Transcripts For CSPAN3 Hearing Examines The Medicaid Program 20170217

Good morning, everyone. Welcome to the newly refurbished i dont want to call it the oversight investigation room. Which is sometimes used by energy and commerce. What a beautiful room. And it will be more conducive to hearings. This is the first of the 115th congress. Welcome here. And welcome to our Witnesses Today. This is our and welcome back to my friend and colleague, Ranking Member from colorado. This is our medicaid oversight hearing on ways to strengthen the problem. The subcommittee convenes this hearing to examine a critical component of the Patient Protection and Affordable Care act. Medicaid and Medicaid Expansion. As the Worlds Largest health program, medicaid provides Health Care Coverage for over 70 million americans, and accounts for more than 15 of Health Care Spending in the United States. In 2015 alone, federal taxpayers spent over 350 billion on medicaid. The costs continue to rise each other. The federal share and medicaid spending is expected to rise significantly over the coming decade, from 371 billion in 2016, to 624 billion in 2026. Ten years. In a time when Medicaid Program costs are skyrocketing it makes sense to ask the question, is medicaid adequately serving our most vulnerable populations. Medicaid was originally designed as a safety net to care for health of some of our most vulnerable populations, lowincome children, pregnant women, the elderly, individuals with disabilities and i know i treated many kids without disabilities without their disability coverage for medicaid, it would be a struggle for them. Far too often medicaids own rules keep it from serving the families it was designed to help. These restrictions surrounding medicaid do not allow doctors and nurses the flexibility they need for the best outcome for patients. They do not use physician focused moeltsds that can improve care and reduce costs. Studies show that medicaid coverage does not necessarily result in Better Health outcomes. One often cited study in oregon shows it increases Health Care Use and selfreported health and Mental Health while having no effect on mortality or physical health. Similarly, the National Bureau of Economic Research found enrollees obtain only 20 to 40 cents of value of each dollar the government spends. Reports by nonpartisan watchdogs, two of which are here today, show that the Medicaid Program remains a target for waste, fraud and abuse. Because of the size and scale of the program, improper payments, including payments made for people not eligible for medicaid, or for service that is were not provided are extremely high. The Government Accountability office estimates medicaid paid out over 17 billion in improper payments in fiscal year 2014 alone. For these reasons, medicaid has been designated as a highrisk program by the gao for 14 years. Since 2003. And despite the longstanding problems of the Medicaid Program, the Patient Protection and Affordable Care act expanded medicaid to a whole new population. Benefits have been opened up to adults under the age of 65, who make less than 133 of the Poverty Level. Since open enrollment began in october 2013, roughly 11 million individuals have signed up for medicaid coverage under the new eligibility parameters. This means that the majority of individuals covered under obamacare have been rolled through the Medicaid Program instead of purchasing private Health Insurance plans. The costs associated with insuring the 11 million new medicaid enrollees have been far more expensive than the Obama Administration predicted. A report released said the cost was nearly 50 higher than projected. Medicaid expansion enrollees average 6,366 in 2015, which is 49 higher than the agency predicted the year prior. This means that not only are expansion enrollees expensive to insure, but the costs are impossible to predict. The vast majority of expenses associated with new enrollees, unfortunately reports show both states and the federal government cannot effectively oversee and implement Medicaid Expansion. The gao found areas in Medicaid Eligibility that could lead to misspending of funds. The Inspector General found troubling evidence that the federal government failed to implement requirements in the Patient Protection and Affordable Care act that would improve integrity. We all acknowledge there are serious weaknesses in how this program operates, we also recognize the responsibility of the federal government to provide a safety net to the most vulnerable among us. That means insuring taxpayer dollars are spent in a way that actually improves Health Outcomes and serves the medicaid population. We want this to work. Not hinder services. I hope we can in a bipartisan way support its strengths, acknowledge the problems, and together find some solutions. Tomorrow the Health Subcommittee will discuss legislative solutions to strengthen medicaid, but as we move forward we must be careful not to repeat or worsen the problems that already exist in the program. We have a lot of work to do and i would like to thank our witnesses for appearing today and look forward to an informative discussion. I recognize the Ranking Member for five minutes. Thank you very much, mr. Chairman. Its good to be back for another session of congress. We have two new members on our side of the aisle on this subcommittee this year. And im so happy to welcome them. Dr. Ruiz is here with us. Hes an actual emergency room doctor, and hell be able to bring us so much great perspective on issues like this hearing, and other hearings. And then scott peters, whos not here at this moment, im pleased hes here. He and i comprise twothirds of the nyu law graduate delegation to congress. So im happy were loading up this committee with nyu law grads. You know, i think id be deceiving myself if i thought that todays hearing was intended, actually to strengthen the Medicaid Program. Although i hope its not so. I fear that this discussion about medicaid is intended to lay the groundwork for drastic cuts to the program, and eventually to repeal the Affordable Care act historic Medicaid Expansion. I would like to talk about the importance of this program and what Medicaid Expansion has accomplished for the American People. Today, more than 70 million lowincome americans, including seniors, children, adults, and people with disabilities have access to Quality Health care thanks to medicaid. And contrary, frankly, to what my colleagues on the other side of the aisle think, the Medicaid Program delivers this care efficiently and effectively. The costs per beneficiary are actually substantially lower than for private insurance, and have been growing more slowly for beneficiaries. Numerous studies have shown that medicaid has helped make millions of americans healthier, by improving access to primary and Preventive Care, and by helping americans manage and treat serious disease. In fact, the Medicaid Program literally saves lives. Research published in the new england journal of medicine reported that previous expansions of medicaid coverage for lowincome adults in arizona, maine and new york actually reduced deaths by 6. 1 . The acas historic Medicaid Expansion has let states build on this record of success, and provide insurance to millions of americans who otherwise would not have had access to health care. Last year, and we need to think about this more than 12 million lowincome adults had Health Care Coverage because of the Medicaid Expansion. This is astonishing. And combined with other important provisions of the aca, this has helped drive the uninsured rate to the lowest level in our countrys history. Its important to note, these are not people who shifted from private insurance to the Medicaid Expansion, this is people who had no insurance, and were using the Emergency Rooms as their primary care facilities. In colorado, for example, the rate of the uninsured was cut in half since the enactment of the aca, and the expansion of medicaid. Aside from the benefits accrued to the people, medicaid has actually resulted in tremendous savings for the states. Hospitals nationwide have seen their uncompensated care burden drop by 10. 4 billion since the aca became law. Denver Health Medical center which is in my district, this week reported to my office that their uncompensated care claims actually fell by 30 since passage of the aca. This is real savings. And also, we know that medicaid is helping people get access to Vital Health Care services. I had a listening session last week in denver about the aca. I had 200 people show up at this listening session. And most of the people who told their heartrending stories talked about how they were employed, but they couldnt afford private insurance, and due to the Medicaid Expansion, they now had Mental Health services. They had drug treatment and opioid treatment services. They had services for catastrophic accidents that they had had. And on and on. It got to the point where i literally had to take a packet of kleenex out of my purse and put it on the podium. Because everybody, including my staff and myself, were in tears listening to these stories. This is what the majority wants to take away. And this is what were talking about. We can all talk about eliminating waste, fraud and abuse in the program. Were all for that. And i would support that 100 . But taking away Vital Health Care for so many millions of americans is wrong. And we must fight against taking that important benefit away. I yield back. Lady yields back and we dont have anybody else on our side of the aisle to make an Opening Statement. Mr. Wald will come back later. He is in a meeting. Ranking member of the committee is recognized for five minutes. Thank you, mr. Chairman. Its great to be back in our room here today. It looks really nice. For seven years now, Congressional Republicans have railed against the Affordable Care act with a steady drumbeat of repeal and replace. And for seven years, theyve sabotaged implementation of the law. Here we are today, republicans are misleading the public, in my opinion, with falsehoods that the law is failing. That could not be further from the truth. The truth is, after seven years of claiming they could do better, they have no plan to replace the Affordable Care act. The subcommittee should be evaluating the impact that repeal would have on the American People, and the National Health care system. Instead, republicans