Transcripts For CSPAN3 Alliance For Health Reform Examines Future Of Medicaid 20170403

Next, a look at the future of medicaid and how it could be impacted by proposed Health Care Policy changes hosted by the alliance for health reform. All right, were ready. Good afternoon. Welcome. Im sarah dash, im president and coceo for the alliance for health reform, and for those of you not familiar with us, the alliance is a nonpartisan, not for profit organization. Weve been around for 25 years, and our mission is to inform policy makers and help policy leaders on the most pressing Health Policy issues and get you guys the foundations of Health Policy, the evidence, and the practice, and today we are here to talk about one of the most pressing Health Policy issues that has been making a lot of headlines recently, and that is the Medicaid Program. Medicaid covers over 70 Million People, as we will hear, and it is responsible for taking care of very, very diverse populations with an enormous range of medical needs, from healthy newborn babies, to children with very special health care needs, to low income adults, people with serious illness and disability, and more. And as we all know, recent legislation proposed the American Health care act would have made major changes to the Medicaid Program, and certainly the discussion about the program is not over, so todays briefing is going to examine the relationship between medicaid coverage, access to care and Health Outcomes, as well as what might be next for medicaid in the states, in congress, and in the administration. And id like to thank, first, our sponsor for todays event, our partner, the Commonwealth Fund. Were very grateful for their support of this briefing, and before i introduce our panel, i just want to take care of a couple of housekeeping details. First, for those of you who need wifi credentials, they should be up on the screen. You can tweet t to futureofmedicaid, and when the time comes for questions, many of you know the drill, but write your question on a green question card or come to one of the mikes on either side of the aisle, or tweet your question to futureofmedicaid. So, without further adieu, im going to go ahead and introduce our panelists. We are still waiting on one panelist, but she will be joining us shortly. So, our panel to my left is Sarah Collins. She is Vice President for Health Care Coverage and access at the Commonwealth Fund. Gael walensky will join us. Shes an economyist and senior fellow at project hope. She directed the medicare and Medicaid Programs under george h. W. Bush, and all the way to the left there is Sarah Rosenbaum, the harold and james hirsh director of health and policy and the founding chair of Health Policy at George Washington University School of public health. So without further adieu, im going to turn it over to Sarah Collins and well go ahead and get started. Thanks. Thank you, sarah. Good afternoon to everybody, and thank you to the alliance and also the panelists for joining us today. As sarah mentioned, a major focus of the American Health care act was the Medicaid Program. Both the Medicaid Expansion and also the traditional Medicaid Program. The bill likely would have ended the Medicaid Expansion over time, and it would have placed a federal funding cap on the traditional Medicaid Program. In the wake of the failure of that bill, the question before us now on the panel and for all of you is whats next for medicaid . To set us up for this discussion, im going to focus on the Medicaid Expansion, refreshing our memories about where the states stand on their decisions to expand the program and taking a look at the latest research on the effects of the expansion on coverage, as well as other key indicators. As of today, 31 states and the district of columbia, have expanded eligibility for medicaid. Of those, six have used 1115 demonstration waivers granted by hhs. These six states have struggled to reach political consensus on expansion and found agreement in alternative approaches such as enrolling medicaid beneficiaries in marketplace plans, in the case of arkansas, and imposing greater financial responsibilities on beneficiaries, including higher premiums and cost sharing. There are currently four states that are actively discussing expansion, the Kansas Legislature has passed a bill to expand medicaid, although the governor has vetoed that bill. The legislature is attempting to override it. Governor diehl of georgia has expressed interest in expanding medicaid. In maine, Medicaid Expansion is on the ballot this year and a bill to the legislature would expand medicaid with the republican controlled legislature, considering it this week. Other states where expansion has previously been under discussion might be states to watch this year, they include idaho, south dakota, tennessee, utah, wyoming, and other and a few other states. Based on Commonwealth Funds latest score card, which we released in march, and numerous other federal and private surveys, its pretty evident by now with three full years of experience in the Medicaid Expansion that its made a significant difference in coverage in states across the country. Uninsured rates have fallen in every state since the major coverage expansions of the Affordable Care act went into effect, but fallen the furthest in the states that expanded medicaid. Nine states saw declines of ten Percentage Points or more by 2015 and they were all in Medicaid Expansion states. Kentucky had the largest decline, followed by california, new mexico, and West Virginia. Since 2014, coverage gains have been the strongest among adults with lower incomes, and its in this income range where the differences between Medicaid Expansion and nonexpansion states have been the most evident. Uninsured rates in expansion states among adults with incomes under 200 of poverty fell by 14 Percentage Points from 2013 to 2015 compared to nonexpansion states. Coverage gains since the passage of the Affordable Care act have been associated with gains in access to health care, but these gains in access on average have been greatest in states that expanded medicaid. If you look at the middle bars in this chart, the share of low income adults reporting that they had skipped health care because of costs fell by 5 1 2 Percentage Points between 2013 and 2015. In states that expanded medicaid, compared to decline of about half that in states that hnlt expanded their programs. Likewise, fewer adults across the country report they dont have a regular doctor, but again these declines have been the greatest in states that expanded their programs. So lets just consider the case of kentucky and tennessee, and i use this example because these are border states in the south with somewhat similar demographic profiles, but which took polar opposite approaches to their Medicaid Expansions. Kentucky expanded their Medicaid Program and ran their own marketplace for a few years anyway and also conducted an aggressive Outreach Campaign to encourage enrollment. Tennessee did not expand medicaid and did not run their own marketplace. The states had similar uninsured rates prior to the Affordable Care act. The uninsured rate in kentucky among adults with low incomes fell by 25 Percentage Points, fell by only 9 Percentage Points in tennessee. Kentucky also experienced the largest decline in the country in costrelated problems getting care. The share of low income adults who said they had gone without health care because of costs fell from 34 in 2013 to 21 in 2015. In contrast, tennessee experienced no significant improvement on this measure. Likewise, many fewer adults in kentucky reported in 2015 they didnt have a regular source of compare compared to 2013 and tennessee did not see any measurable improvement in this measure. Ben summers has been conducting a survey of low income adults in three states since 2013 to track the effects of Medicaid Expansion. He selected arkansas and kentucky, both of which expanded their programs, and texas, which did not expand. His analyses have found significant improvements on key measures of Health Care Use and self reported Health Status in arkansas and kentucky relative to texas. For example, compared to adults in texas, adults in arkansas and kentucky had significant increases in getting checkups and significant decreases in visits to the emergency room. Ben also found low income adults in arkansas and kentucky experienced marked improvements in affordability, including a drop in out of pocket spending since 2013 compared to adults in texas. One of the policy rationales for repealing the Medicaid Expansion weve heard a lot about is the contention medicaid provides inferior coverage compared to private insurance and having medicaid is almost like being uninsured, but research hasnt really supported this claim. For example, this