think we see a really devastating change for childrens coverage. Let me follow up and ask you, do you think of the children who lose their insurance or lose some of the specialized benefits under the cuts, could they be covered by chip . Chip is not designed both in its financing at in its benefit structure to pick up those children. To pick up those kids. And if youre pulling the 22 points away from chip will see a ratcheting down of chip. Chip is really designed to be in addition speedy thats right. Not a substitute. It meets the Foundation Medicaid how to operate well. The administration said theyr might allow states to know the bar on medicaid benefits, sherry and other attributes. If, and i think you alluded to this but if those changes go into effect and how is that going to impact kids in light ow the proposed cuts . Many ways in which, whether its increase costsharing and premiums for children and families with very low incomes, can we talked about lottery winners of most of the children in medicaid at incomes below the poverty line. For a family of three thats about 1700 a month to support three people every month for rent, food, utilities, all that they need. At so those kinds of responsible may be hard for families to bear. In addition, if the reductions in the benefits come if theres waivers to eps think it can get dental services for kids cant get transportation, doctor some the problems that children face in rural areas. They need help getting transportation to medical care. So those are all of the kinds of ways besides just absolutely cutting a group of children who are high Needs Children off the program that states may have determined to under caps and further budget cuts. States have their own set ofs budget issues. In my state we have a constitutionaaconstitutional prn against raising taxes without a vote. Its not like states that huge pools of money theyre going to pour into this. Thanks you so much and they get back. The chair recognizes the gentleman from thank you, mr. Chairman. I was with coach martin as a went up to the hospital, so i havent been able to follow all the activities that event going on in the ring, and i think its safe to say bipartisan lies, that bipartisan wise, we support the Medicaid Program and we support chip. The real debate from what im gathering is tied into whatever the sin is doing whatever we did. Let me just ask a question, does anyone on the panel know our National Debt . Vander boon oh how much our National Debt is . I believe it is close to 20 trillion. Ms. Snyder . [inaudible] ms. Mann . 19. 6 i think, a little over 13 is public. What is it that . When we say that, what is that . Is a safe to say its our promises to pay you to services . Either, we know what drives are National Debt. Its a mandatory spending the no programs. People dont like to say this but its just true. Its medicare, medicaid, Social Security and Interest Payments. Ill point everybody up to the pie chart which i use this a gazillion times. So thats 2015 spending, and when we find out on budget were fighting to bluray which his discretion and will be going through that. Does anyone reject that pie chart as being accurate depiction of our federal spending . No . What we put up is accurate. So in the red we have automatic spending, salsa sturdy, medicare, medicaid which means we are not engaged in determining those costs. They are automatic. Of the mandatory Interest Payments and the blue is a recall discretion are spending. So go to the next chart. So this is whats happening in our nation since 1965. As you see that the mandatory Spending Continues to grow, squeezing out the discretionary budget, which are things like defense, education, hhs, department of energy, roads, bridges, infrastructure and the like. And so if left unchecked in 2026, we continue to start having big problems and thats why we discuss, we dont discuss the debate on mandatory spending out of a desire to be mean, vindictive. We discuss this to save our country. Admiral mullins said in testimony before the Armed Services committee, our debt is our national threat. The threat to our country relies in that depiction. So what we did in the healthcare bill, and im not sure what my colleagues on the other side into that saying, but the fact is we have medicaid spending and we have a percentage of growth per capita growth. As much as he want to say its a cut, over the years its increase medicaid spending at a slower rate than what would happen if you left it automatic. Thats the reality of the state. If someone is saying you are cutting medicaid, in real dollars they are not telling the real truth. Its an inaccurate depiction of what we have done. And my guess is thats whats been going on today in the hearing. Where we are trying to get control of the threat to our nation, which is our nationall debt, and were trying to provide to our providers Stable Funding stream that grows, and lets them to the Medicaid Program and the state manage how best to provide for their citizens in the state, empowering governors who actually closer, and medicaid is it just compels me to raise that much time is almost over, but i would in on this. This is from a report, and i can provide it to the minority. Im not asking for it to be submitted into the record, but current projections, no resume was to a picture in which people are struggling