are holding yet another hearing to highlight their ongoing opposition to the laws Medicaid Expansion, despite clear evidence that the expansion has made Health Care Affordable and available for the first time to 12 Million People nationwide. Tomorrow and thursday the committee is Holding Hearings on what republicans consider the first pieces of the Gop Health Care replacement plan. The fact is, none of these bills will prevent 30 million americans from losing their Health Care Coverage. None of them will reduce the chaos in the Health Care System that will inevitably result if republicans successfully repeal the Affordable Care act. The fact is, republicans are already creating uncertainty and instability in the individual market. This instability will ultimately result in higher premiums and endanger the health and welfare of millions of americans. In other words, the republicanmade chaos in the Health Care System has already begun. Of course, were seeing the same thing with the president S Immigration executive orders. I just hope that at some point our gop colleagues join us against what i consider reckless and rash actions and oppose President Trumps actions. Congressional republicans continue to ask the American People to trust them and they have a plan. Somehow everything will be okay. Theyve repeatedly assured the American Public no one will lose coverage with the republican replacement plan, a claim President Trump and his advisers also continue to make. Recently released audio at a closed door meeting from the republican retreat last week confirms that they simply have no plan. At that meeting, republicans admitted that repealing the Affordable Care act could disarray coverage for the roughly 20 million americans now covered through state and federal marketplaces. As well as those covered under the Medicaid Expansion. In fact, one republican member at the retreat warned, and i quote, wed better be sure were prepared to live with the market weve created with repeal. My republican colleagues are also trying to claim that the Affordable Care act is already collapsing under its own weight and that the replacement plant will rescue the American People from obamacare. Republicans are so scared to own the chaos theyre causing, that theyre trying to pretend that the law is imploding on its own which could not be further from the truth. Americans today have Better Health coverage and Health Care Thanks to the Affordable Care act. The laws Medicaid Expansion improved the quality and affordability of health care for millions of americans. My colleagues would be wise to consider the impact that their actions will have on the millions of americans who are currently benefiting from the Affordable Care act. If my republican colleagues finally took their ideological blinders off, they would realize the Affordable Care act should not be repealed. I say this because i dont really care about the ideology, the fact of the matter is real people are going to be harmed if the Affordable Care act is repealed. I hope at some point my republican colleagues will admit that. And that we can Work Together to improve the Health Care System. I yield back. Well move forward now with our witnesses. I want to ask unanimous consent, however, that the members Opening Statements be introduced into the record. Without objection, the documents will be entered into the record. Id like to introduce our five witnesses. Miss carolyn yo com, welcome, directory of health care. Next, we welcome ms. Ann maxwell, assistant inspector gem in the office of evaluation and inspections in the u. S. Department of health and Human Services office. Next we want to welcome mr. Paul howard, who is a senior fellow and director of Health Policy at the manhattan institute. As well as mr. Josh archambault from the foundation of Government Accountability. And mr. Timothy m. Westmoreland, professor from practice and senior scholar and health law. Welcome all of you. Thank you to all our witnesses for being here today, providing testimony before the subcommittee. We look forward to hearing from you on this important issue. Youre aware that the committee is holding an investigative hearing and has the practice of taking doesnt under oath. Do any of you have any objection to testifying under oath . Seeing no objections, we move forward. The chair that advises you, under the house rules committee, entitled to be advised by counsel. Do you want to be advised by counsel . Please rise and raise your right hand and ill swear you in. Do you swear the testimony youre about to give will be the truth, the whole truth and nothing but the truth . You are now sworn in subject under the penalties of the United States code. Were going to call upon you each to give a fiveminute summary of your is there some lights down there that will go on for them when they are right in front of you . Green means talk, yellow means finish up and red means stop. Miss yocom, you may begin. Chairman murphy, Ranking Member, members of the subcommittee, its a pleasure to be here today to discuss actions needed to prevent improper payments in medicaid. Medicaid finances health care for a diverse population, including children, adults, people who are elderly, or those with disabilities. It also offers a comprehensive set of acute and longterm Health Care Services. Medicaid is one of the largest programs in the federal and one of the largest components of state budgets as well. In fiscal year 2016 medicaid covered about 70 Million People and federal expenditures were projected to total about 363 billion. Unfortunately over 10 of these expenditures, over 36 billion, are estimated to be improper, that is, made for treatments or services that were not covered by the program, were not medically necessary or were never provided. The programs size and diversity make it vulnerable to improper payments. By design, medicaid is a federal state partnership and it states are the first loon of defense against improper payments. They have responsibility for screening providers, detecting and recovering overpayments and referring suspected cases of fraud and abuse. At the federal level, cms supports and oversees state program in ttegrity efforts. In 2010 the Affordable Care act gave states an provider and integrity oversight tools and provided millions of low income americans new options for obtaining Health Insurance coverage. Through possible expansions of medicaid or through exchange a marketplace where eligible individuals may compare and purchase Health Insurance. My Statement Today focuses on four key Medicaid Program integrity issues that we have identified. Steps cms has taken and the related challenge of the aeng agency and states continue to face. first, with regard to ensuring only eligible individuals are enrolled in medicate cms has taken a variety of steps to make the process more data driven yet gaps exist in thafrts to their efforts to ensure enrollment for those eligible as a result of the expansion. As one example, we found that federal and selected state based marketplace has approved federal Health Insurance coverage and subsidies for nine of 12 fictitious applications made during the 2016 special enrollment period. Second, efforts to improve oversight of medicaid managed care. Cms provided states with more guidance on identifying improper payments made to providers and has acted in response to our recommendations requirements for states to audit managed Care Organizations and providing states with additional audit support, but further actions are needed. In particular, in counter data which allows them to track those in managed care are not always available, timely or reliable. Third cms has taken the steps of strength being the screening of providers. There are new riskbased initiatives for overseeing provider checks and these are important steps but there are additional challenges that remain to ensure the data bases check eligibility and states can share information with each other on providers who are ineligible for coverage. Lastly cms has implemented a number of policies and procedures aimed at minimizing duplicate coverage between medicaid and the exchanges. Our work did identify some duplicate coverage and since our report, cms has started connecting checks on duplicate coverage and intends to perform these checks at least two times per coverage year. This could save federal and beneficiary dollars but cms needs to develop this plan a little more broadly and make sure that they are assessing the sufficiency of these checks. In closing, medicaid is an important source of health care for tens of millions of americans. Its longterm sustainability is critical and requires effective federal and state oversight. Chairman murphiy, Ranking Member and members of the committee, this concludes my prepared statement. I would be pleased to respond to questions. Miss maxwell, you are recognized for five minutes. Good morning. Thank you for the opportunity to appear before you today to discuss how to protect taxpayers and medicaid patients from fraud, waste and abuse. I first wanted to give you a sense of what medicaid fraud looks like. It can be very complex and include very different kinds of schemes. For example, in one instance, we indicted the owners of a network of over 30 Nursing Homes and assisted living facilities that billed for services that patients didnt need. In another example, we convicted a doctor for writing fake prescriptions for expensive drugs that were then sold in the black market or billed to medicaid. It is exactly these types of schemes that highlight the need to protect medicaid against unscrupulous providers who steal at the expense of taxpayers and put patients at risk. Today, i want to highlight actions that we can take to better protect medicaid from these types of fraud schemes and other vulnerabilities facing medicaid. State medicaid agencies and the centers for medicare and medicaid known as cms share a responsibility for funding as well as protecting medicaid. We recommend they focus on three straightforward Program Integrity principles. Prevent, detect and enforce. First and foremost, cms and states must prevent fraud, waste and abuse. Focusing on prevention is critical and common sense but Medicaid Programs sometimes fall short and end up chasing after providers to remove them from the program or to recover overpayments. State medicaid agencies should know who they are doing business with before they