Transcripts For CSPAN3 Health Insurance Outlook Part 2 20170420

Were going to talk about the considerations and possible implications moving forward. So we are lucky to have with us today three exceptional panelists, youll notice there is one empty seat and that belongs to trish riley. Unfortunately because of the crazy weather we had d. C. Trishas not going to be able to get into town. So she will not be with us. Fear not, our three other panelists here watch whats happening in the states very closely and will be able to give us a full picture of whats happening. So first to my left, we have diane roland, executive Vice President of the Kaiser Family foundation. Diane was also the inaugural chair of mac pac which advised congress on medicaid policy. To her left is josh archambault. He spent time here in d. C. With the heritage foundation. Hes up in massachusetts where he also worked for former governor mitt romney. And at the end of the panel, we have judith solomon, judy is Vice President for Health Policy at the center for budget and policy priorities. I wont go into further detail. You have their full bioes in your packet. Id like to ask diane if you would please help everyone in the room to understand whats our starting point here . What happened with that was created by the aca and just where are we . What is our starting point . We spent much of the last few years talking about medicaid in a very narrow way. Weve been talking primarily because of the Affordable Care act about medicaids role as an Expansion Program to cover additional adults who are very low income, but who didnt previously qualify for the program. And i think to remind you that goes back to the history of medicaid, enacted in 1965 as the program that was intended to provide coverage at that time, to the welfare population. Its expanded tremendously. In that era, the deserving poor were considered the aged, blind and disabled, children and adults with dependent children. Initially just single adults with dependent children. And as weve seen over time, weve expanded the role of medicaid to be more of an insurer for many children, help with Long Term Service and supports for the elderly and disabled as well as children with special health needs. States were unable to obtain the federal matching funds if they wanted to afford coverage to adults without dependent children because they were not one of the categories of medicaid. And what the Affordable Care act did was to say eligibility should no longer be based on whether or not you fit a category, but instead should be based on whether or not you are truly low income. And defined that as 138 of the federal Poverty Level, about 23,000 for a family of three. The big change in the Affordable Care act was to really reframe medicaid as a program for low income individuals that would provide Health Insurance and healthcare. They intended to build on the mandate that was already in place in the medicaid statute of covering all children up to 100 of poverty and for younger children, 138. By extending that to adults, which would have raised eligibility for the parents of many of the children who were well below the Poverty Level in terms of their state coverage and also to try and provide for National Standard of how many low income people would be covered. When the Supreme Court weighed in, it weighed in to say that should be for adult coverage, state option, rather than a requirement. Even though initially the federal funding was 100 . So i think much of the discussion has been which states are going to expand, which states did expand. What was the impact. What kind of individuals were covered by this expansion. We know that in the 32 states it expanded, 11 million individuals became newly eligible for coverage. When we look at where the debate is going today, its not just stopping at what should we do about the expansion population. But instead in the gop house bill that we just saw brought to the committees and then possibly someday to the floor, its now taking on the entire Medicaid Program. And i want to remind everyone here that medicaid is a far Bigger Program than the expansion. It is our largest Health Insurance program that takes care of some 74 million americans. Including many of the 20 who are Medicare Beneficiaries who need medicaid to help supplement medicare as well as to provide for Long Term Services and supports. It takes care of many of the Mental Health and other challenges. Its been one of the front line programs today on the opioid addiction program. Its been structured over time to provide states with the ability to draw down federal matching funds to cover the population that they are covering. As long as they abide by some basic federal rules about who they can cover, what they can cover. But a lot of built in Optional Services and optional coverage. So the proposals to change that open ended federal financing to some sort of a percapita cap have been introduced over time. The federal government seems periodically to give the states more flexibility in return for being able to limit the federal governments commitment to the program. That was part of the debate going around the gop house proposals. We have two issues here, really what happens to the expansion in the expansion population and what happens to the broader Medicaid Program and its role as our state Health Safety net. Lets take that one at a time, those two pieces. One is the broader conversation of do we move to a per capita grant, what do we do in the long term, if anything. Lets talk about the more immediate question. Without that broader conversation, we are here and now, looking at some states thinking about waivers, some states deciding now whether or not they are going to join the expansion. And so id like to ask all of our panelists, where are we now and what are we likely to see happen . Why dont we start with josh on that one and then others can weigh in. Sure, so thank you so much for having me this morning. So first, i would say with a new administration, its from a state perspective, its a whole new world when it comes to what they can ask for flexibility for. So we have been involved in a number of conversations and heard from a number of governor and medicaid offices theyre thinking very differently than they have in the past about what theyre going to ask for for flexibility from the federal government. Thats certainly we can unpack that a little bit as we go. There is a big discussion about plan designs and what kind of how you set up these programs outside of the financing. The second question on medicaid expansion, you know, we have seen already a couple states look at expanding, kansas being the most recent one. Thats a multiyear campaign by hospitals and insurers in the state to fund candidates who are more sympathetic to that. That should not be viewed in isolation. What i think ultimately comes down to is if the house bill moves. If the house bill moves as it is currently structured and the senate makes tweaks but largely stays the same, i actually dont first of all, the first managers amendment restricted new states from expanding. That would end that conversation if it became law. Then we move to that bigger question about financing. So the expansion debate i think is active in a couple states at the moment. Not as active in others. Theyre waiting to see will the house bill move as its currently conceived or how much will that change. Sure. Thanks for having me. So i would love to step back a little bit on waivers i think you know, we go full steam into that conversation without really thinking about what they are and what theyre supposed to do in the Medicaid Program. If we think about medicaid, it has numerous options that dont require waiver. Its a very flexible program. And waivers are really on top of that to give additional things states can do. What they really are is saying, you know, we have a medicaid statute that was passed by congress and amended over the years. And in some cases, if a state wants to try something and wants to try something that is going to pursue the objectives of the statute, which is essentially to provide healthcare to low income and Vulnerable People in this country, then well let you try that and well let you try it for a limited period of time. And well look at it and well test it. And so if we start there, then i think its a good framework for thinking about some of the things that are coming up as josh said. A lot of new things are coming up. Things that have never been allowed and things that have never been tried. And among those things are work requirements and we can get into sort of the details of why we believe very strongly that these are a bad idea for medicaid. And the rejection of them in the past has been right. Theres really no evidence based. But things like premiums, where the medicaid statute says we have a low income people were covering here. They cant afford to pay premiums. So you shouldnt charge them premiums. So giving a waiver when we know and weve tried this in other situations and weve actually seen that waivers keep people from participating in the program. So if you go back to really the beginning and when the aca was passed as diane described, why we had the expansion, it was to have a continuum of Health Options for, you know, low income people. Particularly working people in jobs that didnt provide healthcare. To say now were going to do something that we know will decrease participation, i think is not really consistent with the purposes of the waivers. And i think its just really always important to think about these as demonstration projects and that they are supposed to pursue the objectives of the program. You know, i think its really interesting that sometimes waivers precede legislation. Thats certainly the case with the Affordable Care act expansion. Because