study that the Commonwealth Fund did using the Commonwealth Fund biannual Health Insurance survey found medicaid provided adults access to health care and financial protection that on most measures was comparable or better than that provided by private insurance and better than being uninsured. Cbo estimates that by 2026 more than 70 Million People will get their Insurance Coverage through medicaid, as sarah said, that many get their coverage now through medicaid, and 15 million of them through the Affordable Care acts Medicaid Expansion. This quick overview that i just went through suggests the value of this coverage in helping people get the health care they need, particularly large numbers of people with low incomes across the country, the program is really a cornerstone at this point in the u. S. Health insurance system, and it really should be the concern of policy makers to ensure its strength and viability over time. In terms of what you might see in the next year in terms of medicaid policy, some of the key questions are, will more states move forward on expansion . Will cms grant greater flexibility for states through the 1115 waiver process, and what will be the implications of that for enrollees . Will congress return to pursuing policies that would place state caps on federal funding of medicaid, such as block grants, and if so, what are the potential implications for enrollees . And ill stop there and turn this over to sarah. Thank you. Thank you, sarah. So, we may be we have a bias towards people named sarah today. Gael walensky is here. While shes getting settled, let me ask, many of you obviously have been following the debate, but for those who maybe need a little refresher, can you just explain the difference between block grants and per capita caps . And ill let Sarah Rosenbaum chime in this on that, as well. Thanks. Good morning, everybody. Can you hear me . Yeah, okay. Good morning. So, a block grant is a model of federal funding in which the federal government basically comes up with an aggregate cap on the federal contribution to state Medicaid Programs. Many factors go into that aggregate cap. The Congressional Budget Office has very useful information on some of the factors that go into, or could go into, estimating an aggregate cap. The Commonwealth Fund put out a short piece on how aggregate caps are built, but the point is, its an aggregate cap and it doesnt necessarily relate to and certainly over time probably would not relate to actual population growth. A per capita cap is an approach to federal funding limits that would presumably tie to the number of people actually insured. So as the number of people goes up or goes down, the cap, the amount of funds would change, but as with an aggregate cap, a per capita cap also includes many factors that determine how its going to grow Going Forward. So while a per capita cap might grow in relation to population, its not necessarily the case that it would grow in relation to changes in service intensity, changes in the price of insurance, or the price of health care, and other changes that would affect spending on a perperson basis. Thank you so much. So, im just going to give gail a moment here to get settled. Again, were thrilled to have gail with us. She, again, ran the medicare and Medicaid Programs under president george h. W. Bush and has many accomplishments besides that, as do the other panelists, and i hope youll check out their bios in the packets. With that, we heard from Sarah Collins, and ill turn it over to gail walensky. Thanks, gail. For those of you who dont know it, the metro is shut down between metro center and union station, and we have opening of the ballpark, and so there are a gazillion people trying to drive around, but im delighted to have been able to join you. Fortunately, i had seen Sarah Collins powerpoint, so i know the points that she was making. I have a couple of observations that i wanted to share with you. The first is that it is important to acknowledge that medicaid has been the acas clear success story, and i dont think we can ignore what weve been able to see, that Medicaid Expansion actually accounts for the majority of newly insured. It has been able to do this without experiencing the kind of churn that we have seen in the exchanges, but on the somewhat negative side, the spending is running much higher on a perperson level than was predicted. The second year, as expected, tends to be Lower Per Capita spending than the first year somebody is on, even so, it is way above what the expectations were, so thats one observation point. The second, and this is something that not actually related to the aca other than a very in a very peripheral way, the medicaid current match structure really makes very little sense for anything other than to start a program. What you have with the aca expansion is the highest match rate covering the higher income of the poor lowincome population. It started, as you all know, at 100 . Its in the process of walking itself down to 90 . Even so, that is way beyond the matching rate that exists for the base medicaid population, which as you know is between 50 and 73 . It not only doesnt make any sense to have different match rates for different parts of medicaid, ship, of course, follows into this, as well, but this seems to really have it backwards. You would think the federal government ought to pay a larger share for the poorest of the poor and not for those that are near the cutoff in terms of Medicaid Expansion. We understand why that happened to try to lure as many states in as possible, but once we are on any kind of stable footing, that needs to be resolved. We need to find a match rate, probably somewhere between the base match rate and the new match rate, and have it applied for the entire Medicaid Program. Having these three different match rates for different pieces of medicaidship makes no logical sense whatsoever. The third issue that i want to raise is something that i have been commenting on now probably longer than id like to remember, but at least the last 25 years, which is that the states, we dont usually give them enough credit for creative financing and creative thinking, but the states have shown themselves very able to find various types of financing strategies. The end result of which is their part of the money is less than what is statutorily required. It has gone through various versions. The first started just before i was running medicare and medicaid, around 1989, 1990, with something called voluntary donations. Its in some ways, because it was the most egregious, the easiest to explain and understand, for those of you who didnt recall this activity started in West Virginia and basically what happened was the hospitals would put up a state share of the matching rate by donating money. Thats the voluntary donation part, to the state. The state would then use that money as its match money for the federal government. It would get the federal match and the money would then go back to the hospitals, including their piece, which meant that basically the only new money in the system was that that came from the federal government. There are various other strategies that eventually was sufficiently egregious that it was shut down, but provider taxes frequently function in basically the same way. A tax gets put on a group of either physicians or hospitals. That money is part of what is used for the match. The match comes in. The matched money and the base money goes back to the source, either in its entirety or in large part. There have been more sophisticated ways, which make it harder sometimes to shut down, involving intergovernmental revenue sharing. Since that is a legitimate activity between the state and the counties and state and the city, thats harder to get rid of. Also, not having an upper payment limit that bears any relationship to cost has allowed states to do this. The upshot, and this was has been true as late as an oig report that came out in 2016 for 2014, right before the match started, is that what weve assumed was the major constraint, that is the states share of the match, isnt really doing the job in the structure that it was intended to do. One could question if the match was as small as 25 , whether it would have anyway for the poorest of the states, but it is just not a structure that continues to make sense. As an economist, i was actually taught matching grants are a good structure to follow, because it gets contributions from the person receiving the money and is a way to try to have a maintenance of effort. Good in theory, this has proven not so good in actual practice. Which is why i would like people not to be so dismissive of the notion of a per capita block grant. It fundamentally depends on the baseline that you use, the starting point, which is at the