give them the green light to start billing. To help with that we recommend states fully implement criminal background checks, conduct site visits, and collect accurate data about providers. In addition, to prevent incorrectly paying providers, we recommend that states learn from past administrative errors and proactively update their systems to prevent improper payments. Medicaid should only be paying the right amount for the right service. The next critical safeguard is the ability to detect fraud, waste and abuse in a timely manner. Accurate data is an essential tool for doing this. However as we have just heard, and our work shows, National Medicaid data including data from managed Care Companies has deficiencies. Sophisticated Data Analytics exist to detect potential fraud, patient harm and even to target oversight, but they are ineffective without accurate and timely data. Further, without National Data, states cannot see the whole picture. For example, we found providers enrolled in one state Medicaid Program that had been terminated by another state but without shared data, states had no way of knowing this and had to find out the hard way that they had enrolled fraudulent and abusive providers. Finally, its imperative to take swift and appropriate enforcement action to correct problems as well as to prevent future harm. Federal and state enforcement efforts have very high return on investment, yielding annual recoveries in the billions of dollars, and imposing criminal penalties on thousands of wrongdoers each year. However, states face challenges in taking full advantage of their administrative authorities including suspending provider payments and terminating providers where appropriate. In addition, state medicaid Fraud Control units lack a key authority. Currently, these units can investigate allegations of patient abuse that occur within institutions but if that alleged abuse took place in a patients home or a Different Community setting, they cannot. Medicaid patients receiving services in their home should have as many protections as those in institutions. In closing, our work reveals a number of opportunities to improve medicaid safeguards. In particular, a heightened focus on the Program Integrity principles of prevention, detection and enforcement will help protect medicaid now and as it evolves. Prioritizing Program Integrity will ensure that medicaid funds are used as intended to provide needed Health Care Services and longterm nursing home care for those who are in most need. We appreciate the committees attention to Medicaid Program integrity. We have seen it strengthened in the last year thanks to the efforts here in congress and we hope that our work will continue to be a catalyst for continued positive change. Thank you. Thank you. Now mr. Howard, you are recognized for five minutes. Thank you. Thank you, chairman murphy, members of the committee. Thank you for the opportunity to testify today about Medicaid Program oversight and ways we might strengthen the program. Medicaid is undoubtedly a vital component of the nations safety net for low income and vulnerable populations. But an openended automatic federal matching formula has had vast unintended fiscal consequences both for the states and the federal government. Often crowding out funding for other Safety Net Services and supports that might have a bigger impact on the measured health of these populations and their prospects for continued economic mobility. As you know, medicaid is a hybrid program that on average pays approximately 62 through its federal match. Although the upper limit is around 80 and the lowest match is 50 . This encourages states to maximize the drawdown of federal dollars through a number of sometimes legally questionable funding designs that my colleagues at gao and hhsoig just mentioned. This byzantine funding structure makes it extraordinarily difficult for the federal government to oversee effectively Program Integrity. It also encourages wealthier states to spend more on their programs to draw down more federal dollars. In a 2010 book, mark pauley and john granaman highlighted that the highest quintile of states by income spent 90 more than the lowest. When it comes to waste, fraud and abuse, we see new york state which is historically spent much more than other states, even though it has only 6 of the nations population, it has spent approximately 11 of total medicaid expenditures and spends 44 more per enrollee. Over a period of 20 years, the state had an improper payment rate for state Developmental Centers which the state was overpaid by 15 billion simply because of payment structure that the state and federal government agreed to in 1990, was never updated to reflect the fact the state had, in fact, moved the disabled out of the Developmental Centers and into community supports. To the states credit, Governor Cuomo in 2011 created a Medicaid Redesign Team that began to address the program and began first by conceding the program delivered poor value for beneficiaries and taxpayers. Since then, through a number of farreaching highly aggressive reforms including capping most of the states state spending outside of the disabled population, lowering that spending from 6. 2 to 4 , the state has saved hundreds of millions of dollars, shifted an emphasis from institutional care to community care, and begun to address some of the behavioral components of poor health that leave these populations using disproportionately Emergency Rooms. The right way to view our Health Care Dollars is not to say that medicaid has per unit costs that are very low, thus its more efficient. The better question to ask is, are dollars that were automatically spoeent on medica, might they be better purposed to other programs, an expanded state earned income tax credit, Supportive Housing for the seriously mental ill or any other support or service that might have a bigger impact on improving measured Health Outcomes. My colleague orrin task last year put out a very important study that noted from the period of 1975 to 2012, our spending on low income supports had doubled but that 90 of the increase had gone to health care. He estimated that if our median spending either by enrollment or per enrollee was nationalized we could save as much as 100 billion annually and that is money that could be placed elsewhere in other support programs. In short, we have thickened one strand of our safety net for low income americans while neglecting others. If the safety net feels threadbare in places its because we have encouraged the states to overspend on health care. What im not saying is that medicaid has no value. There is clear research that shows medicaid has an extraordinary rate of return on investments in Maternal Health and child health. But large rigorous randomized experiments have shown no increase in measured Health Outcomes. Other studies continue to show that the social determinants of health have a much bigger impact on more ttality than simply spending on Health Insurance per se. I would like to suggest just a few ways we can address this disparity in conclusion. We should agree on broader safety net goals that hold the states responsible for meeting them in ways that are transparent both to the states and the federal government. We should reform the financing incentives of the program to ensure we are not Incentivizing States to automatically funnel additional federal dollars to health care. They might choose to do so, but we shouldnt effectively bribe them to do so. Finally, cms should continue to give more leeway to the states in programming, designing and spending medicaid dollars including on nonhealth supports. I believe that these reforms would serve both conservative and liberal ends and should be the focus of the 115th congress. Thank you very much. Thank you. You are recognized for five minutes. Chairman murphiy, members of the committee, im jeff archambault. I work at the foundation for Government Accountability, a think tank active in 37 states specializing in health and welfare reform. I would like to highlight how the acas Medicaid Expansion has worsened problems for the truly needy and i would like to start with a video. For nearly her entire life, shes one of thousands on a waiting list that state leaders are looking for ways to trim. Tonight, so much your sides Jason Peterson shares some ideas. Jason . A year ago, skyler overman was given a month to live. The grim prognosis followed a life racked by a rare neurological condition. She has multiple seizures a day, she requires constant care. Thankfully, she has a mom who is up to the job. I give her her medicine at 8 45 and im in bed not too long after her because theres just, you know, people dont realize how much care these kids need. But they also dont understand how worth it it is. Taking care of her and having her in my life has been the best part of my life. Parents like lindsey cant just call a babysitter. Specialized care is expensive. A medicaid waiver would help pay for that. Over 4,000 arkansas families have one. Nearly 3,000 families including the overmans are waiting for one. And its a long wait. She is still 670s. Shes moved less than ten spots in nine years. Thats a sad fact, is that at the rate its going, there are people that will die before they get to receive their services. Sadly, skylers story represents just one of nearly 600,000 individuals currently sitting on waiting lists for immediaMedicaid Services. Children with Mental Health sdfrs sdodz and traumatic brain injuries who are less likely to receive the needed care now that medicaid has been expended. The aca expanded medicaid to a brand new population which consists largely of childless, ablebodied adults who are working age and have only dimmed the hopes further for families like skyler. But the problems go much farther beyond situations like hers. The governor of arkansas due to expansion costs has proposed nearly 1 billion in cuts to traditional medicaid, primarily from patients with expensive medical needs, the developmentally disabled and the mentally ill what is he said. Why is this happening around the country . The new obamacare expansion population is awarded a higher match rate. This funding formula has pernicious unintended consequences. Let me explain it this way. If a state needs to balance a budget which they all do need to every year, state officials have to turn to medicaid because its the biggest line item. Also growing faster than revenue. If you want to save one state dollar in state funds on average you need to cut just over 2 from the traditional medicaid population, the aged, blind, disabled, pregnant women and children. But if they want to save that same 1 in state funds for the expansion population this year they need to cut 20. I know you all can guess who faces cuts first and its heartbreaking. Overenrollment under obamas Medicaid Expansion would encourage states into deeper cuts. 24 of the expansion states show enrollment has been over by 110 on average, more than double initial estimates. The cost overruns have been significant, just to name a few. California found themselves 222 over budget. Ohio, 4. 