prior to that 11 states had come in for waivers saying cant we cover these adults without dependent children, many of them have a lot of disabilities but they dont yet meet the disability threshold. It was a series of demonstrations that led to the argument that maybe extending coverage through the legislation would be possible. And i think that is generally one of the purposes of the waivers, both to see if states can test new methods, but to see if those new methods are things that ought to be made available more broadly maybe through legislative change or at least through broader adoption by the states. Family planning waivers are even a good example of that where states were allowed to provide Family Planning services to adults that werent otherwise eligible for the program and that was shown to prevent pregnancies that were not desired at the time and also now is in the statute. So thats the kind of approaches you know, that requires rigorous evaluation. Perhaps i could offer a slightly different perspective here on waivers. In our experience, regardless of the political stripes of a state, you can find a blue state medicaid director that will gripe at least privately about the whole waiver process for a variety of reasons. And it is important to realize that there are a couple different ways states can get flexibility whether its a state plan amendment and rules around that or the 1115 waiver process. Usually is the bigger medicaid waivers. But what is not told about the flexibility is usually it takes well the average is well over a year for approval for those sorts of waivers. So if im a medicaid director and at the state level and i have to balance my budget every year, unlike congress, i know, but at the state level i have to balance my budget. It takes me a year to get a yes or no on whether i can do something dramatically different, thats not flexibility. And from their standpoint. The otherwise thing i have to go to d. C. To ask if i can do something yes or no. When im partially funding the program. But not fully. It depends on the state. This is a state federal partnership. I want to reflect theres a lot of frustration at the state level with how this process has play immediate out over the years and the fact they simply have to come. And you have states why probably more republican governors are interested, look, let me wash my hands of this whole process. Let me determine how i want to do it. If it means i have to put more state dollars on the table ill consider it. I can design the program i want to design and cover the populations i want to cover. I know theres a big federalism discussion here happening and were bouncing around funding piece of this. That largely drives this conversation. But i do want it to be heard that a lot of people in the state level dont think its actually that flexible a process. Even though they can ask for a lot. It takes long time. The waiver process is different from the process for asking not even asking for indicating which options you want to adopt in the Medicaid Program. Theres multiple options in terms of the benefits that are provided. What kind of how you want to design your Delivery Systems. When were talking about waivers that take time and have to be requested its because youre asking to change the law essentially. Youre asking for permission to do something that is different than what the law allows. And it would be pretty untoward if we were going to say that states could just do that and not have to come to washington or write to washington and just do it. We want to protect the people that are the intended beneficiaries of these programs. And these are really important protections around premiums, cost sharing, continuous coverage. All of that. Who is covered, how long theyre covered. I dont think anyone should apologize for the fact that permission needs to be requested. So lets take a half step back now and talk about flexibility and how much flexibility already exists, what can states do currently. Lets start there. How flexible is the program to begin with at the base line . One of the most flexible areas of the program is really what can be done for home and Community Based service and for a lot of the services to the elderly and the disables. There you can get special sometimes its a waiver, its not a 1115 to be able to cover children with special needs for whom private insurance is not sufficient to help cover those children. A lot of states have liked to use waivers in that case because they can limit the population, they can have slots for home and Community Based services and not have to open it state wide. So thats i think an area that its very important to really only requirements for the elderly and the disabled for benefits are more nursing home care and states have really broadly used their authority for Optional Service and for some waivers to expand what they can do around keeping people in the community, rebalancing Long Term Services. Give us an idea of how widely waivers are currently used if im not mistaken every state has them. Every state has multiple waiver. Certainly for the home and Community Based services, multiple waivers targeted at different populations, the reason those are waivers is because basically as diane said, nursing home care is a required service in medicaid. Providing services in the home, which is more advantageous, more desired by people and now is more than half of Long Term Services and support is basically optional. And what the waivers do is allow states to design packages of services that are specifically targeted to the population. So they may have, you know, waivers for people with intellectual disabilities, seniors, children with special needs, different packages of services. Some of the things that are not normally covered by medicaid, such as respite care. Theres a lot of flexibility there. Theres a lot of flexibility in how you provide services, whether its managed care, different forms of managed care. Were now seeing things like Accountable Care organizations. Similar to what medicare is doing. Last years, and a lot of that has been, you know, facilitated by the states being able to get some upfront federal dollars to allow them to improve their Delivery System, set up better means of coordinating across providers, integration of behavioral and Mental Health services. All of that including delivery for people with Substance Abuse disorders. Thought is what would be add risk if the federal matching system is changed to a capped funding stream. Wed be down to paying for doctors and hospitals. So josh, what is it that some republican governors are looking for to do with waivers moving forward now . Yeah, so i think this gets at a bigger issue about medicaid. Is it Health Insurance or is it a Welfare Program . And depending on how you answer that question is how you think about how you design it. And so you have a lot of republican governors, in particularly, you have some democrats, governor in West Virginia comes to mind, where they look at it a little bit more like a welfare entitlement program. If youre going to follow that logic, work requirements, time limits become things you want to look at for some populations on medicaid. I think theres a decent amount of research on other Welfare Programs showing for certain populations its beneficial. Food stamps for example. Weve done Great Research on that. If you view it more like Health Insurance youll want it to look a little bit more like Health Insurance. The discussion about plan design. Deductibles. Premiums. Copays. That when you show up at the emergency room and its not an emergency, you have some financial skin in the game. And then when it comes to the actual benefits that are mandated. There are a lot of states to give one microsystem, nonemergency transport. Tremendously expensive. Nonemergency medical transport. Do states have flexible in how they set that up . Could they work with uber or lyft. For certain things you live near a bus route, take the bus, take the subway. Theres not a lot of flexibility in how States Imagine around those. The authority is quite wide. But for the Obama Administration in particular and really the bigger problem, its what the interpretation. I think republican governors are thinking wide answer broader than they have in the past. Theyre seeing a political window to ask for things. The cms folks there now have been welcoming that. Theyve sent out letters saying wed like flexibility. Come to us with your ideas. Well have to wait and see how flexible they are and whether they have stipulations. I should mention waivers are temporary, perhaps some see that as a good thing. But perhaps others see it as a bad thing. Political winds change in d. C. And so oh, i object to that for ideological reasons, take it off you dont get it anymore in your next waiver request. If its proven to work we would want it to continue not be ideologically driven. Thoughts what were hearing in state capitols. Youve started to see kentucky has a waiver in that involves work requirements for their expansion population. Arizona is about to put in one. Has time limits and work requirements. Maine and kansas are working on waiver requests that will come in with a bunch of different new things. I think very shortly well start to see those details fleshed out in actual waiver requests. Those are all of that very narrow part of the role medicaid plays. Thats about adults, not about children. And its not about the aged, blind, and disabled who really are where the bulk of the dollars of medicaid are spent. Where i think most of the innovation needs to be how to better deliver services to those high need populations. Rather than trying to focus on looking at this narrow slice and saying this is what the whole program is about o. And certainly the issues we were raising around home and Community