moment a bit awkward in the sense that 31 states, mostly blue states, have expanded. The other states have not. Mostly red states. Kansas is trying. Governor vetoed it. North carolina and georgia are thinking about it, but we need to find a rational starting point and we need to have a reasonable index to use. Something maybe not quite as high as cpim, the medical component, but definitely higher than the regular cpi, at least to start at cpim and walk down a little bit as the Exchange Subsidies really wanted to do. If we were going to do Something Like that and throw in the requirement of a few outcome metrics, five or six, we could have a very rational program. If you look at a medicaid per capita block grant as a way of providing large amounts of revenue saving, then what i said really doesnt hold. Thank you, gail. Ill turn to Sarah Rosenbaum now. Thank you very much. So, i think weve sort of heard a couple of things now. One, of course, from Sarah Collins, has medicaid worked and does it work, and the answer is yes. When you measure it in terms of coverage or access to care, medicaid appears to do just what we want insurance to do. And the second point, which is the one that gails raising, is what should the Financial Partnership in medicaid look like, what are ways to allow the program to do what its supposed to do while maintaining some sort of control over programs size and growth, and the third is, which sort of flows from the second point, is if the Financial Partnership is going to change, how do we change, or do we change, some of the structural aspects of the Medicaid Program. I think it is absolutely imperative that we find answers to these questions. I first encountered the Medicaid Program as a 24yearold Legal Services lawyer in 1975 or thereabouts in Rural Vermont and have spent 42 years just extraordinarily moved, really, by what this program can do and what it means to people. And i think that this is not a program that we want to see live in a world of terrible uncertainty. Its a program that we should really spend some time reaching consensus on, careful consensus. Its size tells us we need to do that. 71 Million People and counting. It is the least costly way to insure people. Its costs are appreciably lower than buying into commercial insurance in the private market, assuming that youre going to buy coverage. It does not leave people with breathtaking deductibles and cost sharing, and its clearly a program that is able to achieve a mission, and i think despite arguments to the contrary, its very hard to sort of overcome the kind of evidence that sarah presented and that other studies have shown. The complexity in medicaid is reaching some sort of new stasis, and thats because medicaid, as far as i can see, plays five basic roles in the Nations Health system, and there really is no substitute for this program. Medicare doesnt perform like medicaid. Small discretionary Grant Programs dont really perform like medicaid, and commercial insurance cant perform like medicaid. Its not built to carry the kind of burdens that medicaid carries. The First Mission or the first role, of course, is the one that really was brought into focus by the Affordable Care act, and that is medicaid as an insurance system for the working population and their families. The normal mechanism by which medicaid achieves that level of coverage, of course, is through enrollment and managed care plans, and i actually suspect, im not sure, that that sort of initial bump up on a substantial pump up was because states and plans had a tough time, just like in the commercial insurance market, in figuring out exactly where and how to set rates for a newly insured population that includes a lot of young, healthy people, Young Healthy workers, but also older, sicker people entitled to alternative benefit coverage. Second, the program is really and, you know, part of it is im at a school of public health, so i think about this, but medicaid is a central strategy at this point for dealing with the highest Priority Issues in Population Health, whether thats infant mortality, internal mortality, children with Developmental Disabilities who need to be able to be integrated into school and community settings, whether its Longterm Services and supports for people with chronic conditions, whether its the opioid epidemic, medicaid is really in many ways the most flexible means we have for dealing with Population Health priorities, and it has played that role now in the eyes of congress and a series of administrations for decades. It, of course, is a partner to medicare. I think its the thing that many people forget about, but it really makes the Medicare Program work for lower income Medicare Beneficiaries. It is a first health responder in times of crisis, whether its naturally occurring crises or manmade crises, it is a program that has been there to insure people in terrible times, and its capable of handling surges. And finally, medicaid, and i think this is something that we had to go through the expansion for in order to fully understand, particularly in the expansion states, it is the financing system that anchors Health System delivery reform and medically underserved communities. We have 65 Million People living in medically underserved communities, and medicaid is the primary insurer. So it plays sort of this ecological role, and, therefore, when youre doing medicaid reform, you have to think of all of these issues, and even if you just wanted to pick one issue, you have to think about the spillover effects in other areas. So it is a very difficult program to sort of get your mind around and any sort of reform effort has to be put into these contexts. There are two big areas, obviously now that i think most of us who spend a lot of time with medicaid are watching. One is Sarah Collins mentioned is this issue of the 19 remaining expansion states. Will they, in fact, come in for the expansion, and, you know, will they come in as straightup expansion states . They have the option to simply adopt the expansion, or will they potentially come in for expansion under certain circumstances, that is under 1115 authority, which im sure well talk more about. And some of the conditions being talked about are ones that might be applied through 1115, are ties to work, work requirements, premiums with a lockout period for nonpayment, open enrollment periods in medicaid as opposed to enrollment as the need arises system, and an end to what we call retroactive eligibility, which is a longstanding part of the program, a slimmer benefit package, timelines for coverage. These are some of the issues that have bubbled up either from current demonstrations or from past requests that havent been acted on yet. The other big issue that everybodys watching is this issue of sort of broader medicaid reform. How do we want the Medicaid Program to run, some of the points that gail raised, and this all important issue that is of particular interest in the expansion states, which is new strategies for delivery reform, you know, how do we use medicaid and the broader medicaid coverage to shape delivery of care, how do we get greater efficiency in care, how do we integrate Mental Health and physical health care, how do we integrate health and social services more, and particularly this is the case for populations for whom medicaid is a huge buyer with really the ability to influence an entire sector of the Health Care System. Weve known that this is the case for a long time in maternity and pediatrics. It is clearly the case for Mental Illness and addiction. It is clearly the case for Longterm Services and support. So these are the big areas of, you know, high profile policy reform. So, there are sort of two basic reform pathways in medicaid, and we have three very different views going on right now about those two pathways to reform. One is the legislative pathway, and one is an administrative pathway because of the uniqueness of 1115 of the Social Security act. And within the legislative pathway over the past few weeks now weve seen two competing visions. One is a quick strike system that takes a lot of money out of medicaid. Close to a trillion dollars. And basically uses potentially a follow on administrative structure, potentially follow on legislative reforms to rebuild the program. So all the financing changes and none of the structural changes. And then we have the strategy that actually four governors in a very interesting letter to house and Senate Leadership sent, and their vision is a vision that sort of turns the first vision on its head, which is very careful introduction of the kinds of financing reforms that gail mentioned with also a clear choice on the part of states to remain in a current financing structure, but with some limits, but allowing states also to move into more aggressive financing reform, coupled with very sweeping legislative structural changes in the program on basically all aspects of the program. So we see these two very strong competitors for a reform vision. Finally, there is the question of 1115, which obviously can work by itself, or it can work in connection with some of these other reform efforts, and i will close here by saying that i think, quite frankly, 1115 has been way overblown. 