7 billion or 87 over budget. These enrollment and Budget Trends mean fewer resources for the truly needy. Now, history could have warned us of this. Arizona and maine both expanded medicaid to the same ablebodied childless Adult Population before the aca and both had to take measures to rein in costs. Arizona had to stop a number of organ transplants. Maine capped enrollment, created wait lists. This happened even without the lopsided extra funds that follow expansion enrollees. Which brings me to my last point. Concerns over eligibility issues. Fgas work around the country has found deep systemic problems. First, states need to be checking eligibility far more frequently and second, states need to be checking more data when they check eligibility. Life changes such as moving out of state, getting a raise are going unnoticed for far too long. Meanwhile, states continue to cut checks to managed Care Companies for cases that no longer qualify for the program. My written testimony highlights a couple of those states that have had bipartisan success in tackling this waste and fraud but much more is needed. Thank you. Thank you. I recognize from westmoreland for five minutes. Thank you for the invitation to speak today. I take a back seat to no one on Program Integrity issues in the Medicaid Program. People who care about federal programs have to work to ensure that federal funds are well used. Program integrity problems are, however, not new. Military contractors cheated the union army during the civil war, where money is being spent whether it be private, state or federal and no matter how good the cause, there are bad actors trying to steal it. Program integrity efforts are especially important in medicaid. This is because billions of dollars are at stake, as are the health and wellbeing of the most Vulnerable People in america. This importance is wellillustrated by the fact that at the same time the aca expanded medicaid coverage it also made significant improvements in Program Integrity efforts. As important as combatting fraud and abuse in medicaid is, policy makers should keep it in perspective. As big as they are, the numbers must be viewed as what they are and as a whole. First, we should be careful about our terms. Not all of what is labeled improper payments in the vernacular is fraud or even mistaken. Most are appropriate but simply badly documented and may even be underpayments. The actual loss to the government is much smaller than it may appear. The oig and gao footnotes in my testimony cite to this terminology. But as the prepared statements of gao and oig witnesses of todays hearing have outlined, hhs has already implemented many efforts to address the more Serious Problems of Program Integrity. Some of these efforts are longstanding and some of them are just under way, but there are many efforts focused on making sure medicaid is spending its money well and they are having an effect. But im especially concerned today that policy makers often respond to waste, fraud and abuse with blunt instruments aimed at the wrong targets. Any review of the actual Medicaid Program dollars that were stolen or misspent will reveal that the major culprits are unscrupulous providers. Pharmaceutical companies that price gouge, Equipment Suppliers that dont deliver and medicaid mills of doctors, dentists and clinics that dont provide that provide Unnecessary Services if they provide services at all. That all too frequently, the political and legislative response is to institute cuts or restrictions on beneficiaries and the providers who actually care for them. There is simply nothing in the recent reviews of Program Integrity that justify the policy proposals that are now on the table and before this committee. Reduced capped federal funding does nothing to improve Program Integrity but it does put coverage at risk for low income americans and shifts the cost for the most Expensive Services to states, localities, providers and charities. This is wrong. Program integrity problems are meaningful only when theyre considered in the context of the many successes of the Medicaid Program. For example, the Medicaid Expansion of the aca means that 11 Million People have medicaid coverage who did not have it three years ago. The percentage of people without insurance in america is at an alltime low of 8. 9 . The burden of uninsured care in hospitals and expansion states is down 39 and costs to those states are commensurately lower. Rural hospitals in expansion states are at half the risk of closure of those in nonexpansion states. Community Health Centers are seeing 40 more patients. People with serious Mental Illnesses are 30 more likely to receive services in the expansion states. Services for opioid addiction are available to working age adults often for the first time. Medicaid expansion of the aca has fundamentally repaired longstanding mistake in the program. People always had to fit into some sort of category. But this categorical eligibility has never made sense. Poor women need Health Insurance both before and after they have babies. Poor children keep needing Health Insurance even when they turn 19. Poor people with chronic ill nsas need Health Insurance before they become disabled. Poor older adults need Health Insurance when they are 64, not suddenly when they are 65. The real problems here are poverty and uninsurance. In the 32 states that have adopted the Medicaid Expansion, where making this part of the insurance system finally make sense and be fair for Vulnerable People. Please do not turn back this response. Lincoln did not give up on the civil war because the government was sold bad mules. We do not stop buying drugs because drug makers charge fraudulent prices. We punish the wrongdoers, correct the price, and get the treatment to the people in need. That is what should be done here. Dont reverse all this progress by rationalizing the Program Integrity problems demand wholesale legislative changes in medicaid. There are real babies in that bath water. Thank you. Thank you. I recognize myself for five minutes of questioning. Miss yoc oshom, your report fou gaps that limit cms ability to check eligibility for some groups. Newly eligible under expansion and previously eligible are appropriately matched with federal funds. In the federal facilitated exchange states, cms will not be able to assess the accuracy of eligibility determinations until 2018. Does this create the potential for improper payments then . It certainly creates a lot of questions about what is going on with eligibility and whether progress is being made. The decision to suspend the estimate of eligibility was based on trying to give states time to understand the new rules and the new range of matching rates that could be applied. From our perspective, though, transparency of the process and how it is proceeding, it would not be a bad thing. It would be good to know whats going on. In states that determine eligibility, gao found that eight out of the nine states audited identified eligibility determination errors and improper payments associated with those errors. Are those errors reflected in cms eligibility determination error rate and does cms correct these errors and why or why not . Right now, they are not reflected in the eligibility rate estimates that cms puts out. Instead, there is a rate that was produced a couple years ago of 3. 1 and thats being applied until 2018. Why does it apply until 2018 . Im not sure the reasoning for that year. I think time i guess. Was that an accurate number . That is an accurate number . Its a number i believe that goes back to 2013 or 2014. That was just continuing that on. So that leads to my next question. I heard that cms has put a freeze on measuring eligibility determinations for medicaid. What does this freeze mean . How will we measure eligibility errors and improper payments . It means that we are relying on an error rate thats about three or four years old. We dont right now know whats going on with the eligibility determinations. So we are using old data thats not accurate anymore . We are asking a question whats the error rate. We dont know so we are going to use a number from a few years ago . Thats correct. Okay. So a parent asks their child how did you do on your report card, they say got all as, could be accurate, except you are maybe dealing with a High School Senior that you didnt specifically say, im just assuming the grades i got in third grade, i will continue to carry those over year to year so im valedictorian. That doesnt make sense, of course. You are saying the same thing applies here . Yes. Right now they are not publishing or i believe even calculating an improper payment rate right now. They are working with the states on a state by state basis. So when people make a statement everythings fine, things are staying pretty stable, we have inaccurate data. We want to fix this. But we dont have accurate data to help us know how big the problem is. Is that correct . At this point, we dont know. Mr. Archambault, since we cant measure the actual eligibility improper payments due to this freeze thats been imposed, in the past administration, lets try and get an idea of the types of eligibility errors and how much they cost the federal government. Do you have any examples from your work of improper eligibility determinations and how that translates to improper spending . Sure. Theres a couple of states that i highlight in my written testimony. In illinois in 2012 they passed a law to hire an outside Third Party Vendor to look at eligibility errors. Their track record has been quite impressive. The first year they found about 300,000 individuals who werent eligible for medicaid. In their second year they actually found 400,000 individuals who were ineligible for their program. It runs the gamut from individuals who had passed away in the 1980s who were still on their program to individuals who were simply moving out of state, got a raise, didnt report that information. State of arkansas recently also did a review of their Medicaid Program and found things like 43,000 individuals who didnt live in the state who remained on their Medicaid Program. 