Based service and all of those kinds of innovations are ones we want and we see that im going to channel trish who is not here. We see a lot of innovation going on in the payment and delivery and organization of care. And i think everyones always poised that the states are backward because they dont have enough doctors seeing patients. Yet weve seen them move tremendously into managed care, into better managed care trying to do better coordination across the board. I think thats where the promising future of medicaid is. You know, we can look at who could work and isnt working when we tried to look at the expansion population. The majority of them were working, they were just working in such low wage jobs they didnt have Health Insurance or they were ill and couldnt work. I think we really need to look more at how broadly if work requirements are put into effect how broadly would they apply to that Huge Population that now depends on medicaid. How much money would we spend administering that . Even if we leave aside our ideological difference here, i think we should be able to agree that spending huge amounts of money, the kentucky waivers a great example, for three months you dont have a work requirement. And then at three months you have to work i think its, you know, five hours a week or three hours a week. And it keeps going up each month. And certain kinds of activities count and certain kinds dont. And thats going to have to be monitored. Thats going to have to be sort of interacting with people, why didnt you work, was it because of childcare. All of that, not really good use of funds. Same thing for a lot of these very complicated systems of accounts. You know, they say theyre hsas but theyre not because the Government Funds them. And you know, and then theyre supposed to be incentives if you can roll over part of the money. But what we see clearly in several states that have used these is that theyre not understood. So if you dont understand you have this account, and you can use some of the money later for something else, its not an incentive to do anything. Because it really is hard to explain to people exactly how these things work. Theyre extremely complicated. Yet we have vendor contracts, big vendor contracts, administering these accounts and making sure that people are not being charged more than the law requires. Monitoring whether theyre making the payments. So, i mean, it really is sort of narrowly focusing on a small part of the population for purposes that are not consistent with what medicaid is supposed to do and taking away from the ability to innovate and spend time on improving the delivery of care and quality of outcomes. I think josh is really pointing out, though, where we do have a big philosophical debate going on, especially with the adult population. Whether this is a Welfare Program or its a health program. Many of us see medicaids roots as being based in welfare. But having evolved more and more to be the Healthcare Program for the low income population. The place where its still closer to welfare is for the aged blind and disabled. Where there is mandatory coverage of the ssi population, which does have work disincentives built into it. But i think that is the debate thats going on. What should we be doing. And i think i look at it as saying lets try to figure out in the continuum of how to give the American Population Affordable Healthcare and how does this program fit with the next layer up of tax credits or what were doing. I think thats an important part of why i see it as a healthcare debate rather than a welfare debate. But i do understand some of the concerns that have come up in the state legislatures around the countries. This is not an issue that josh has made up. Its an issue thats real for many of the governor and legislators. A couple points on work requirements. This is 80 20. 80 of the public support it for able bodied adults. Regardless of your own political feeling, theres political wind behind this. One of the questions for us to ask is, if states want to do this what is the administrative left . Many of these states have experience in tanf and s. N. A. P. Following compliance. Really the issue is, do we want folks to move off of medicaid . Is that a goal . Is that success or is it how many people are on the program is the goal . And youll get different answers in different states on that. For those that say one of the outcomes we want to track is how many people get back into the labor force. The best way to get people back in the labor force is, encourage them to work or volunteer or get education. Thats one of the lessons we have learned from welfare reform over the years. Is that folks can work their way off the program. That are able, im not saying it should apply to anybody. I dont want anybody to think im saying kids should have a work requirement. For the populations that arent in the expansion population, 60 report no income. Shouldnt we look closer . Do we want them to remain on medicaid . I dont think so. We ultimately want them on a tax credit or an employer based insurance. How do we orient our program to point in that direction for the populations that should . But your point is right. This is one subset of the medicaid population. Theres another discussion to be had, theres a lot of governor whose would be interested in trying to move pregnant or women or kids off the program. Its a little bit crazy to them that you have families on private insurance but their kids are on medicaid. Why wouldnt you have them on the same plan . So those sorts of discussions of being able to move people off or kids in particular off, even though theyre relatively cheap to cover, but at least you get a little bit more of a handle on your program. Long term care services, Nursing Home Services, this is probably when you go into a Medicaid Agency the area where they want to bang their head against the wall. There has been innovations about trying to get people out of Nursing Homes into homebased care. What is the fundamental problem . We dont have a robust market. This has become the default. You have this whole industry, many of you in the room probably know this of lawyers and other Financial Planners that basically help families take advantage of thesome system. Is that what we want, ultimately . Its costing us a fortune. What do we need to change about medicaid so we actually do have a robust Insurance Program for people who end up needing this end of life care, which is so important and so expensive, but we have to crack that nut and we havent gotten there yet. I dont hear a ton of conversation about it. And the acas attempt to a shut down right away. It was ill conceived. What else can we try . What are other alternatives . We clearly have eased into the discussion of what is the purpose of medicaid. Were looking a little longer term now. And so, josh, you raised the question of Long Term Services and supports. And thats i love to hear from one of you what some of the facts are about numbers and costs for people with ltss and clearly the Affordable Care act did pass the class act which was supposed to be a selfsustaining program. And that was eventually killed, you know, after passage because it was determined that it would not be selfsustaining. Lets talk just a little bit about some of the other purposes, whether were talking about it being insurance or, you know, Welfare Program. We have groups like the Long Term Care group. Is it a high risk pool . Is it a safety net . What about Population Health . Certainly the Long Term Care debate has gone on for as long as ive been its a long time trying to do healthcare policy. Weve had commission after commission try and figure out what an alternative is. Weve had demonstrations and investment in trying to develop the private Long Term Care market, which never really developed. Weve tried partnerships between medicaid and private Long Term Care insurance. And i think part of the problem is just that its a very hard market to create a risk pool in. And people in Public Opinion polling think that medicares going to cover those services when they need them. So theyre not exactly investing in those kinds of plans. There has been some growth over time but theyre mostly related to nursing home care, not to care in the community, which is the preferred care. And then we have in medicaid that you have to spend down to get on to the program. We do have issues over time of trying to tighten on the asset rules. But basically, as a country, we are failing in having a comprehensive Public Private partnership that provides for Long Term Services and supports. And so i think we keep ending up with medicaid as the default. But for those who need those services, its a very important default. But i personally am concerned that as we see weve been talking about the baby boomers aging forever. And now they really are. Its time to really try and say how do we provide that continuum of care so that the alzheimers population and those with really severe needs who could i think many could be maintained in the community, but people in the Community Need some support to do that. And were very Different Society now with so many people working, that theres no one at home to take care of some of the frail elders. So its a policy dilemma still to be solved in my mind. In some ways its where the biggest threat of a change in the financing structure hits. Of medicaid. For a couple reasons. First, that that baby boomer aging, if you think about how you would structure a capped funding system. And spending now is a population of seniors that tends on the younger side. So they are not if you set your cap based on young or old, 10, 15 years from now, when you have a lot more 85 and 90yearolds, it is going to fall short. The trend to providing more care in the community and this is not just for