to been on medicaid would lose the benefits are to the contrary cms estimates that medicaid involvement would stay roughly constant at current levels under the aca while still beingng substantially higher than projected before the Affordable Care act was passed. Indeed, cms finds that many states would still cover some of the ac expansion population even if lawmakers do away with the aca inside federal matching payment rates. This would mean expanded coverage relative to preaca levels while also being equitable for the aca. My time has expired and i yelled back. Picture thinks the gentleman. The time of the gentleman has expired. The chair recognize the judgment from california five minutes for questions please. Thank you, mr. Chairman. Appreciate the opportunity to have been witnesses and the opinions of our colleagues. Unfortunately, my colleague mr. Shimkus come his time was expired but i would like at least one of the witnesses to take an opportunity to responde to the narrative that we just heard the last five plus minutes. Ms. Mann, would you like to maybe and lightness of the bit about the juxtaposition between the argument that was just made on expenditures versus healthcare . Sure. Ill take a stab at that, thank you. Let me say couple of things. F one is that the medicaid reductions in spending in the bill largely are not being used to reduce the deficit. They are largely being used to finance new tax cuts in the bill. So the connection there is not as strong as it might otherwise seem. But i think the bigger issue in terms of the healthcare debate is, there is no dispute i think among anyone, healthcare policy experts, hospital administrators, consumers, state medicaid agencies that we need to do what we can to bring down Health Care Costs. And that is that i think what people have been engaged in particularly in the last four or five years, the integration of Behavior Health, physical health, they Care Management, the telehealth. Those are all mechanisms to deliver better care, and to do that in a way that lowers costs. What will that work is if you simply take one part of the healthcare system, the largest source of coverage for the lowest income people, and to say on that program were going to put the cap. That doesnt change the cost. That doesnt change the healthcare needs. Its a tougher job in the long run what you just described, if you take away dollars and reduce benefits of being able to see a doctor and getting healthcare, in the long run doesnt that set us on a trajectory to increase costs and reduce the health level of americans . I think that is absolutely right. When people dont figure at the right time at the right place they go to emergency rooms. They have more inpatient admissions. Invented it care . Stick in nine saves time. When i was a kid i hate duringh that but now that i may adult, it makes a lot of sense. Ms. Snyder, taking a swap of money like trillion dollars away from our american Health Care System and then i do and i do agree with me but having less people having direct access to care, doesnt that create in the long when we put ourselves on charting the course of hoops, now perperson longterm we are probably spending more for health care and maybe not even having better care. Just more emergency care, more lastminute care. So what i would say is i think the chip Program Actually provides us with a greattu opportunity to look at a program that does into some of those Critical Concepts into the Program Framework that can help to drive down costs. Those include state administrative flexibility, thee inclusion of personal responsibility and but with all due respect state flexibility something that is thrown around a lot. If you have more flexibly and a heck of lot money or resources to provide care for state constituents, People Living estate, can that contribute to hoops, we are now setting u ourselves on a course for less care in time early on, less Preventative Care means that oops we are now still one for Different Reasons tha after more expenditure need on care . I think thats a great question and i think whats the answer . Is that an accurate narrative or, im just not seeing it right . What i would say is it is incumbent upon states and is going to be more crucial than ever that state excuse me. I used to be a statete legislature. I used to be the baggage of us i know what its like to make those tough decisions sinewave all the think we would love to do which is not enough money. Then when the physical rinsing wheel lock which you and all of a sudden we went from taking off as you how much money the fed gets us and t the recent oh, my gosh, that didnt reduce the need to provide for our constituents. Out and it is we have less money to do it with. And i believe that isnt the case. So what is going to run a call on us to do is to critically evaluate the data that we have on hand and ensuring that we are making informed and smart decision. With all due respect, if i were a single mother with two children and people are telling me we evaluate your families situation and have no healthcare coverage for my children, that analysis aint going to do me diddley when my son gets really sick and gets a fever and ihe dont have a clinic to go to and i dont have coverage and im not part of chip anymore because im on a waiting list or ironnet medicating more because im at