7,000 who had never lived in the state. Are those people who are making medicaid claims, do we know . So in many cases, this is why its so important. As states have moved towards managed care environment, it almost doesnt matter. States continue to cut a check to managed Care Companies regardless of whether those individuals are showing up to the doctor or not. Thats why this is even more important now as states have moved in that direction. Its hundreds of thousands of people in this category that they are still getting paid even though they are not alive in the state or getting care. Correct. In some cases its just waste. If somebody moves and is still medicaid eligible we just want to make sure two states arent paying two different managed Care Companies for their care. In other cases its outright fraud. We have a total dollar value for that . When you are not measuring its very hard to see but i will say my written testimony goes through and documents a number of state audits that show eligibility is a huge issue when it comes to applications. My time has expired. Miss degette . You talked about the complex investigations your agency is undertaking into some of these medicaid fraud issues. These investigations involve large numbers of personnel and also technical support, is that right . They are complex investigations . Correct . Absolutely. We partner with the state medicaid Fraud Control units. Do you know approximately how many people at your agency are involved in these investigations . Well, in some respects we all are. Even though the Inspector General has a cadre of inspectors who are auditors, evaluators, lawyers and all of us contribute to the fraud fighting efforts of the Inspector Generals office. Okay. Are you familiar with the executive order that President Trump issued on january 22nd in which he said that quote, no vacant positions existing at noon on january 22nd, 2017, may be filled and no new positions may be created except in limited circumstances, end quote . I am familiar with that. Has your agency determined, will that freeze the hiring at your agency . Given that its quite new, there hasnt been an assessment yet of how that will affect the oig. I can tell you as you have pointed out that the work we do does rely on personnel. We use sophisticated let me stop you then. If the personnel at your agency, the hiring was frozen, what would that do to your ongoing fraud investigations . We would need to double down and do as much as we could with the resources that we have. Would it impact those investigations . Absolutely. We need the personnel to analyze the data in order to fight fraud most effectively. Thank you. I wanted to ask you a quick question, mr. Archambault. The question i wanted to ask, you showed that really heart rending tape about the young girl on the waiting list for some length of time for the care she needed. She was in arkansas, is that correct . The governors of the states decide whether they are going to use that money for cases like that or they decide how they are going to use the medicaid money that comes to their states, is that correct . Within limits. Yes. The federal government sets the guidelines but the governor of arkansas decided where that money would be spent, decided not to put it into that kind of a program, is that right . Again, the question and point im trying to make no, no. My question is yes or no. As far as the governor decided how to allocate that money. Yes or no . They have funds that come in and they can decide to invest thats the governor that decides that. In a nonexpansion state we have seen states buy down their wait list. Thank you very much. Yes or no would have worked. I want to ask you, mr. Westmoreland, a couple questions. Now, uncompensated care costs are what hospitals pay for patients that cannot pay their bills, is that correct . Yes. Who bears the cost of uncompensated care . Its a complicated question but the direct costs are usually borne by state and municipal governments because they pay for public general hospitals. Then who where do they get their money from . By and large, from taxpayers. Okay. Now, i talked in my Opening Statement about how the aca Medicaid Expansion is driving uncompensated care costs lower. Can you briefly explain why thats correct . Yes. If a hospital is dealing with people who have no source of insurance it by and large can provide the services and chase them down and people oftentimes have no money or declare bankruptcy. In the instance in which they are insured, either through the exchanges or through the Medicaid Program, the hospital can turn to a Third Party Payer and they are no longer uncompensated care. They can get some payment from those Insurance Companies or medicaid. Okay. Now, some of the states that did not expand the medicaid component of the aca have not experienced as large a reduction in uncompensated care costs. Is that correct . Yes. Why is that . Those states are still dealing with the same number of people without Health Insurance who are low income. The states who have expanded have a source to turn to, their Medicaid Program, which is in the Medicaid Expansion situation largely paid for by the federal government. Great. Thank you. I yield back. Now recognize mr. Barton for five minutes. Thank you, mr. Chairman. Im glad to be part muof the fit oversight hearing. Im glad we have some new blood on the subcommittee. We have a new doctor on the democratic side. Glad to have him. We have dr. Burgess on our side. When the bloodletting begins, we will have two doctors that can take care of us. And keep us going. I want to focus the panels attention on a few numbers. First number is 20 trillion. Second number is 325 million. Our National Debts about 20 trillion give or take a trillion or two. We have around 325 millions. If you divide, you get about 66,000, 67,000 that every american owes of the National Debt. Our hearing memo says there are 70 Million People that are covered by medicaid. You subtract the 70 Million People covered by medicaid from the 325 million citizens, it means there are 250 million americans that owe not only their share of the National Debt but also the 66,000, 67,000 times 70 million that the medicaid recipients owe because by definition, medicaid recipients are below the Poverty Level and cant pay it back. Those are big numbers. We are spending at the federal level about 350 billion a year and the states are adding another 150 billion so we are spending about 500 billion a year to provide health care for low income americans. That may or may not be sustainable but we know that we cant sustain adding half a trillion to a trillion dollars every year to the National Debt. We all want to keep medicaid but we want to improve it. Thats what this oversight subcommittee is looking at. How do we improve medicaid so that we get more bang for the buck, Real Health Care to real people that need it, and yet make it affordable so the taxpayers who are funding it can continue on fund it. Mr. Howard, you talked about in your Opening Statement a little bit about new york with 6 of the population getting 11 of the medicaid dollars. You want to explain to the subcommittee why thats so or would you like for me to explain it . Thank you, congressman. There is clearly an incentive given the openeneded federal match for wealthier states both because of ideology and because they have a Larger Tax Base to draw down more federal dollars. It also inhibits attempts to pursue Program Efficiency when you think of a state like new york, say new york wanted to design a more efficient primary care program that saved 1 million. Because of the 50 federal match, it would have to cut spending by 2 million. So theres a rachet inherent in the open ended federal match that tends to bid it up for states that have the funds to do it but makes it hard to turn the rachet around and correct it and find more efficient ways to deliver care. I think thats the challenge facing the nation, not just of course for medicaid but for private insurance and medicare as well. In an environment where theres no incentive for providers to look outside the box in new ways to deliver care more efficiently, more Cost Effectively they simply dont pursue those areas. Some of the changes Governor Cuomo instituted in new york, they were done by a Republican Administration i think we would have heard howls of outrage but because it is a democratic administration, you capped spending, ended automatic payment increases, did a lot of things that are quote, unquote, progressive but are really nonpartisan ways to improve Program Efficiency. I think that other states and the federal government should look at ways to give states more Program Efficiency and better incentives. You think it would be appropriate to look at the way the formula allocates dollars per state to try to harmonize it with current low income populations across the nation . I think thats an important tool. I think states would also really appreciate the opportunity to be able to spend medicaid dollars on nonhealth related supports that might actually, in terms of accessing transportation and other services, that might make those populations both more compliant with care and in Better Health in the long term. I think they would be very open to that. My time is about to expire. I will have some questions for the record dealing with block granting programs back to the states. I do want to welcome mr. Westmoreland back to the committee. Nobody yet has admitted it but at one point in time he was one of the brain trusts on the Minority Side and helped mr. Waxman and mr. Dingell actually create the Affordable Care act. We appreciate your expertise coming back before the committee. Its nice to be back. Thank you. I yield back. I now recognize mr. Pallone for five minutes. Thank you, mr. Chairman. My questions are to mr. Westmoreland. Mr. Westmoreland, mr. Archambault made some claims illustrate i illustrated with a video. Im concerned that the testimony attributed a causal