seniors. This is also very important. The role for people with disabilities, physical and intellectual. A lot of the homing Community Based services are provided. Because states dont have to provide these services, they are optional. It is only the Nursing Home Services that are optional. If you move to a capped funding system, you could see, diminishment diminution of the homing Community Based services and leading to families to have to figure out what to do. The other thing that i think that is worth mentioning, it is a little bit unrelated but that i have been struck by is the fact that we talk about that there is a coming together of these populations, that the adults and that there are a large share of caregivers of the people in homing Community Based services that are fuelly covered by medicaid. Whether it is the families that have to stay at home to take care of their loved ones or workers in home care that dont have an of of health care. So i think all of these threads if you sort of begin to look at it, it is woven together. In that New York Times article that was so great about medicare coming of age, they talk about it being part of the fabric. That is, for me, where it really is. When you put all the pieces together and see the multiple roles that it plays and how if you pull up one of those threads, you are going to have some unforeseen consequences. If i could speak from a state budget perspective, this is pacmaning state budgets, whether you expand it or not. The issue about how much money you have and how much you are spending is now hitting education, roads, public safety, because you go to a state like massachusetts where i live. It is over 40 of our state budget. Thats a ton of money. So the question then becomes, are you getting value for every dollar that youre spending . We have been talking about longterm care and services. Really important. Thats why so many people were scratching their head when the aca came out in saying, wait a second, we are struggling to afford longterm care and services. We have waiting lists in our states for disabled kids and others for homeland Community Based services and now we are going to put more towards able bodied kids with dependants. Some who have employerbased insurance. Why . Thats part of the opposition in some states that hasnt expanded. The media almost never tells that story. If you talk to state legislate terse, thats their awareness. For them, even though they only have to pay 10 of the expansion population, thats a ton of money when you have to balance your budget. They are seeing and making these tradeoffs that are heartbreaking. Schuyler in arkansas, 13yearold disabled girl, she cant speak. She is in a wheelchair on a wait list for home and communitybased services. She is number 600. After expansion, she is 700. They have to have all this money for ablebodied population. Im not saying we dont want to make sure folks get coverage, but how you do it and the value is get for every dollar you are spending should be the dollar you are spending. Giving somebody a plastic card is not accessed. We need to be a little more nuanced. Is our goal getting people on the program, off the program, getting them access or getting them an insurance card. That is ir no connection between expansion and waiting lists for home and Community Based services. You know that and i think you actually admitted it at a hearing. [ applause ] seriously. States that have the biggest waiting lists are florida and texas that havent expanded. Whether it is prioritizing buying your wait list down or more money for classroom or other public priority, there is a relationship. If they design their waivers to have a number of slots so they create the waiting list. They are put in that position to have to do it is my point. No, theyre not so lets talk. They dont have to do that. Or they have to take money from somewhere towles spend have the thats my point. Correct . 14 states have no waiting list. Ten have expanded. There really is no expansion. It was given four pea noekios in the the washington post. I think you are correct in that there are decisions states make every day about what to cover, how much to pay providers and how much to do other services. Correct. Expansion states cut provider rates. I am saying they are connected have the thats my broader point. For us to say theres no connection, you have not spoken to state buddet writers who have to make these tough decisions. Maybe you are saying the federal government should be putting more money into the program. Maybe im saying thats a policy discussion. Ultimately, i think as a country, we need to decide when we have 20 trillion of debt. How do we prior Tire Research . This isnt just me. You have harvard professors writing, every health care dollar that is not delivering value for that individual is wasted and taken from some other public priority. This isnt just me, im going around the state capitals. We have to ask a value question. I dont understand why people would object to that. It was bound to come to money. Lets talk about the tradeoffs. Right now, we are in a place we didnt have a big bill. We may in the future. Were talking about waivers and some states and some governors trying to do to achieve what theyre saying is greater flexibility and were talking about having a cms that appears to be ready to talk to these particular governors and what is the tradeoff between flexibility and potentially, josh, you had said that some of the states may be willing to take less federal money to gain the flexibility . Lets talk about that tradeoff. If we are talking about money, i think then we should look at where the money is, right . I think some of the things that are being done now have been shown and theyre being done by blue states, red states, purple states, all states and that is focusing on the people with multiple chronic conditions and theyre providing and there are renew options in the Affordable Care act to do that and weve seen things like in missouri a Home Health Program save money and have better outcomes. We dont disagree on looking for value for the dollar. I think if we decide to change the structure of medicaid an cut federal funds. I dont see how that helps the state buddet issue. I think around Better Services for people with eating disorders and beginning to think more with social determinates, and looking at justiceinvolved populations. A lot of things that can be done are in the Value Proposition and not only saving money in the Medicaid Budget but better coordinating better budgets. There is a ton that can be done without arbitrary caps on the federal funds. I think the real place where there needs to be more work done. We have an opioid epidemic. Medicaid is a place on the front lines that can help provide support for some of the counseling and treatment services. We have seen thats been an important part. Governor kasich noted in ohio that that was an important part of what he was able to do, expansion funding. So i think we really need to focus on some of the things that medicaid does that are uniquely different from what a standard private Health Insurance plan would do. That really is around looking at much of the role the program plays in Behavioral Health and in trying to see how can he can better provide those services. Because i think that has been one of the outstanding gaps in the system has worked for the poorest individuals with Behavioral Health challenges. I am going to move a slightly different direction. Lets start with getting people off the program that dont qualify. Illinois, in 2012, passed a bipartisan bill that ended up removing close to 350,000 individuals. Many of them were deceased, moved out of state or had had a job change, never reported it. The point im getting here on finances. I have no argument here. If you are not alive and eligible, you shouldnt be on it. Right. The concern is how many other states are doing this . I have known of two or three others. States dont have a reason to do it. They lose a ton of federal money if they do it. How about in this discussion about getting the incentives right, they get to keep some of that money, that, if there is some sort of cap or whatever conceived and comes from washington, they actually now have a motivation to tackle waste, fraud, and abuse. Let me tell you this is the common sense stuff. If somebody moves in a managed care roll which we pretty much are in medicaid and most states, if you are enrolled and you move across the state, you sign up for another Medicaid Program. You are now paying two managed Care Companies every month. The aca says you cant check eligibility again for 12 months from when they first reentered. Why . Were just wasting money. There is no way for a state, the federal databases that are set up for this are terrible. So were now have these situations where we are just spending money out the door. This gets at why a lot of republicans in particular are saying, change the incentives, because states will get really serious about these sorts of efforts. Illinois saved almost 400 million. Pennsylvania did this under a Previous Administration and saved 160 million in ten months. Add that up across the whole country. It doesnt solve the Financing Program but it helps. We can have conversations about where does it redirect the money. And that is why republicans are talking about putting Something Like this on the budget so states have the right incentives to tackle Something Like that. Lets turn to some of your questions. Do we have a question in the audience . Okay. We have one up here in the front. Please identify yourself. Carl pullser, Health Policy analyst. I have a client who is an assisted living provider. I have been working for her for a long time. Josh, your comment about waivers being temporary struck me since more than half of the spending for