a waiting list for my state. All of a sudden yes what im going to do as a single mom. Im going to end up in the emergency room and i think its going to cost the state more, its going to cost that hospital more. Its not going to help my child for heaven sakes in my child is a fever because he has a more serious condition and if i wouldve taken into a doctor twn years ago they wouldve found it early all of a sudden now my child has for the state Something Else. Believe me we are going in the wrong direction and appreciate your generosity, mr. Chairman, for allowing some of us to go for a time on both sides of the other 90. Im out of time. The gentleman just back. The chair recognizes the gentleman from new york for five minutes of questions please. Thank you very much, mr. Cha. I want to make a statement and then have a couple of questions for ms. Mann. Let me say at the outset that a strong support chip, Childrens Health Insurance Program, and our nations committed to Health Centers. I was very proud to support the medicare access and chip reauthorization act back in 2015, and most recently extended those two vital programs. Id like to point out though that those reauthorizations passed the house in march 2015 and was signed into law by mid april and yet here we are at the end of june without a plan to Fund Programs set to expire in september. R. It certainly is not right. In reality our timeline is even tighter than that. Months before their funds are depleted some states must start the process of shutting their chip programs down and that means if congress doesnt act fast its entirely possible that children will see their coverage disrupted. I think mr. Cardenas pointed that out. Why hasnt congress acted yet . Why did we go to extend funding for chip, the Community Health centers in march of getting 2015 . And the answer is that trumpcare monopolize the house time represented us from doing all these important things. Thats of the only thing that trumpcare has endangered. It cuts, trumpcare will cut and cap care for the 37. 1 million children on medicaid and on top of that trumpcare is a radical restructuring of medicaid is dangerous and locations for the chip program a structured program depends on a strong Medicaid Program. They work in concert to afford children comprehensive coverage. Howell first of all more than half of children with chip are actually enrolled in expanded medicaid coverage that is financed by chip. These programs also Work Together to meet the needs of different populations of kids since medicaid covered benefits other insurance do not. Fi chip reauthorization is vitally important for americas kids. I dont dispute it. My democratic colleagues dont dispute it but in discussion on this topic, a discussion of the topic cant occur in effect. If trumpcare becomes law and republicans succeed decimating medicaid, theres no way to go arounabout it, children will beh worse off. I want to talk about president trumps budget which unfortunately exacerbates the problems that trumpcare creates for kids. While we should enact a full longterm extension of chip, this budget proposes harmful changes to the program. What does it to . It will abolish the enhanced t federal funding match the states get now, will overturn the requirement that states maintain childrens current eligibility levels, turning back the clock on historic coverage improvements and cut off support for chip kids about 250 of the federal Poverty Level. 25 want to talk more about this last point because right now toy for states have income eligibility for medicaid and chip, a great event to 150 of the federal Poverty Level. This includes my state of new york. We are a high cost of living state so what you buy in new york, you buy a lot less for the same money than did in other states. Its ridiculous to penalize states like mine. The administration wants to cut off the federal dollars to give nearly half of all states the flexibly. We hear a lot about states rights and yet we want to take away flexibility the states have with programs states deem are important for them. We want to tell them the federal government that they can and cannot do. So much for states rights. If this takes effect i have to imagine states will have no choice but to restrict eligibility for the chip program thus cutting of care for children the chip coverage today. So its bad enough we will not be helping children who need this coverage, we will be throwing children off who have it today. So let me ask you, ms. Mann, if this provision would affect my district where onethird children are covered im concerned about its potential effect. Can you tell us what we can expect to happen if federal support for chip kids about 250 of the federal Poverty Level is cut off . Thank you for the question. You were absolute right. We have about 24 states that cover children at some income levels above 250 of the popular line. Most of the children actually in the program, 97 have incomes below 250 of the poverty line. But those dates that increase a eligibility levels have made a determination, have exercised their states flexibility because of costs in the state, because of parking conditions in the state, for various reasons of concerns for kids have decided having chip is an option for those children is really important. And i should say new york like every other state that