1115 is a 1962 demonstration authority. It was enacted in order to create authority in the secretary of then h. E. W. , now hhs, to introduce important changes, test those changes, evaluate those changes, and determine whether certain changes are such that congress ought to consider building them into the statute. Now, in fact, weve used 1115 quite well. One, actually, were a series of demonstrations begun actually a long time ago, broadened under the clinton administration, and carried over by the Bush Administration to think about, essentially, giving medicaid to people based on income. Whether a slimmed down package or a broader package, using income as the test. The other big two other big areas in which 1115 was used, tested, evaluated, were a Longterm Services and supports, where 1115 played a crucial role in essentially restructuring the medicaid statute, ultimately, to give states a lot more leeway and enable beneficiaries to live in community settings. And finally manage care. The balanced budget act amendments of 1997, the managed care changes that were quite sweeping, built on many years of testing managed care for medicaid beneficiaries. First allowing some smaller changes, then allowing states to do demonstrations with larger compulsory managed care reforms, and finally introducing a new series of state options. 1115 is not authority in the secretary to make wholesale changes in the statute, in the medicaid statute. 1115 is a pilot and testing system, and the question now is where do we want to see pilots, where do we want to see tests, what kinds of evaluation should we expect as a policy matter before an idea goes, you know, goes forward on a massive scale, and at what point is it proper and appropriate for states and the federal government, congress, to expect that, in fact, certain kinds of issues will come up in the legislative arena as opposed to piloting and demonstrations. So why dont i stop there . 14 years for arizona . Well, there is the question of whether certain and this is an issue whether certain longterm sanction demonstrations finally get a legislative sanction to go forward, but that was one state, you know, now having proven its meddle. Great. Thank you so much. So, were actually at the question and answer portion of the briefing, so while you all want to think about your questions, you can stand at the mikes, you can fill out a green card and somebody will come around and pick it up and then well try to answer it, or you can tweet to futureofmedicaid. But while you all are getting organized, let me kick it off with a question. So weve heard weve heard about successes of medicaid, particularly with respect to in this briefing expanding coverage under the Affordable Care act. Weve also heard about some challenges, some cost challenges, some distortions in terms of how the federal match works, and so this is a huge program. So what is the let me just ask each of you, what is the biggest problem we are trying to solve in terms of medicaid reform, if you could in your own words . What is the problem were trying to resolve, and then on the flip side, what is the biggest opportunity for the Medicaid Program . And ill let any of you kick that off. Thanks. The problem that were trying to solve is the problem were trying to solve is how to be sure the major source of coverage expansion under the aca, medicaid, goes forward on a rational, stabilized basis. I mean, thats generally the issue. And to assume that this one piece of medicaid would continue along with ship at a 90 match rate, where the base Medicaid Program is at a different one doesnt make sense, and trying to integrate at whatever level the congress is willing to support, those various rates is one of the issues. I know that what sarah said in principle and in law is correct about the function of the 1115 waivers. I was teasing her about arizona as an example. Arizona was the last state to come into medicaid. By waiting so long, it decided that it should try to avoid some of the most common problems, which is having a lot of people show up either at the e. R. Or without ambulatory support, so they gave people a structure with ambulatory choice opportunities. They stayed on their 1115 waiver until the balanced budget act, because the congress didnt want to shut it down, and there was not a legislative vehicle handy, so, yes, in principle the 1115 process should be used to try out ideas, see how they work, and then legislation should move from that. Sometimes it happens, sometimes it doesnt. Its a very important function if it, obviously, can be challenged in the courts and on occasion it gets challenged as to whether its beyond its bounds. The real opportunity i see is to think about medicaid, the medicaid population, and the population right above it, say, to 200 of the poverty line or to 225 of the poverty line as basically extensions of each other. And to try to make it easier to move money rather than people. One of the issues that Sarah Rosenbaum and i have talked about over the last couple years is the frustration that as you cross from 138 of the poverty line to 140 or 150 , you are basically forced to change your whole delivery system, which you may just have finally gotten to understand and to work, because many states seem to take pride in the fact that there are people providing care under medicaid were different than the people providing care in the exchanges. One of the options that has made sense to me is to basically let people use whatever subsidy money they are entitled to at that area of low income, and to either buy into medicaid, which seems to have been able to handle the expansion better than the many of the private plans, the ones that did seem to handle it better were basically Companies Like molina that structure their plans to look very similar to their Medicaid Managed Care plans, and, of course, i would give the option the other way, as well, we need to think about this more as a continuum and have opportunities for people to move their money rather than to be forced into a different delivery system. That makes no sense. So i think that the observation that on a comparative basis medicaid seems to have handled the bulk of the expansion reasonably well. We dont want to force a disruption of that, but as a matter of fairness or appropriateness, i would let the option go both directions. I just dont think it would actually be used very often. But i also think that were going to see a lot of use of both the 1115 waivers and the 1332 waivers that were built into the Affordable Care act, because they will provide the opportunity for many states to try. Thanks, gail. Sarah or sara, would you like to comment . I think that with medicaid, the biggest problem we are trying to solve now, and its actually weve gone through sort of periods where this is the biggest problem in medicaid, is less sort of specific an operational, although i certainly do agree with gail that the financial structure of the program is paramount and becomes sort of part of the overall problem, but i think the problem that we are always trying to solve with medicaid is aligning the dependence on the program and the role that the program plays with political views about the program. And by that i mean that medicaid is part of the dna of the Health Care System at this point. It its functions are so important, and unfortunately a lot of those functions are not immediately visible to us and would disappear only if the program were really mortally injured in some way. I can remember a year back 20 years ago when the ability of all of the district of columbias children who need special education was imperilled, the ability to start school on time was imperilled because of the billing and recovery mechanisms in d. C. Medicaid that had the city behind on recovering funds, and it was, you know, so serious that when the school year began, the question was, would these children be able to go to school . So these are the kinds of things that you understand if you understand medicaid, you see that everybodys ability to live in communities that the Child Welfare system, that the special ed system, that entire Delivery Systems all depend on medicaid, and so were just at one of those moments right now where i think our biggest problem is this perception problem, this gulf between what medicaid does in the world and at least some political viewpoints about