longterm care is now home based or assisted living care. Are you proposing that be made a permanent feature alongside nursing home care or should it be . The second question is broader. If we are going to have these block grants, are they going to be mandated benefits in that people are talking about the hospital care or nursing care would be mandated or would states be able to choose to keep home and Community Based and not have the nursing home as a mandated care . How flexible are they . Has it been written down . Your question is, how flexible is the 11 15 Waiver Authority when it comes to that . [ inaudible ] i think the discussion that i was hearing was actually about some carve outs. What ends up at the end of being carve out from a per capita or block grant structure makes a big difference and the growth rate of funding. The first managers amendment had an increase for certain older populations. I think the funding would slightly influence the structure of how states would set those up. My brief point about the timing is that just most waivers are 35 years and can be rescinded at any time. There are two sides to the coin. One argument is, if it is not working and the federal government should rescind it. I understand that. This is not just a federal program. So the other flip side is, if the states wants to do something for ten years or five states have already been approved for a waiver, why does it take over a year to get approval for it too . Not always but often. Should theren an ex paidated process where if it has already been approved and one evaluation has shown some sort of positive outcome, it should be almost instantly approved. Without having to go through that process. It doesnt get directly at the niche of what you are asking about. I do think it could apply to that population as well. There are examples where we know of individuals who are on the wait list for home and communitybased services. The only way they can skip up the wait list is if they were institutionalized first. That doesnt make any sense. We dont want that to happen. We need to change some rules. Communitybased services arent always cheap are. In minnesota, they switched. There were family members that were taking care of their own family members for free and now all of the sudden you are paying them. It is not a silver bullet. I think there needs to be more discussion. The republicans in general have not given be a lot of thought to longterm care services. Ill be blunt. They need to spend more time thinking about it. Maybe democratic governors havent either. But i do think there needs to be more effort and thought around that. There is so much money that is spent. We be want to make sure people are taken care of at the ends of life but how you deliver that is the real challenge. The answer is that the devil is always in the details of what can be done and not done under a block grant. They sometimes have strings. Sometimes they m. The last discussion was only applying to children and adults as opposed to the elderly and the disabled even per capita cap. What services are actually counted in the per capita cap . How do you base it and where do you go forward . Lots of questions, always. Another question . Hi. Kim zarabic with the American Academy of nursing. I wanted to raise a question with josh. Actually three things. Some comments seem to be very much for a big sound bite and it gets a great applause. Take one layer down, it is a whole other issue. For example, you were saying about children of parents who arent on insurance. Why are they on medicaid . One perfect exam is that children under 26 on parents insurance that do not have a job, that covers them with insurance. Those grandchildren, ie, the grandchild of the person providing the insurance, that grandchild has no access to insurance if it were not for medicaid. Thats one example. Another example, you pointed out that nonemergency transport. Who is to say and when what is nonemergency. Is it after the fact. Elderly person in a wheelchair with oxygen. Do they call the ambulance, do they not . Are they charged when somebody else determines it wasnt an emergency . Thats another question. The third issue you brought up was people staying home caring for people for free. Lets look at the economics there. Nobody is doing that for free. They are either giving up a job, taking lower hour force themselves, forfeiting future medicare for themselves. It is not for free. Those are all issues that have much deeper layers. Thank you for your comments. Im not trying to be glib. I dont think in this audience im saying it for applause. My broader point, can they explore things. The example of a grandparent, its a valid concern, but are there cases where it could apply and we should move the child off . Sure. Why arent we having that discussion. I dont know if we should go point by point. Im just raising the issue. Im not trying to say, lets take a broad brush approach here. I am actually articulating, lets allow for a nuance discussion and a state. Sometimes states arent allowed to have that nuance discussion to dive a little bit deeper on it. The nonmedical transport. My point when i said it was, are you near Public Transit . Are there other options . Sure, the devil is in the details on how you structure this stuff. Of course. Having that conversation about flexibility, we are saying, you have had 150 rides this year and 40 missed medical appointments. Thats a real example. So what do we do about that . How do we allow states to say, look, no. We are spending all this money. We are not getting value. You are not even showing up to the doctors appointments. I spent most of my career at the state level. I would say on just those two examples, all of that can be and is addressed. The transportation benefit for people who can use public transportation, thats what they get. They dont get a cab. In some cases we are talking about people who need to get to dialysis. It is not an emergency if we dont provide that it will become an emergency. So the devil is in the details for sure. I think for kids, medicaid provides for poor kids in particular a benefit that is really critical to their Healthy Development and we now have evidence to show as these children are now adults that it is paying off. They are paying more taxes. They are getting more education. So i think there are some sort of sound bites. I think particularly on the work, on the drug testing, all of this. I really appreciated your comments because i think they are attempting to look at people, because this is at the end of the day, there are real people here. It isnt so simple to just say, you can work and you should. If you dont, you shouldnt get your health coverage. I would just say, there have been some waivers granted, around nonemergency transportation. One of the important things about waivers to also have the evaluation of what the impact has been to make better informed choices. Maybe we will see from these demos of eliminating that, that there is a better way to do it. So lets learn from experimentation and not just try and make decisions without some of the facts. I guess as a researcher, i believe facts do sometimes matter. We have one more question up here. Lets go ahead and take that. Then, well think about transitioning to our next panel. Thank you. David shulke with Health Quality strategies. There has been a lot of growth in managed medicaid Longterm Services and support contractors taking on the burdens of these contracts and they have had a lot of flexibility to reallocate the money and meet social determinates and move people out of institutions and do unusual things that states have not been able to do in the past to keep people out of institutional services. What do we know about the impact of these contracting arrangements and these care arrangements on quality and access where they have been implemented . I think we are still learning and evaluating. Those are some of the waivers that the state found to be the most difficult to negotiate because they had to negotiate medicaid and medicare together, which is always a challenge for the eligible population. I think in some places they have seen that the savings are not there, that there is a lot of need that gets met. But i think we are still looking at really the impact on that population. As judy said, that is the high need chronically ill population that Needs Services but we want to get the best value for those services and also make sure they are being effectively integrated so we are not paying for duplication. Okay. So we are going to im going to ask the next panel to start working their way up here. While i ask our panelists one final question. What is the one thing you will be watching from the administration, whether you think it is a great move or a horrible move . What is the one thing the administration could potentially do that would trouble you or you would applaud . I will be watching the type of waivers that will be approved around and the details and the evaluation plans and really trying to just see what develops and try to really make the case that these are, whether or not they are evidencebased. It is all about the waivers, i think. I generally agree with that. One of the things, in in particular, do they allow grandfathering. Do they allow waivers where you hold one population harmless and a new regime to come on. I think about pension reform, often where we think this through. Do they allow that in medicaid and how quickly in waivers . I will be watching to see what happens with the chip reauthorization and how children are addressed in the coming months since we know chip expires in september. There needs to be some action sooner rather than later. Also, watching specially what happened to the role of medicaid for people with disabilities and the disability population. I think