relationship between Medicaid Expansion and hcbs waiting lists and somehow the Medicaid Expansion he claims exacerbates or causes these waiting lists. I dont believe that to be true. I dont think the facts show that its true. I think the wait lists are a result of state decisions and cutting or capping or block granting medicaid will only make the situation worse. I like to use anecdotes. One year i went to a conference, a couple years ago in houston with mr. Green, i think mr. Burgess was there, too. In between the Health Conference i went over to the texas Childrens Hospital at the Medical Center and you know, i talked to the officials there and it was a beautiful place with this beautiful lobby but literally, people, particularly mothers with their children, were just literally camped out in the lobby of this place that looked like a hotel and i asked why are they all here. It was because they couldnt access the emergency room because there were so many people that they were literally waiting for hours to use the emergency room with their kids. This notion that somehow the Medicaid Expansion is causing the waiting list, i think its just the opposite. I think its the lack of Medicaid Expansion in these states thats causing the problems in most situations. In any case, let me just ask you some questions, mr. Westmoreland. Can you provide some background on the hcbs waivers in the Medicaid Program . Isnt it true the decision to have an hcbs waiting list is a state flexibility that is their direct result of state choices on the design of their Medicaid Programs and the amount much resources states make available to provide hcbs . Yes. Theres no restriction at the federal level on how much a state may turn to hcbs instead of to traditional institutional services. Its a state decision. So if i can just summarize, states decide whether to limit their hcbs waivers to a defined number of slots and create waiting lists one the slots are filled, and cms allows states to increase or decrease the number of slots as they wish and isnt it actually true that in the case of arkansas, the federal government would be willing to pay 69 of the costs of care if the state chose to increase the number of its slots and that until january 1st of this year, the state was spending none of its own funds on the expansion population . I have to admit i dont know theth specifics of the last par of your question but other than that, yes, its entirely a state decision. Arkansas has made the decision of the size of the waiver. Isnt it also true that 12 states and the district of columbia have no waiting lists at all and the overwhelming majority of those states that have no waiting list have actually also expanded medicaid . I believe so, yes, sir. Isnt it also true that the two states with the longest waiting lists are texas and florida, which have not expanded medicaid . Of course, i use my example, my a anecdotal evidence of the Childrens Hospital at the texas Medical Center. These are the two states that have the longest waiting lists . I know texas and florida have not expanded. I did not know they were the longest waiting lists. I know they have waiting lists. My problem is, i just think theres no evidence that states are choosing to expand medicaid or keep their expansions at the expense of Vulnerable People waiting for hcbs and the examining state choices on both expansion and hcbs waivers actually leads to a contrary conclusion. If anything, all the federal expansion dollars only strengthen the arkansas economy and revenue by reducing uncompensated care as has been shown in multiple states around the nation. I think it just makes basic sense. If states expand medicaid they are getting 100 federal dollars and they have a lot more money to care for people. Its only going to be natural that they have more money to spend on people who are eligible. So this notion that somehow by cutting the expansion, he lum nating expansion, cutting medicaid, theres no way in the world thats going to help the situation with people, you know, who are trying to seek care. They will just end up in Emergency Rooms, they will be waiting for the emergency room. They are not going to get Preventive Care, not see a doctor. None of it makes sense. In i may, i would like to juxtapose your comment with that of chairman barton. Who points out that possibly there will be proposals to block grant and cap the federal funding. I have to say that if the congress adopts capped funding for medicaid, we are going to see more, not fewer, waiting lists. Less funding and the loss of the individual entitlement to services is exactly whats underlying the story in that video. If the program is capped, federal participation is limited, it will only get worse, not better. Thank you. I recognize the new vice chairman of the subcommittee, mr. Griffith of virginia. Thank you, mr. Chairman. Mr. Archambault, get out your money. You ready . My understanding of your testimony was that you were in fact saying that the states have to make choices with their limited resources and that the federal government under the aca is going to lower its Medicaid Expansion money down to 90 , as states find themselves with larger burdens than was anticipated when they expanded medicaid, they have to make decisions on where its cut and we have created through the aca, i say we loosely because i wasnt here when they voted on that, but the congress and the government created a situation where the states are rewarded for cutting traditional medicaid which deals mostly with children and people who are in greater need and that because of that disensi dis disincentive or incentive to spend it on the new folks, newly found under the new medicaid, the new categories, we create the situation where states are having to make a decision as to whether they quicken the shortage on the waivers, get rid of the waivers as fast as they can or whether they spend that money somewhere else. Is my understanding correct . Correct, congressman. Theres both direct and indirect outcomes as related to expansion. My point is that we are not fulfilling the promises to the most vulnerable in our society. Wait list or not. But we are making new promises to an ablebodied population that does not qualify for longterm Welfare Benefits in any other place and states are being put in a situation where they are having to make very tough decisions in making cuts in reimbursement rates that directly impact those with Developmental Disabilities, those in Nursing Homes. The access and quality questions that surrounded medicaid for decades will only get worse for the truly needy. So what you are saying is we need to Pay Attention to that and need to make sure we have incentives that encourage people to take care of the truly needy and the young and might be the new group, we need to refigure that formula, that is what youre saying . Absolutely. I think as part of the repeal and replace discussion as we are talking about changing medicaid going forward, it absolutely must be on the table. We would strongly recommend looking at freezing new enrollment in expansion states and not allowing other states to expand so you can address the underlying issue of refocusing programs on the truly needy. We have a real habit of doing that. I thought that 20 bill versus the 2 was very instructive. Mr. Howard, you touched on this but you didnt get into detail. We have a situation where even in traditional medicaid we have rewarded states that play games. Virginia elected not to have a sick tax. Thats what it was called when there was a proposal a number of years ago, couple decades ago to start taxing the beds of the sick so that they could create that money and put it into medicaid and get matching money from the federal government even though we are a fairly low match, that would have given up those 2 for money kwleewe coll from sick people but many states came up with schemes to get money by claiming they are charging more but what they are doing is creating some kind of sick tax scheme and shouldnt we put a stop to that . Over time, not saying we have to get rid of it immediately but shouldnt we be trying to get rid of that so Everybody Knows exactly what they are getting, not having to charge sick people money so we can get more money for medicaid . The federal government has capped the amount of provider taxes that states are able to use but still, we are talking very significant amount of money. The last estimate was about 25 billion. Many, many states use these provider taxes. They use enhanced payment rates for state owned facilities, intergovernmental transfers to draw down and raise their he fkive federal match. While they may be legal, there are ethical questions about that, right . Absolutely. I want to move to something else. I heard somebody earlier say that obamacare wasnt collapsing. That was some myth. We got all kinds of numbers, 25 average increase, nearly a third of u. S. Counties have only one insurer, 1 trillion in new taxes, 4. 7 americans had to change their Health Care Plan because they fwgot kicked off t plan they liked. All kinds of problems out there. You know what i find instructive is anecdotal. Happened to me yesterday twice. After church group, i generally go to lunch. I try to stay out of politics at lunch. A discussion broke out at the otherened of the table i was not involved in where they were talking about what do we do going forward. One fellow said as a christian i dont mind paying some more money but when my insurance rates have gone from 450, 500, to 1250 a year and im getting less insurance its hurting my family and thats a problem. Later that evening in a Small Group Gathering of different people, there was a big discussion about whether or not they could a family could afford to justify spending money for their daughter who had the flu. Several families have been ravaged by flu over the last couple weeks because in order to afford Health Insurance they have gotten such a high deductible it would cost them 75 to get tamiflu and they were debating whether or not they should do that if their other kids got it. These are real life examples of how obamacare is in fact failing the American People. I yield back. Now recognize miss castor for five minutes. Thank goodness for medicaid in america, especially back home in florida. 3. 