medicaid. So thats the problem. The opportunity in medicaid is what i have always felt the opportunity was in medicaid, which was that it represents the best handle weve got for addressing those aspects of Population Health needs that involve the Health Care System. Many Population Health needs do not involve the Health Care System. They involve other remedies that are not the subject of todays discussion, but when it comes to health care, medicaid is the way in which we have chosen to finance health care for low income people. Weve ended up making this decision for lots and lots of reasons, and i think in this struggle over how to reform medicaid, we see particularly in the governors letter, a tremendous understanding of the importance of medicaid to local Health Care Delivery, and its a matter of reading and listening to states very carefully at this point who are in the end the force for Health Care Delivery and shaping federal Health Policy to enable states to move more actively in sort of more wholistic directions. Ask questions, but just to put a finer point on sarah and gails overviews of whats important, the political log jam in the 19 states that havent expanded yet is really having an effect on overall measures of system performance in those states, and in our Commonwealth Funds state score card, we ranked, we had 44 measures of Health System performance, of which on a coverage, access to care, access to Preventive Care are part of that, and in the top, we do this every few years, and in the top quartile, every single state in that group has expanded their Medicaid Programs, and this year three states that hadnt expanded their Medicaid Programs dropped out of that into a lower level, lower court, into the next lower quartile, so its a program that exists as a key part in peoples overall Health Systems in states, and so getting through the politics and the political opposition to it is going to be really important to states overall performance Going Forward. Great, thank you all. So, we have someone at the mike, well go to the mike, and we have a lot of Great Questions on the cards. Hi, my names carl polzer, long time Health Policy analyst, and ive worked for one of the speakers and alongside another, but i wont specify which ones so they wont be embarrassed. My question is really as this focus shifts from the legislative to the administrative on the work requirements and other types of requirements that states are either reupping their Medicaid Expansions or proposing new ones, these seem to be the most controversial new requirements. Now, they may seem very attractive to a conservative economist, but i think theres some practical issues. So im getting a bit facetious, but would it make sense to put employment offices, state employment offices, in Emergency Rooms . People do have a lot of time to fill out forms and to take training there and decide what they want to do with their lives. Does it make would you maybe help to have the Civil Rights Office there, because people when they go to work with illnesses, they might need protections, like if they show up with hives or drip bags at mcdonalds or places, they might get jobs, and they might need sick leave like most people at that wage dont get sick leave and theres no legal requirement for it, so that would be actually opportunity for a bipartisan agreement sick leave. Finally im a consultant now. And i have cards. [ laughter ] i know there are a lot of nonprofit entrepreneurs in here and business guys and like lobbyists. So after the meeting we can talk about the hospice population. Because theres really great possibilities for temp work there, i think. I really think that some of them could really work quite effectively right up until the last minute. You can save money on investing in their pensions. Not to be facetious, you need to think through the practicality of some of these requirements and just how deeply you could apply there. Id just like a discussion on the work requirements. We also have a question here about the work requirements. Lets dive into this for a second, this intersection between employment and medicaid and sometimes its a little bit of chicken or the egg, either youre healthy so you can work, or you have to work so that you can get Health Insurance. Lets just talk about that. What can we expect to see out of the new administration . Is that going to come under the form of 1115 waivers, and what is the likely impact going to be . I think it is likely to come through 1115 waivers. Theyve already indicated that. I was part actually, so was sara part of an interesting conversation a couple of days ago on this issue. A couple of points that may be made that may be able to be helpful in the situation. The first issue is whether or not the people that are actually could work after you exclude all the obvious candidates, including pregnant women, people who having Young Children at home, et cetera, narrows down the group considerably. Childless adults who dont have major kinds of Health Problems or people whose children are in school. The question is whether we would want, and the states would want, to cut off health care if someone doesnt do any of the actions which usually include training or education, in addition to working. But another strategy that seemed to go after the same end point was the proportion of people likely to receive food stamps and whether or not the work requirements in food stamps might be a better way to look at making sure there were strong work requirements. Because the notion of cutting off someones health care because for whatever reason they arent following through on the Work Activity or efforts theyre supposed to be doing seems not very likely. And the work requirement for food stamps may be able to have a much better handle on something that a state might actually consider. So i think that the spirit is understood of why this was raised. It is possible a slightly more sensible strategy to produce a similar outcome might be able to be developed. So i want to get back to a point that was raised earlier about the connection between medicaid and the health of the population and medicaids role as a program in a very it serves many populations, but a very lowincome population, medically underserved communities. And this idea of a wraparound between medicaid, work, transportation, those kinds of things. What can we expect what has been happening in terms of medicaids role in this overall continuum of helping to improve peoples health, and what can we expect to see Going Forward . Well, first of all, i think it is important to note of course, it goes to all of these issues, whether it is work requirements or time limits or other conditions on eligibility basically. One of the striking things about poverty in the United States is that while poverty is everywhere, we have many, many, many communities, urban and rural, where poverty is highly concentrated. And so in those communities, medicaid becomes not only a means for purchasing health care, but it becomes an absolute staple of a local economy. If its able to support a Health Care Economy that in turn supports other sectors in the economy. And its also a program that supports certain kinds of entities, anchoring entities, whether it is a rural hospital, whether it is Community Health centers, a rural health clinic, that themselves offer an array of services. And so you have this interaction between medicaid and local economies and local health care economies that makes the program a logical program for building out as an intervention. There is a very interesting report from the National Academy of social insurance. They came out early this winter looking at what states are trying to do to build new approaches to delivering health care to people who are enrolled in medicaid that utilizes both certain kinds of Health Care Providers and that expects Health Care Providers to have formal affiliation agreements with other kinds of entities, including schools, including job creation programs, including social services. And so one way to think about getting at this dynamic from the earlier questioning is to maximize the opportunities that states have to think about Health Care Delivery as part of a continuum of services that are targeted on communities that just are working with fewer resources. There are fewer jobs to have. And so if you if you look at what a rural hospital does in terms of its local economy, what a Health Center or rural clinic does in terms of its local economy, these are huge issues to factor in, along with the fact that you have the kind of anchoring health care in a local economy that then attracts other forms of commerce. So its less than thinking about things like a work requirement as a condition of eligibility, having the sort of more sophisticated thought process about medicaid