covers children at higher income levels requires the families to pay a portion for their care. So theres premiums and the premiums slide in accordance with income. E it in a state like new york with high Health Care Costs and high premiums for other kinds of coverage have to into their coverage, go down to two or 50 of poverty, those children will be scrambling for other kinds of care. They will pay higher costs, thec benefits will not be as pediatric focused as he read the new chip program, many of them because of whats called the family glitch will not be able to qualify for subsidies in the marketplace. Though i had a couple more questions but usually answered them about how this in turn would affect coverage levels. Thats good because your time has expired. We have earned the gentleman yields back and the chair thinks the gentle force participation o i want tot recognize the some for questions. The chair would point out that youre detailing his questions until the end to all other members to ask the questions and accommodate the travel plans if use the entire five minutes because this is been a very robust and insightful discussion. We do have a task ahead of us which is the funding for the state Childrens Health Insurance Program which concludes on september 30 of this year, the end of the fiscal year. That of course was a fiscal clip that was set in motion under the Affordable Care act when thehe Affordable Care act past it was signed into law in 2010 schip was reauthorize at the end of fiscal year 2019. Funded only to the end of fiscal year 2015. Your chairman as part of the sgr repeal managed to get two years of funding until calendar fiscal year 2017, and that is the task that is ahead of us at this time. So ms. Snyder, i need to ask you what is there practical and texas focused question but since the majority of the dice numbers now are from texas, it will be appropriate. You said in your testimony with what you provide us in your testimony that texas, course texas has just concluded its website slush and correct . And texas, the legislation is every two years. Your budget is now set until the next legislative session in 2019, is the correct correct . That is correct. There were some assumptions made by the finance committees that are there in the texas house and texas income of the budget committees in the house and senate, the were assumptions made that the funding for state Childrens Health Insurance Program would in fact, continue until 2019, is that correct . Yes, with a 23 additional bump. So changes that we make now, after the fact for what your state senators and state representatives assumed to be what was going to be available for them to include in their budget. And any changes we make now what have a significant effect on the state budget that is alreadysign been passed and doubly signed into law, is that correct . 809 impact over the biennial. I understand the importance of getting this done 800 million. Under the Affordable Care act, under current law, something happens to distortion sur chiffn texas, doesnt it . What is it that happens . Funds they go to hospitals that see a disproportionate share of medicaid lowincome and uninsured. What happens to those funds inpp texas . Can ask you to clarify the question . What happened under current law, under the Affordable Care act, so cultish funston a disproportionate share funds, additional funds paid to hospitals, paid institutions to see a disproportionate share of medicaid, low income and uninsured, what happens to those funds at the end of this fiscal year . Im sorry, i do know the answer to the question. I know the answer. And ill be glad i know the answer. Of the glad to share with the committee. Those funds under the Affordable Care act of course everyone is going to be lying down the allegiant fields of obamacare. Theres going to need to provide additional funding to those hospitals because everybody has got this wonderful Health Insurance that was provided under the aca. But under current law, under current law texas is going to lose those funds in october of this year and that was an effort we did try to crack that in the bill that passed through this committee and a 20 hour market and passed on the floor of the house the first part of may. I know my state counterparts are interested that we take care of that discrepancy, and i think that we have. Let me just ask you, because i brought all of it long with that. We all want our dollars to be spent appropriately, and medicaid has a history,ately sometimes, the dollars are not always spent appropriately. But over and above the dollars they spent appropriately, if a patient is eligible for medicaid but they also have commercial insurance, another third party that is supposed be liable for their medical care, sometimes the path of least resistance is just to build a medicaid systeme and this seems to be a quick way of collecting the money. One of the things weve been working on is to enhance the ability to collect the thirdparty liability if there is coverage that is owed by another payer or commercial insurer. Ur so whats your experience been in managing potential overpayments within the state related to thirdparty liability . We are committed in the state of texas to ensuring when theres another payer source that we are capitalizing on that payer source, that medicaid remains