6 million rely on medicaid for their health services. A lot of my neighbors in Skilled Nursing, alzheimers patients, medicaid is the lifeline for these families. Not to mention 50 of children if flori in florida rely on medicaid to go see the pediatrician and get their checkups along with the state Childrens Health program. Florida didnt expand medicaid so that 3. 6 million number are really our neighbors in nursing home or Community Based care or children or my neighbors with disabilities, and based upon what they tell me, medicaid is working for them. It works, medicaid spending growth is lower than private Health Insurance, lower than medicare. Thats because sometime states try to get by on the cheap in prayi paying providers. Thats one place, if we could pay our providers a little more and do better there. Medicaid is flexible. I watched in florida as they have moved to a managed care system. I have questions about that but that was a decision of the state. They had all that flexibility under medicaid. They have also began a change towards more home and Community Based services to help keep older folks out of Skilled Nursing which can be very expensive. Then but we have to remain mindful about the fiscal cost and fiscal responsibility. Thats why in the Affordable Care act, we passed a lot of new Program Integrity provisions to strengthen medicaid, the most important provisions involved a shift from the traditional pay and chase model to preventive approach by keeping fraudulent suppliers out of the program before they can commit fraud. All participating providers in medicaid and c. H. I. P. Programs must be screened upon enrollment and revalidated every five years. Think about that as you move towards repeal of the Affordable Care act, why would we want to repeal these important Program Integrity provisions relating to medicaid . I dont think thats the path that we all want to go down. What this is, though, i think the real fear is that this whole terminology of block grants and per capita caps is simply a stalking horse for less care for my neighbors back in florida and all americans, for every alzheimers patient, for every child that needs to go see the pediatrician. I want folks to be aware what block grants and per capita caps means because it sounds good but what that means is devastation and sabotage to the Medicaid Program. Mr. Westmoreland, describe the impact on the delivery of Health Care Services to americans if this approach is taken, block grants and per capita caps. As i understand, some of the proposals that are made, the basic point is to limit federal participation in the state costs of running the Medicaid Program. As Health Care Costs grow over time, the states will be left holding the bag for those increased state costs, for medicaid costs, and as changes occur in the population, as the baby boomer demographic enters into the population, as more and more services are provided for people with disabilities, as Prescription Drug costs go up, the increased cost over time will not be matched by the federal government. States will be left holding the bag. Isnt it interesting that some republican governors believe this approach will have disastrous consequences for their ability to care for their older neighbors, neighbors with disabilities and children, for example, governor, republican governor from massachusetts in a letter to congressman Kevin Mccarthy stated we are very concerned that a shift to block grants or per capita caps for medicaid would remove flexibility from states as the result of reduced federal funding. States would most likely make decisions based mainly on fiscal reasons rather than the Health Care Needs of vulnerable populations and the stability of the insurance market. Could you elaborate a little more what this would mean . You would have, i think in my state they may not raise taxes, thats the choice, though, isnt it . Raise taxes to support our neighbors or cut . If federal participation is limited in these fashions, its the only way that would respond to mr. Bartons concerns about deficit reduction, if federal participation is limited in that fashion, the states will have a choice either of reducing the number of people that they serve, cutting back on rationing of the services to those people, or raising state and local taxes. Mr. Chairman, thank you. I would like to ask unanimous consent to enter into the record, if anyone is interested in learning more about medicaid march of dimes and a number of experts are having a lunch provided Forum Tomorrow or excuse me, thursday, february 2nd, 12 30 to 1 30 right here in rayburn, in the sam johnson room, rayburn 2020, to learn why medicaid matters to kids. I encourage you all to attend. Could you send a copy over to me . I recognize dr. Burgess for five minutes. Thank you, mr. Chairman. I want to thank our panelists for being here today. Very interesting discussion. Certainly very timely discussion. Miss yocom, let me ask you, chairman murphy was directing some of his questions about improper eligibility determinations and one of the things that has concerned me for some time is the issue of Third Party Liability. A medicaid patient who has actually other insurance but also has medicaid and my understanding is what happens is sometimes its hard to collect from the party of the first part, the commercial insurer, medicaid is more straightforward, so you end up in a situation where the person who should be responsible for the bill, the Insurance Company who has been contracted to provide care for that patient, actually is inadvertently let out of the equation because it just becomes easier to chase the dollars in the medicaid system. Is that a real phenomenon . It is. We did some work i believe that took a look at Third Party Liability on some of the issues that the Medicaid Program encountered. Some of its about Information Systems and just being aware of the coverage but then even within that, its about the interaction between the state Medicaid Programs and the Insurance Companies and being able to assert the fact that they should be paying first. So to what extent are the states able to address the underpayments by commercial insurers, overpayments by medicaid . Dwee make some recommendations to cms to provide Additional Support and data on these issues. I would need to check to see whether or not they have been implemented and a little more about the specifics. Im given to understand that this is not a trivial problem. There are significant number of dollars involved. Is that correct . Yes. Yes. And i think safe to say it does vary from state to state, some states do better than others, so you, if i recall correctly back in the mid 2000s, 2005, 2006, 2007, you had created a list of states where the percentages of dollars left behind were attributed to each state. There were some significant differences. I think texas was kind of middle of the pack. Iowa did very well. Some other states did very poorly. State. There were some significant differences. I think texas was kind of middle of the pack. Iowa did very well. Some other states did very poorly. Is that do i recall that correctly . I believe thats right. And i think some of it is the more health plans involved, i think the harder it becomes. Some of the states that had a Smaller Group of insurers to work with i think were able to establish better relationships. Just gets to the point, that was a gao report of over ten years ago. Is this problem fixable . Is it worth fixing . I think there have been some fixes done. But i am not sure i remember well enough to tell you much more than that right now. I would just let there is some very insightful legislation coming on this subject. And i hope people will join me on that. Miss maxwell, let me ask you, just staying on the Third Party Liability issue, youve discussed medicaid overpayments in regard to providers not reconciling credit balances with the states. Is that correct . Thats correct. So it would stand to reason since states are not active in tracking down Third Party Liability claims theyre aware of beneficiaries with overlapping coverage that might receive services that are unintentionally paid for both by third parties and the state medicaid plan. Is that a reasonable assumption . Correct. Is it possible for states to take advantage of inhouse data like this to approach practices that might not have reconciled their credit balances . Yeah, thats what our recommendation focuses on, the the ability of states to identify those overpayments and then recover them. Were looking at the report we looked at was 25 million in which credit balances were not reconciled. States had not been able to say that number again. 25 million. For i believe it was eight states, i believe. But its not an inconsequential number. Its a number worthy of our attention. Even though we deal with big numbers up here, mr. Barton talked about trillions of dollars and dazzled everybody with that. But even going even focusing on these amounts is important, is it not . Absolutely. From the office of the generals perspective, every dollar counts, every dollar that is overpaid or goes to a fraudulent provider means there is a dollar less to provide services. Thank you. Mr. Chairman, i want to point out that ten days ago or so, a day before the inauguration, we had round tables with the governors up here both on the senate side and the house side and it was one of the most impactful days i have seen up here. There is so much energy and enthusiasm on the part of the governors who want reforms in their system. They want this to be right. They want to deliver the care to their citizens. There is not unanimity of opinion whether it is block grant for beneficiary allotment. A lot of discussion around the moving parts. But ill just tell you i was very encouraged about the level of involvement of our governors in this issue. Ill yield back. Thank you, i now recognize the gentleman from new york, mr. Tonko for five minutes. Thank you, mr. Chairman. Welcome to our panelists. Mr. Archambault, i know that in your testimony you addressed the waiting lists and the corresponding decline of services or inability of services. I know that our ranking representative pallone asked you a bit about this or the panel about it. And i just want to dig a little deeper into a claim that you did make where you insinuate that expanding medicaid will lead to the 600,000 individuals on medicaid waiting lists being less likely to receive services. First of all, can you explain what you mean by medicaid waiting list . I assume youre referring