as part of an economic engine system i think would get us further. Thank you. So weve had a couple of questions. Im going to turn to the population thats covered under medicaid, the Longterm Services and supports population. So we have a couple of questions about this. One question is that with twothirds of medicaid spending in states going to seniors and individuals with disabilities, an age baby boomer population and little stable private longterm Care Insurance to speak of, what is medicaids role in covering that population, and then a related question was could somebody please expand on the influence of the per capita cap and block grant proposals on Medicaid Services for people with disabilities . Im happy to start. One of medicaids greatest achievements i mean where you see the power of medicaid compared to any other payer is what it is able to do for people whose disabilities are serious, whether theyre young, whether theyre working age, whether theyre elderly, whether medicaid is functioning as a companion to medicare, whether medicaid we forget about one of the most interesting and important amendments relatively small but significant that senator grassley championed over a decade ago now to make it possible for families with children with very serious disabilities to essentially buy up, to buy medicaid to complement employer coverage in order to get the benefit of home under a communitybased service that employer plans just dont cover. It is just not where employer coverage goes. I would be horrified and dumbstruck if most medicaid spending didnt tip toward this population. These are the populations who really need a lot of health care. Most medicaid beneficiaries are healthy workingage adults, or relatively healthy, and children, of course, who we hope are healthy. And so like with any insurance, its normal to think that medicaid is going to skew in its spending toward highcost, highneed people. Thats the Way Insurance of any type works. In terms of federal funding limits, obviously as Congress Goes back to and thinks about introducing limits on funding, these will be the crucial questions, which is to make sure that funding limits dont spill over on to the costliest populations. For example, you know, a per capita cap is population sensitive, but badly structured it could also intennivize states to eliminate potentially a lot of optional eligibility groups that have their eligibility based on disability. But to the extent that per capita spending falls behind where it needs to be, a state may feel that it is just carrying too much financial exposure to maintain optional coverage for Longterm Services and support populations. So this is a crucial issue for the disability community. A block grant, of course, is even more problematic, or at least, you know, has problematic implications because of the concern on the part of states that if theyre too overload odd, as they would see it, with people who have very, very highcost needs, their own financial exposure is huge. And this is obviously in a country where such an emphasis is now placed on high value on large and insuring the best quality of life regardless of severe disability. This is probably the number one issue we have to grapple with in medicaid. Some of the legislation has talked about having carveout or different growth rates allowed for the aging disabled versus the nonaged disabled populations that are on medicaid and obviously its not a trivial issue, but recognizing that this is a different population with different needs. So i dont know. Well have to see what if theres the next round what it looks like in terms of that level of detail. I thought i heard you say, gail, maybe you could clarify. You said that if there were a different financing structure, that was different from the current, that we could have a more rational structure. I believe i heard you say if it comes with significant revenue cuts or if its seen as a vehicle for significant cuts in funding, that that is problematic. Can you talk about that . I mean i guess what im trying to get at is, why are per capita caps in block grants the answer, if you will, to some of the distortions you mentioned, like the higher f map for different populations and the creative financing, and so forth. And then is there a way to address those issues without significant financial cuts to the program. Let me go back to the basic point that i tried to lead off with. The two Big Questions are the starting point and the growth rates. The starting point now i think will be very difficult to step back very far from where we are. Maybe some for the expanded population, but most of the bills that weve been talking about outside of the major aca legislation, if you look at what the governors have talked about, you look at cassidy, collins, assume the start keeps most of the new money in and the big question and i think it is going to be hard for many members of congress to try to claw back a lot of that expansion money. We saw a lot of the pushback that was coming on. The question is how do you try to balance the states that have expanded from those that dont in terms of coming out with an acceptable starting point for the per capita block grant. And then how do you try to allow it to grow. The issue as to how you want to look at the distribution between what the state had been doing in setting up the block grant the initial starting point is one where you can take a count, if you want, of various base income levels in the state. Its a very serious point about where you start. It is understanding that, once you do that, it becomes where is the growth rate. Of course the reason that the per capita part, to my mind, is so critical, as opposed to just a fixed block grant, is the state would be completely at risk for any kind of economic downturns or any kind of changes that affected the number of people who you would expect would be using this program. So i gather there seem to be some states that make noise like they just want the option to have a full block grant, but i dont understand why they would. That would seem to be a level of risk that no governor should want to take if they understand what it means in terms of Going Forward in a recession or following a major epidemic or something that would clearly impact the relative population. We talk about accountability for just a second. Then well get to the question at the mike. We have a couple questions on this. So this notion of flexibility and accountability. What should what are states accountable right now under the Medicaid Program and what, if anything, should they be more accountable for . Well, its why when ive talked about not just dismissing a per capita block grant in medicaid as without any merit, which i think is just not correct, i would, in exchange for the substantial increase in flexibility that that provides, put on, not an unreasonable number, but some five, six, seven outcome metrics that states would have to report on. The reason this has bothered me greatly for a long time is besides other foundations sponsor, there is precious Little Information about what actually happens to the Health Outcomes of the population that is covered by the program. And for me, the quid pro quo would be substantially greater flexibility, substantially fewer occasions of mother, may i kind of requirements coming in for waiver requests, and in exchange, some credible metrics about what happens to the population thats affected. Yeah. If i could just add, i have to say from my perspective, i think actually states are accountable at this point for an extraordinary dw really an extraordinary thing. In some ways the move to manage care has driven this point home. Which is, at one point when i first began to work in medicaid, states were accountable for determining eligibility, and giving a card to an eligible person if the person qualified, and obviously claims payment. So sort of a Third Party Claims payment structure. Today, much because of their own choices, they sought this power and they have the power now, and they are using this power tremendously. States actually have taken unto themselves the responsibility of making sure poor people get health care and medically poor people get health care. Do we have the way to know whether theyre getting the kind of value both in terms of Health Outcome and terms of costs, terms of quality out of the arrangements theyve developed that we would like . No. Its not this is not my area of expertise and my breath is constantly taken away when im sitting with people who do this kind of work, just how complicated it is to come up with these kinds of measures. Then the data systems to collect the information that would tell you what performance looks like. But i think that what we havent embraced enough, at least here in washington, is the tremendous