there is a lot of great need to provide services in a more Cost Effective way and to meet the needs of that population. I know there are others who are even challenging what defines someone as disabled. There may be an ongoing discussion of the disability programs more broadly and how that will affect their health care. Thank you. Ladies and gentlemen, please join me in thanking our panel for a very rich discussion. Now, we will turn the mike over to noah levy with the l. A. Times and he will introduce our next panel. Come on up, folks. Before we head to this panel, i want to let you know, if you do need to leave us before the end of the program, please fill out the blue evaluation program. It really helps us to understand what you would like to see and to hear from us. We really do take that into consideration. I am going to turn it over to noah to hear from our next panel, the doctors, the insurance groups to get all the information and what they are thinking. Thank you, marilyn and thank you all for sticking with us. Before you rush for the exits, i know we are standing between you and lunch. I will make one plea that you stick around. We are very lucky to have four people on the front lines of whats happening in the American Health care system. I probably dont need to remind this audience. Thats a perspective that is oddly missing in a lot of the Health Care Debate we have. In this town. We only have half an hour. We are going to be lightning fast. Hopefully, provocative. Let me introduce our four speakers. I guess working this way. Michael aubin is president of wilson Childrens Hospital in jacksonville, florida, part of the multihospital Baptist Health system. Kirstin sloan is vicepresident for policy at the American Cancer Societys Cancer Action Network where she leads a team of seven focused on access to care, emerging science and prevention. Keisha davis is a family physician at okay see Health Institute a primary care practice ingation gaithersburg, maryland. Practice in gate thursday burg, maryland, she also serves as a consultant for the center of applied research advising on practice improvement and payment reform and andy chasin is policy director for blue shield of california which covers about 4 Million People in the state. Previously, andy served as Health Policy council to the Senate Public committee where he worked on the Affordable Health care act. We are in the midst of reviewing what is the fate of the Zombie Health care bill on the hill. It is obviously a very contentious debate about the current law and what the future holds. Lets go down here and talk about whats wrong with the debate we are having right now about health care . One of the observations that i was making and a lot of my colleagues was around who we werent talking about. If you think about the debate, who mentioned there were 30 million kids that are in the Medicaid Program that were going to be dramatically impacted. Half of all the nonseniors were going to be dramatically impacted by this program. They only represent about 20 of the total cost of the program. They will be squeezed out as the demand for Senior Services and other services as they take hold. They are the future of taking care of all of us. If we dont get the next batch of 50 million kids in the United States through and into health and employment, were all going to be challenged, because there is not going to be enough of them around to take care of us. Thats a great point. We have definitely left the patient out of the Health Care Debate. We havent talked about what makes health care expensive. We are talking about cutting this and that but havent gotten at the root cause of why it is so expensive, the Specialty Care and drug pricing and all of those things that really factor in to making health care expensive. Thank you for having me. I would like to say for everybody who stayed through three hours of Health Policy conversation, if they gave out a wonk badge, you are in line for that. We reduced down to 7 and thats Real Progress we need to maintain. All the political to and fro with the zombie bill, i think we are losing sight of whats important. Both sides really have talked about it. Thats cause. How do we get cost under control. For us, we like to think about cost in three buckets although trump doesnt like buckets. He likes phases. The first phase would what do we do to provide stability to the market and exchanges. For that it really is to not make things worse. It seems strange you would have to say that but in d. C. , you do. One of the key areas we need stability on is the Cost Reduction payments. You heard the other panel lists talk about that. This is a consumer benefit that helps make coverage more affordable for low income enrollees and reduces their deductible. About 60 of our enrollees receive this benefit. If you pulled that csr benefit from what it is, someone at 150 of federal poverty has a deductible of only 150 because of the csr program. If you eliminate that, their deductible goes up to 5,000. Its a 3,000 increase. So when we talk about this debate, talking about deductibles are too high, its democrat going the wrong direction by taking that program away. I would also like to make a wonky point about this. I understand there is the constitutional issues that the house is standing on in the lawsuit, which are important and they won that case. From a budget fare standpoint, this is already allocated. There is no new money that needs to be appropriated to do this. You just need to pass on the funding thats already there. If you dont, as peter lee pointed out, it costs the federal government more. It would seem as a matter of policy to really make sense to continue this. In the medium term on the exchanges, you really need to bring you need to address whats driving premiums. It does vary somewhat state by state. But nationwide, one alarming trend we have seen are thirdparty payments, particularly the american kidney fund. And what they are doing is moving people from public coverage, medicare and medicaid, into commercial coverage, because we pay higher rates. Thats good for them but bad for the Overall Health of the exchanges and describing the premiums. Thats something we really need to address. Finally, when we look at the longerterm issues, certainly our primary concern is pharmaceuticals, spending. Pharmaceutical costs are the biggest part of the health care dollar. And going up the fastest. 22 cents of every dollar when you include drugs administered by physicians, goes towards drug spending. Thats more than we spend on doctors, more than we spend on hospitals. We are working hard to bring more transparency. We agree with President Trump that we need to bring more balance to this market. I would agree with many things that my panelmates have said. What has really been missing from this debate is the fact the need for health care isnt going away. Several years ago, the American Cancer Society did a study that looked at what happens to a person who is diagnosed with cancer but doesnt have insurance. The problem is that diagnosis comes at stage 3 or 4, when your prognosis is not as good and your costs are much higher. So the fact is, there is a need for health care that isnt going anywhere. In fact, its increasing. Access is still one of the primary issues that people worry about. Predictability and affordability is another one. So lets dig down on a couple of these specifics. You talked about several specific things that blue shield needs to make the marketplace sustainable. Let me ask the three of you starting with kirsten, specifically, you are talking about ensuring Cancer Patients have access to needed treatment. Specifically, i assume you are saying, one of the things we dont want to jeopardize the coverage that exists right now. If there are specific things that need to happen to ensure that access remains, what would they be . First and foremost would be subsidies, making sure people can afford the coverage they get. A lot of times, people will choose a health plan based on the premium. Its that predictability issue. I need to know what my health care is going to cost me. The problem is, oftentimes, if you have cancer or another chronic condition, your back end costs can be really prohibitive. You have purchased a cheaper plan at the front end without thinking about what the copays or deductibles or coinsurance might be. So one, making sure there is premium subsidies. Two, making sure that other outofpocket costs are affordable. And three, that predictability issue, knowing that the package of benefits that i purchase are actually going to meet my needs. You hear the word, you have cancer. In your future is likely going to be a lot of physician visits, surgery, potentially radiation, chemotherapy, drug therapies and a lot of health care visits in the future. You want to make sure that Insurance Plan covers those services that you need so you can budget for those. Keisha, when you think about it from the primary care perspective, what are you seeing out there that bothers you the most and if you could wave a magic wand and make people up the hill here do it, what would you ask them to do . I think a lot of it has to do with access and how do we make sure that patients who have insurance are actually being able to access their doctor. And when you think about access, there are issues on the medicaid side and the private insurance side as well. Right . On the medicaid side, if you have created an Administrative Burden and pricing structures for doctors that makes them less willing to accept the program, while patients have insurance, but they cant find a doctor who is willing to treat them. You have created patient with a false sense of security in that they dont have access to medical care to obtain it. On the flip side, if you have created deductibles that are so high that patients have insurance but are afraid to use it, then they are still coming to the doctor too late. Right . The patient finds the lump but cant afford the nonscreening mammogram. Thats not covered. The screening mammogram is, but now that diagnostic one they have to pay out of pocket for until they met their deductible. They are waiting until it is worse. They are going to the emergency room and they are still not accessing care. You have created a wedge between people being able to access primary care and get the Preventative Services that would allow them to treat things earlier. Which was the point in the first place. What about from the hospital perspective . What would be your what is your big concern that you wish that they would attack . Taking off on the primary care side, we still have a sick care program. We dont really have a program that is preventionoriented. And thats our greatest challenge. We are a relatively small system, five hospitals. We see 400,000 emergency visits a year at our hospitals. 