the payer of last resort. We have efforts underway, both within the medicaid broken and in conjunction with our Inspector General to ensure that we are systemically drawing on the funding that is available for both of the pair sources. Its one of our priorities projects every year understanding that medicaid impact is the payer of last resort. We will have legislation coming on that and i appreciate your input on that. Mr. Holmes, let me just ask you. Certainly appreciate what you do and what other people involved in the Community Health centers and federally qualified Health Centers provide. When a patient sees the physician or Nurse Practitioner at a federally qualified Health Center who is covered by medicaid, is the rate reimbursed by medicaid the same as it would be by a physician practicing in private practice in the same town . Me it is not in most cases. Health centers are paid under a pps system and its a bundled set of services for the medicaid patient and is based on payment methodology those passed through Congress Many years ago. That is different than a discounted feeforservice payment arrangement that currently exists with a number of other medicaid providers. And that would be the provider out in private practice . That is correct, and less of providers are in i cavitation system or in some type of a sealed. Betook him we for decapitation is a bad word this morning. It is a method of payment where you are paid on a per member, per month basis, and for that per member, per month basis you are delivering the scope of care within that agreement. And another aspect of the difference between the doctor and private practice and a doctor working in a federally qualified Health Center is the libel to question, is that not correct . Correct. A doctor in private practice and security medical libel insurance which in some areas can be quite expensive but in federally qualified Health Center that cost is ameliorated by participation of the federal tort claims act, is that correct . That is correct and it was under congresses direction to include Health Center physicians and providers and ftca because they felt healthcare dollars. I dont disagree with that. In fact, probably when jean green was in the statehouse in the early 1990s and howard state legislature provided doctors who did a certain percentage of medicaid in their practice, the first 100,000 of liability coverage. That didnt last that i dont know why. It was probably too expensive as a state program but if you want to encourage the number of providers to see patients were covered by medicaid, that seems to me to be a very forwardrd leaning aspect of what they did back in the early 1990s. I want to thank my colleagues in texas are unsure he was the main driver of that liability assistance when it occurred. I want to thank all of our witnesses. Seeing no other members wishing to ask questions, i do what you think the witnesses for being te here. We received outside the back from a number of organizations on these bills. So i would like to submit statements from the following for the record. T the American Academy of the a dermatology association, americas essential hospitals, American Academy of familyicians physicians, the Healthcare Leadership council, our house colleagues to minnesota, chip letter from 1200 local state and national organizations, without objection, so ordered. Mr. Chairman, before you, i want to ask for the four minutes extra you have on your five minutes. That was a cumulative, i accrued all of the extra minutes i gave on your side and utilize them for our side because i knew my question would speak i appreciate your activity but that was taken at the event only want to do is give me one minute. The judgment is recognize. First of all i was in the legislature in 91 and im not sure but after that i ran for congress to the state of texas is going to be in special session. Is that not correct . In the next two weeks. Having been done that, nobody likes special sessions in the summer. By the other issue is texas is not expand medicaid, is that correct . That is correct. And the other issue is thirdparty coverage. Thats not unusual because if you have an auto accident, the hospital in texas isomeric or else has a right but a hospital lien on that, whatever, whatever you went from the lawsuit. So i dont have any problem off texas doing that in medicaid, but, so thats pretty common. But thats not going to solve our problem in medicaid and terrible program with in texas and even when democrats were in the majority, texas always was very conservative. Our Medicaid Program is nothing compared to some others. I will give one example here during after katrina, the houston received a quarter of a Million People. We brought them in under our medicaid system, although state legislature was out of session. We were able to get federal money to do the state match for those folks, and over a third of time they either went back to louisiana or they became texans. Thats what event at the louisiana actually gets 75 federal reimbursement. In texas received 67 . I would hope maybe our subcommittee could look at that and see why is it more expensive it is will the gentleman yield . Collective. I do not know you can find the last few minutes of the searing on our website, cspan. Org. Right now we take you live to the floor of the u. S. Senate