responsibility that states have taken on that looks nothing like responsibility looked 30 years ago. And the question always to me is less whether the responsibility is enough and more whether they need tools that they dont have at the moment to do a better job. The ability, flexibility to use medicaid financing to do certain things that are slightly off the beaten path for a commercial insurance plan. Frankly, i dont see the value in giving states more flexibility to take people off the Medicaid Program. My tendency would be to think hard about where they need flexibility in order to be more effective and efficient in the delivery of health care itself. Thanks. We saw i just want to just point out, in sara collins slides, we saw that in the states that did expand medicaid there were improvements in access to care and improvements in sort of measures of financial risk for the individuals. So im wondering if, sarah, if youd like to comment or any of the other panelists would like to comment on again, now we are back to talking about the expansion population. But what more is needed to help to get those numbers even better in terms of access to care, and then Health Outcomes . And i want to link that, too, to something that really struck me in the state scorecard, which was that the state scorecard found that Life Expectancy or measure of premature death had increased in twothirds of the states. And weve all kind of heard this. So i mean were dealing with a Population Health crisis, it seems to me. How is this linked to the Medicaid Program and what tools do states need to make that link between having a medicaid card and improving access and improving outcomes . Just a couple comments on ben somers work in arkansas, kentucky and texas. He will look at a large number of access measures. Costrelated problems getting health care, medical bill proble problems, and one striking outcome on aabiliffordability i of outofpocket decline. So major changes that stem from the protections in the Medicaid Program that are actually very different from people who are buying coverage through the marketplaces in states that havent expanded medicaid, particularly on outofpocket cost side, on the premium spending side. The other areas that are really important to look at in the work that hes done is the access to care among people with Chronic Health conditions, the testing of glucose testing for people with diabetes, and really importantly the changes that he is finding in these states three years out on selfreported Health Status. So a significant decline in reports of being in fair or poor health in arkansas and kentucky relative to texas. Now this is a selfreported Health Status is selfreported Health Status, but as actually studies have found, highly indicative of mortality in someones life. So impending mortality. So these are not to be dismissed as measures that are not measures of Health Status. In trying to hold medicaid to a higher standard than we even hold private Insurance Coverage to improvements in Health Status. Everyone goes back to the oregon study which of the medicaid population, which was basically a randomized ended up being a randomized study of enrollment in medicaid and what effects it has on peoples access to care but also some small some measures of Health Status as well. And not finding significant improvements in Health Status in that population. I think what one has to keep in mind when we are thinking about measures is to allow for a significant amount of time to go by before we can see actual impacts on Health Status. Ill give you one quick example of the study done of Medicare Beneficiaries who had been uninsured for most of their 50s and enrolling in medicare at 65. And what their experience was after that. But there was a huge increase in utilization among this population once they got access to medicare. And it took a good seven years for that trend to flatten out so it equalled utilization among people who were in already enrolled in medicare. And the people that benefited the most from that from getting coverage at 65 in medicare after having been uninsured were people with serious Health Problems, like heart disease. That changed but it took several years for those to change. So i think the caution in trying to look at Health Outcome measures in medicaid is not to hold it to a much higher standard than we do other forms of Insurance Coverage and these access measures we are seeing early evidence of really point to possible improvements in Health Status down the road. Id comment. I just think it is important for people not to claim more than in fact we know. The oregon study was, to me, somewhat disappointing that even in areas where you thought in the shortterm you would see some impact like the Hemoglobin Testing or high blood pressure, the hypertension measurements. Its not obvious you would see some impact in those areas. I dont have any problem with people saying we think it will take longer. But it would be much better to say that data eventually will shed some light because it at least has two years of coverage between the two samples and a lot more information about whats actually used. But we shouldnt make claims on the other side about what its done. What we can see, which is hardly surprising given how much money gets spent, is that people have an ability to access in a way they didnt and their outofpocket expenditures would be less. It would be like, well, i should hope so. But will we see something on the effects on the Health Outcomes . It will take more time. And dont make other claims which easily get made. I mean thats not unreasonable. It just needs to be if thats the position people want to take, it just ought to be sold as that and not something else. I think also just to i completely agree. And i think also just thinking about what these measures might look like on Health Status. And is it a onetime decline or onetime drop in an outcome measure, or is it a flattening out of trend. So its just its a tricky area to do analyses of the outcomes of Insurance Programs and i think the thinking about what is a reasonable measure will take a lot of effort. Thank you. We have folks waiting at the mike very patiently. Go ahead and ask your question. Thanks, sarah. Mike miller. I want to go back and drill down a little bit more within the essential providers, talk about rural homts specifically. I know thats something a lot of members are very concerned about. If you and the others could talk about sort of the Current Situation for rural hospitals. My experience going back in some states last few years, theres been an attrition where rural hospitals are slowly being forced to close or convert to noninpatient facilities. Whats the trend line projected given the current status quo with everything going on, and how are the different options for medicaid could impact in either continuing to enable the rural hospitals to survive or possibly the opposite. Thank you. Thank you. Yeah, i think this issue of you know, access to care in Rural America goes through the sort of wafting and waning periods of time. Certainly a small part of the population lives in rural areas, but they are very important part of the population and they right now, a lot of the kinds of Health Trends were seeing in the data that sara collins alluded to are data that i mean you cant watch television now for five minutes without seeing reports about the declining Life Opportunities and life itself for people in poor, rural areas. It is in these areas, whether it is a hospital or a community clinic, that the loss of any capacity is critical. Of course, it has been a factor in the Medicaid Expansion discussion now for years. In kansas where, ever course, as sara collins mentioned, both houses of the legislature voted to expand whether they will override the governors veto is not yet known. But driving that decision was the crucial role that medicaid plays in essentially the health care ecosystem, and it is why i feel so strongly that to understand medicaid simply as the public equivalent of what say employmentbased coverage does for those of us presumably in this room is not to understand the Medicaid Program because of the concentrated nature of poverty in the United States. Here in washington where theres of course, relatively speaking, a high degree of affluence, we see the effects of concentrated affluence in health care and good coverage and good purchasing power because we have so many parts of the city with generous levels of health care. That comes from creating the economic circumstances that allow good Health Care Systems to flourish. If you go to the poorest communities in the city, of course you see the opposite, and thats equally true if you go to poor rural communities. And so getting to a point where people appreciate how Sensitive Health care