20 of them are primary care visits. People who now have insurance but cant get access to primary care, because nobody has that plan. There are just not enough primary care providers that want to take care of that. The other big component is the patients with chronic and complex conditions. They are a small subset. In kids, about 6 . In adults, 10 . The reality of that subset, for kids, it is 40 of all of the cost in the Medicaid Program. For adults, a significant amount of costs in whatever insured program that they are in. If we dont figure out how to focus on those patients in a very different, fundamental way with medical homes that manage all of their care and coordinate it, we are going to spend a lot of time trying to deal with the masses when a lot of the cost fix is really going to be here in better care. You mentioned when we talked a couple days ago that one of your frustrations was that you have so many different payers paying you in different ways and that you want to try to have a valuebased system that rewards you for doing the right thing, not just filling your hospital beds. As a longterm strategy, thats where the future ought to be. It is very hard in the current environment to do that. Talk about why that is such a problem. It is not unusual for a complex Health System like ours to have 50, 60, 70 different managed care plans and managed care models. Everyone is administered differently. In our system, about half of all of the patients are medicare patients. We have one quarter that deals with billing and contract compliance. Dealing with that half of the population. The other three quarters of our work force that deals with billing and collection and sn s insurance and compliance this is not a small number. This is 300 people in our Health System. They spend their time trying to figure out how to get us paid and get paid correctly. It is a total waste in terms of the bureaucratic overhead. That gets combined with we provide the service, but at the end of the day, we spend a lot of time arguing about getting paid for the service that was authorized. So michael, youre paying some of these bills not directly but in a manner of speaking. Andy. Andy, sorry. You are paying bills to hospitals and doctors offices. What do you make of this challenge . How could you work this out . I dont think anybody would argue it is economically efficient or leads to good patient outcomes. We have had Great Success moving to our aco program, which has resulted in Higher Quality care with lower costs. It requires a great deal of partnership between hospitals and ourselves. And a lot of transparency. So far, we have saved 440 million for our customers through our aco program. We are the first to offer an aco on the exchange. We are excited about the progress. We need to push forward from volume to value. We have our new a co2. 0 program. We are working to identify the gaps in care and investing with those providers, whether it is a piece of technology or a person in an office who can help fill those gaps of care that happens to improve the Delivery System for our competitors as well. We think thats how you move it the Delivery System forward as a whole. Keisha, from a primary care perspective . I think you much providers that are very interested in moving to more of a valuebased model an getting away from the services in the hamster wheel. For a provider trying to institute those changes is very difficult. You have providers taking multiple insurances, medicare, medicaid, aco. As youre trying to make those changes of teambased care to operate and evaluate a system the question of whether that funding is going to remain available is up in question. We talked about how it is in place. Thats great for the medicare population. What about those valuebased reimbursements we would like to move to for the rest of our patient panel. And if the conversation now is, well, that might be on hold, theres other priorities, how does a practice make that investment for all of their patients and not just for the 10 that are medicare . Does that benefit patients, moving to a system more in line with it absolutely does. In fact, one of the most important provisions of the aca was the creation of the innovation center. So we have the ability now to test new models of care that we have never been able to test before. Patient centered homes and accountability care. That you referred to. There is even an oncologybundled payment project up and running. It enables the government to bring to scale new models. I think whats really important about that is it involves all of the stakeholders. Plans and insurers and physicians and consumers and patients. In a way that everybody is coming to the table and talking about what are the most important elements of a design that enables patients to be at the center of that, and their experience to be something that guides the way that care is provided. I think its critical. So what i hear all of you saying is that we ought to be moving at double speed, away from fee for service toward a different method of payment that rewards the outcomes that we want, that makes the job of providers easier so they can align what they do. I dont hear any talk about that here in washington. Instead i hear were paying too much money now. I think all of us would agree that that underlying underlying idea is not without merit. But unable to move in that direction fast enough we seem to be doing these other things, which is shifting more costs on to patients and thats a lot of discussion we seem to be having here now. How can we move the discussion to what you are talking about and stop talking about higher deductibles or shifting costs on on to medicaid patients, all of which providers seem to agree doesnt make a lot of sense for anybody . I can tell you that mentioning the innovation center, were participating in one of those multisites with other Childrens Hospitals on around medical homes for chronic and complex kids. We are seeing dramatic improvements in the outcomes and tremendous improvements in the Cost Reduction. It is a program and model that makes sense. There is actually an act this was introduced last year at this point, it is called the ace kids act which would really create a network of major providers for pediatrics that take care of chronic, complex kids across the country. With the medical home model as foundation for that. Again, attacking the 40 cost that happens to be in the Medicaid Program and other programs, as well. Think i there is a will. As a matter of fact, the unique thing about that bill is we had bipartisan support. Almost half of it was republican, half was democratic support. We need to move those kind of ideas that are laser focused as opposed to trying to reinvent the entire system lets focus on the things we can change and manage better. Keisha . I think part of it also i dont know the politics of it but a lot of it is changing the conversation. Maybe its that we start to think about primary care differently, and maybe we start to think about how we pay for primary care and those Preventive Services differently, carving out, looking at changing costs and how thats evaluated. Otherwise we remain in the same conversation and the same hamster wheel. I think the conversation has to shift to just being about, you know, who is getting paid what. How were paying for it. And how are we having a Value Proposition that were actually thinking about how the entire country gets covered and not just how this person gets paid. Andy, you have been in these politics up on the hill. For too long. So how do we get there . I think it is a great question. I think it is important to recognize that the private market is moving forward regardless of whats happening in washington. Washington can help move it forward. Unfortunately, we need to do more of it on our own, because were stuck in this conversation we have been having, for me nine years on the hill. Since before obama came and the aca and were here again. I think you noted in your writing. I think this process of coming to terms with what the Health Care Reform and repeal does and does not mean, hopefully, it has been educational to members about what the reality is, whats the fault of the aca, whats not the fault of the aca and regardless of what happens, were still for 90 of the rest of the market, that gets their coverage in different ways, we have to move to a better system. I think keisha is absolutely right. I think it is changing the conversation. We tend to focus on the immediate and crisis of the day and what we are immediately talking about is changing the system so we are talking about longterm savings and improvements in the quality of care thats delivered. Some of the changes in delivery we are talking about now may not actually result in a lot of savings but may actually improve the