itself is to medicaid policy i think is maybe the highest challenge we have. I was saying before to sara collins that we had done a study which ended up not coming out because of the demise of the American Health care act. But we were about to release a study that showed that, had the medicaid reductions of the level anticipated gone through, in combination with the reductions in Subsidized Health care for people who were in the marketplace, along with an anticipated loss potentially of grant funding, 1 in 4 Community Health centers in the country was reporting to us a reduction of 5,000 patients or more. And it was all over the country, but it was actually, of course, the Health Centers in the states that had expanded medicaid where they had been built up in both urban and rural areas. Just unconscionable loss of primary care capacity. And thats really medicaid talking at this point. And of course it comes from medicaid as an insurer, but it also comes from this phenomenon of medicaid as a source of financing to stabilize health care. The politics of trying to come up with a rational resolution of the issues for rural health are have been quite extraordinary during our political past. One of what i had thought was a very Promising Program started in the 1990s called the each impeach program, of Central Health facilities, and was an attempt to allow communities that couldnt afford their fullfledged hospital in that area to become something that they could support which was a Small Holding center that would keep people temporarily either before they would get moved out to a Rural Referral Center or they could go home. But it was a very limited number of beds and a very limited time they were supposed to hold them, which seemed like a really good transition type of structure. But then politics entered in and everybody wanted one of these and they wanted to continue crease the number of beds they could have, and they wanted to increase the amount of time they could keep them. And basically what had started as a really thoughtful way to try to make a conversion in the shortterm holding, and then move them out to someplace where youd actually prefer that they get care that had any sophistication at complication attached to them. Similar kinds of events where if you make it the differential payment very attractive, you just see a bulldozer coming through to expand who can qualify for essential hospital status. It doesnt matter whether theres one that you can practically spit at nearby, somehow those tend to get swept in. So i mean it is a problem that thoughtful Decision Making ought to be able to help resolve, particularly in an age where you have so many ways to communicate in the kind of capacity telehealth could provide to people who are in very limited facility areas, or whether they have more critical needs to move them out to a place that is like a Rural Referral Center rather than where they are. But the ability to actually keep it focused and not just blow a hole so other groups that want the additional money that is usually attached stay out has eluded my observations of being able to happen. But i dont question the problems that youve described in some of the smallest and especially small, poor areas. Thank you. So we are nearing the end of the briefing. And before i turn to the panelists for one last question, let me just remind you all, have you a little evaluation form in your packet, if you could fill that out before you leave, that would be fantastic. We really do want to hear your ideas for future topics that we should be focused on. So let me just ask each of our panelists to comment on perhaps a slightly provocative question, but just to end it on a broader note. So, you know, if you were talking to somebody right now whos a beneficiary of the Medicaid Program, should they be optimistic Going Forward . What should we tell them about the future of the program as it currently stands with what we know right now . And what should they be looking to elected officials to do . Well, i actually have gotten this question. I do some volunteer work in my community with families who need the program, use the program, use subsidized insurance. Of course i live in virginia, so i am sorry to say that i really havent dealt with many adults who need program or use the program. Typically what im having to do is tell people they dont qualify for the program. But their children do. And i will tell you that the panic level was very high over the past month. It is really hard for those of us in this room i think to fully appreciate unless in fact you have had, whether its through patients or clients or volunteer work or a family member, or whatever its hard to overstate how important the program is to people, and to the Community Providers that serve people. And what i found myself saying to people was, i dont think it will come to this. I dont think it will come to this. That is why i said that i felt that the biggest problem the Program Faces today its always been a problem with medicaid, but it is particularly acute now is the gulf between what this Program Means to people and the Health Care Delivery system, and what the political discussion looks like around the program. And its why i continue to think that along with gail, with whom ive worked for over 30 years on this program, that the answer to medicaids future lies in sort of careful thinking through what you want this program to achieve, what tools we need to achieve it and how to manage its costs. And those are the same questions we would ask about any insurance. The expansion of medicaid has played such a major role in expanding coverage to the previously uninsured, i find it hard to imagine in a political context, in a political environment, having that ripped away. But of course, it is easy for me to say that. My Health Care Access isnt dependent on that. But we saw the kind of pushback from governors that expanded, from republicans who were concerned about what this would mean, that along with the strong pressure from democrats on the issue seems very unlikely to occur. One of the very fortunate outcomes with the election is that we are closer to our usual position in the sense of having, especially in the senate, a very closely divided senate. That puts a brake on having ideas that arent fully thought through with their implications, able to go very far or do very much. They either have to satisfy the budget reconciliation rules which are quite stringent, or they need bipartisan support which is critical to not have a redo of what weve seen with the Affordable Care act. It was truly astounding to me to look at what had been contemplated and hoped for, which is after six years of trashing the Affordable Care act at every possible moment, republicans looked like they wanted to recreate a similar political dynamic on their side. Its like have su learned nothing about what it takes for stable legislation . I think that there are sufficient impacts that it will put a break ake on doing bad th. I think one of the most interesting aspects weve been through over the last couple months is the focus on beneficiaries in medicaid, who have enrolled in Medicaid Expansion, and just hearing how much the this coverage has meant to them. I know from our survey data, we have been hearing high rates of satisfaction with medicaid among people who are enrolled who got coverage through the Medicaid Expansion. 90 of people with medicaid coverage are somewhat or very satisfied. And when you compare it to private coverage, people who got plans through the marketplaces, more than half of medicaid beneficiaries rate it as say that theyre extremely very satisfied with their coverage. Thats a much higher number that you see in the marketplace plans. The other striking finding in the survey data that we continue to see for weve seen for the last three years are people telling us who have medicaid coverage that they who have used their care, 70 saying they wouldnt have been able to get this care prior to enrolling in their plans. So i think that this these numbers have been known for a while, but i think the debate over the American Health care act really brought those voices in to the open. And maybe people not even realizing that they had medicaid, that they had this new expanded coverage and not totally not maybe not linking it to what it actually was. So i think just from policymakers perspective, i think that the voices were heard pretty loudly in this debate. I think it did have an effect on what the ultimate outcome was, and i think Going Forward that people who are enrolled in medicaid are people that policymakers ought to be speaking to. Well, please join me in thanking our panel lists for a great discussion. [ applause ] thanks again to the Commonwealth Fund and please fill out your evaluations on the way out