quality of care and improve the lives of practitioners. Who deliver that care. I want to leave a few minutes at the end for questions from the audience. Raise your hands if you want to get in on the conversation . Maybe we have exhausted everybody. There is one up here. Hold on for the microphone. Im the policy director at the d. C. Primary care association. One of the issues for us is looking at how to utilize the Health Care System on addressing social determinants of health when we are in this environment of scarcity of resources for fundamentally health care but knowing we need to be looking at these social issues that are impacting health. I havent heard anybody really talk about what do we change that gives us the resources to address the things we know that are really impacting peoples ability to get and stay well. Thats a little bit of an unfair question it is so big. Really, open to your thinking on that. Two minutes or less. I can give a short, ontheground answer. About how some things of that have changed. So thinking about a provider that was at a Community Health center. They had what they called care coordinators and before the aca, what their job was mostly was to help the patients that didnt have insurance to find resources to get their care covered. So they would call the hospitals and they would call the specialists and see who would be able to give them a discount or a cash price or how could they work that out. Now that most of those people have been able to move to medicaid, those people are redeployed to work as coaches. Call them to see how they are doing on their tobacco. Cessation. Follow up and make sure they went for the appointments that they were supposed to go to. Sometimes it is furring people up to work within the same role of the Health Care System. The other element of it is, take asthma patients in which we have a lot of them in Childrens Hospitals. We have been able to redeploy personnel that used to take a lot of time taking care of them in their hospital to now taking care of them in their homes, getting at some of the risk factors that exist in their community that are contributing to some of their conditions. To be clear, part of your ability to do that is dependant on you being paid in a way that you can recoup some of the savings of addressing those underlying social determinants. Right . Exactly. We are having to repurpose if when you take the restrictions. Of how every patient doesnt need to see a doctor. Every patient doesnt need to see the nurse. There are lots of things, even our practices, where other personnel can do that work at a much lower cost. Freeing up funds for us to do other things. I think thats what we have been trying to do is repurpose the kind of fixed pot that we have and directing it more on the front end. Andy, as a payer, has blue shield dived into some of these social determine at as . We recently entered the medicaid business. It is really important. This is an issue that you have to confront when you are working with that population. So it is certainly something that were ma expanding and thinking about more. One issue, too, i think we need to think about is the Health Information technology and the ability to look at patients, no matter where they are getting their care, who insures them. We have invested in an effort to share with anthem a 9 million patient records working with providers so that when somebody goes to the doctor, you have a comprehensive view of that patient, who they have been seeing, what their history is. I think thats another way we need to move the Delivery System forward together. We are great fans of patient navigators. We support them and train them. In hospitals. I also think there is something very simple, which is asking patients what they need here. I know that sounds like the obvious. I think in the past, weve created a lot of programs to try and help patients with some of these social determinates of health and we have found it doesnt work because we are not getting at the right things. Building into our programs, the simple art of asking the questions to patients about what they need as part of their care or their care plan. Anybody else . I guess we are done. Nope, nope. I see a question. Under the wire. Hi, my name is julia rosi, a medical student at george washington. Rising fourth year. My question is kind of granular. I might not fully understand the specifics. As i understand it, there is a committee as part of the ama called the ruc that is responsible for determining the cmt reimbursement codes and there is not any primary care physicians on that committee. So a lot of the reimbursements for medical care are being determined primarily by specialists. Can you speak to just potential role of organized medicine to better represent primary care on that level . Keisha, do you want to take that one . Sure. I can take that a little bit. There are primary care, including Family Physicians on the ruc, the relative valuebased committee that help set the fees for everything that providers do when they do a billing code thats how they are reimbursed and paid. It is skewed towards specialists. So primary care does have a voice on the committee. It is a smaller voice relative to Everything Else when you this think about shifting costs in health care and how people are paid, thats a there is a lot that committee can do to change how people are reimbursed. I can tell you the latest survey that came out on Physician Compensation showed that really the the areas that are not growing are those in primary care. And the only one that went down, general pediatrics. Nobody gets excited about being a pediatrician when everything is down, down, down. On that happy note, thank you very much, all four of you. Great. So we would like to thank you all for being here. We know this has been a long morning. We hope you found the conversation helpful. Once again, we would like to ask that you fill out the blue evaluation forms before you leave. And a special thank you to our 25th anniversary sponsors, anthem, ascension, health is primary and also to our insurance summit sponsors, Bluecross Blueshield association, davita, acap and cvs health. Thank you so much. And as a mom whose son ran out of the pediatricians office not once, not twice, four times to avoid getting a shot, whatever they pay you, its not enough. Thank you all for being here for a long but informative morning. Thanks to our panelists. Come back on may 5th for our congressional briefing focusing on a different aspect of Health Insurance. Thanks. Coming up in about 90 minutes, federal Communications Chair ajit pai has a News Conference, appointed to the position by President Trump in january, and he previously served as fcc commissioner after the Senate Unanimously confirmed him in 2012. You can see the briefing live starting at 12 45 eastern this afternoon on cspan. And after that, President Trump will hold a joint News Conference with the italian prime minister. Theyll first meet in the oval office before heading over to the cabinet room for a bilateral meeting. 3 45 eastern, also on cspan. This weekend on American History tv georgia tech professor, the influence of early 19th century, naturalist and painter, john james audubon. And how he helped pioneer citizen science. Really admires audubons ywok and also fieldwork. He was very, very good at what he did and he did it with no binoculars, no field guides, no iphone apps, and the proof here, i think, is in the painting. And at 8 00 on lectures in history, Gettysburg College professor on abraham lincoln, his views on slavery and the u. S. Supreme court decision. What is tony saying here . There is now no restraint. Not even the restraint of popular sovereignty. On taking slaves into the territories. Sunday at 10 00 a. M. Eastern, Opening Ceremony of the museum of the American Revolution in philadelphia with speakers, former Vice President joe biden, historian and author David Mccullough, the museums president and ceo michael quinn. It is my hope that this beautiful new museum helps inspire you to become those active involved citizens in this very great country. Because history has his eyes on you. And then at 8 00, on the presidency, author kathryn sivley talks about first Lady Florence harding and the new president she created as first lady. She had been in hospitals. She had had her kidneys operated on. She had been in really dire straits medically, so she could relate to the things they were going through. Now, it was interesting, because out of this veterans cause came the veterans bureau, right . This was the first time the United States actually had a bureau. What you would call the v. A. Today, to take care of veterans. For our complete American History tv schedule, go to cspan. Org. This week on q a, David Mccullough on his book, the american spirit, who we are and what we stand for, going back to 1989. The senator written about the most is joe mccarthy. There are a dozen books written about mccarthy. But no senator had the backbone to stand up to him first. Margaret j. Smith. Do you remember how you went about preparing for that speech . Oh, did i go about it. Hardest ive ever worked on anything ive ever delivered from a podium. Historian David Mccullough on his book, the american spirit. A selection of his speeches going back to 1989, sunday night at 8 00 eastern, on cspans q a. Congress remains in recess for the easter passover holidays. The house returns tuesday for work on federal spending. Members will also begin the process to raise the debt ceiling which limits government borrowing. See the house live on our companion network, cspan. U. S. Senate will return next monday to hold a vote on President Trumps choice to head the agriculture department. Former georgia governor, sonny perdue, and attorney general nomination. Watch the senate live on cspan 2