to the waiting list that some states maintain to receive home and communitybased Waiver Services. Is that correct . Correct. So i would ask, do you know which state has the longest waiting list for home and communitybased services . It is usually related to population, youre going to have more people who are usually eligible for the program. But thats not there is not a straight correlation that way. Well, my information tells me that texas is the list that has the longest waiting list. Some 163,000plus people in 2014. Do you know how texass waiting list of that 163,000 has been affected by the expansion of medicaid . The data usually is a year or two delayed, so it is hard to draw direct correlation. I would just point out that if we want to make sure that were fulfilling the promises to the most vulnerable, i think getting lost in this discussion is that medicaid is crowding out state spending of all kinds, whether it is education, whether it is Public Safety or infrastructure or the waiting list. I dont want us to i would suggest it depends what states are doing with their Medicaid Program. Texas has not expanded its medicaid. So i that was the answer i would share with you. It is very interesting now that we look at some of the data, mr. Archambault, do you know which state has the second longest waiting list for home and communitybased services . Again, it depends on the population. By category, and there is no correlation between expansion or not. The concern is even states that have expanded also have waiting lists. So for me, it is about priorities. And for state lawmakers, theyre being put in a very tough position where theyre not able to help families like schuylers and thats deeply concerning to me. Well, florida is the second in that list of medicaid numbers, and they have not expanded with their medicaid issue. And, you know, i think we can sense a pattern here, so, you know, we need to cut to the chase, fully 61 of those individuals on waiting lists for home and communitybased Services Live in the 19 states that have not expanded medicaid. My home state of new york, one of the most populous in the country, and one which has enthusiastically expanded medicaid maintains a waiting list of zero individuals for acbs Waiver Services and a track record that has begun to be very favorable about per capita costs for medicaid. It is difficult for me to see the real world correlation that is addressed in testimony like yours where expanding medicaid and waiting lists for home where there is a contrast or choice that has to be made between expanding medicaid or waiting lists that grow for home and communitybased services. Do you have any actual evidence at all that speaks to that expansion and any correlation with acbs . Again, the point is that when you talk to governors and state policymakers, they are being put in a position where in arkansas they have been trying for years to address issues like families like schuyler now theyre having to just yes or no. Is there any correlation that you can cite, and ill remind you, youre under oath, is there any correlation you can cite . What i will say is yes or no, sir . There is no correlation it is not a yes or no question. Then the answer is. There is no correlation expansion or not on whether you have a wait list. So unfortunately, what were seeing from our Witnesses Today is a parade of alternative facts designed to obscure the simple truth. Medicaid expansion is working. It has provided Health Insurance to over 12 Million People. And my colleagues on the other side of the aisle are engaged in a cynical attempt, i believe, to pick good versus good in an attempt to gut this program and Rip Health Care away from millions of americans. I find it unacceptable. I find it shameful. And i dont think we should sit quietly while peoples right to health care is being threatened. With that, i just yield back the balance of my time. Thank you. I now recognize ms. Brooks for five minutes. Thank you, mr. Chairman. I dont think that trying to explore waiting list questions and waiting list issues is an attempt to gut medicaid. In my view its an attempt to strengthen the services and the ability to provide people with Developmental Disabilities, traumatic brain injuries, Mental Illnesses and ensure those people on the significant wait lists receive care. And id like to go back to you, mr. Archambault, with respect to i do think its more complex than a simple yes or no, is there a correlation, is there not a correlation. So could you please go into greater detail with respect to what your foundation, what you all have found, with respect to the waiting lists, with respect to the people who are on the waiting list, with respect to what the states want to do with the waiting list. Going to let you use most of my time. Sure, thank you, congresswoman. I would just say that to focus on a waiting list is a vacuum. Some states have what do you mean some states have deliver care the phrase im sure youre all very familiar with, youve seen one state Medicaid Program, youve seen one. Some states have decided to take their the people that would qualify for a waiting list and include it into an 1115 waiver request and deliver services in a different way. My point is that the principles by which we have as a country, for our safety net, is that we make sure that a Safety Net Program accomplishes a few things. One, is it targeted and tailored to the truly needy . Are we living up to the promises that we are making to these families and individuals before we make new promises . And is it fair to say those currently on waiting lists in the states are the truly needy . Is there any dispute about that . I think there would not be. And i would be happy to explore it, but im not sure how intellectually disabilities or Mental Illness would be seen as ones that we wouldnt want to people who typically cannot take care of themselves, is that correct . In schuylers example. People who are often not working, is that correct . People who truly are incapable of make of taking care of them physically or mentally themselves. Correct, and this was the traditional medicaid population preaca was the aged, the disabled, pregnant children pregnant women and children, excuse me, that we were trying to fulfill that promise to. The aca changed that discussion. And how did the aca change that discussion . Well, expanded to a population that is the vast majority 82 childless, able bodied adults. So, again, these are individuals that dont qualify for tannif, dont qualify for longterm food stamps, they have not traditionally been a population. And what is important for us to remember here is our goal is not to get people to stay on medicaid. We want to make sure they have Better Health outcomes and i think most of us would agree ideally it is if theyre able to work, out in the workforce supporting themselves and on private insurance. Thats ultimately, i think, where we want to be as a country and thats the discussion we need to be having. Is it fair to say most of the people who are on the waiting list who are the developmentally disabled traumatic brain injured people and those with serious Mental Illness are always going to be on medicaid . Correct. It is a different type of population and what has been your discussion and findings with the governors with respect to how most of them would like to take care of this population, if there are if there are consensus among governors, what is the governors and the legislatures view with respect to this population. Yeah, i think there is ongoing concern by governors theyre not able to be able to support these. I will say there are exceptions to that rule. And if you look at the state of kansas, the state of maine, those governors have been able to buy down their wait lists. I think main has gone from 1700 individuals down to 200 how did they do it . Well, they got some budget sanity, they did not expand medicaid and so they have been able to focus on eligibility as we have talked about today, to make sure that their programs are true ly focused on those that are the most needy, the age, the blind, the disabled and made that a priority in their state and they have had success in buying down their wait list. I think we need to continue to explore the states that have found ways to have little to no wait list. I certainly hope today our governor, governor hochom, it is an outstanding program, but i hope folks on both sides of the aisle, it is a way to save and to help those who truly need it. It can be replicated. I believe it is an incredible model that can work. Unfortunately we still have a waiting list. In indiana. We dont want a waiting list, but i certainly hope that with the new nominee to lead cms we seema vermy, a hoosier, we can make all of medicaid a far stronger and Better Program with controls in place. As a former u. S. Attorney ive worked with the units. We need to do more to support them. We need to do more to support all these efforts to make sure our truly vulnerable are protected. With that ill yield back. Okay. Now ill recognize ms. Clark for five minutes. I thank you, mr. Chairman. And i thank our Ranking Member. Before i get into my actual question, i actually want to respond to mr. Howard because as a proud new yorker, i must correct the impression left by your characterization of the empire state. Are you aware that the new york states Medicaid Redesign Team has been a National Leader in controlling costs and improving quality for medicare members . The Empire Center for public policy, selfdescribed as a fiscally conservative think tank and government watchdog released an analysis in september of 2016 that new york medicaid spending per recipient has dropped from 10,684 to 8,731, or 18 between 2010 and 2014. At nearly twice the National Average. According to the independent new york state Controllers Office, the mrt restrained total medicaid spending growth to only 1. 7 annually during the period of fiscal year 2010 to 2013. This marks a significant reduction over the trend for the previous ten years of 5. 3 . During the same three year period, medicaid reenrollment grew by more than half a Million People. Billions of dollars have been saved, and per recipient spending has been slashed. And in fiscal year 1415 alone, a total of 16. 4 billion was saved, thanks to the mrt initiative. This track record of success led the Controllers Office to declare the mrt represents the most comprehensive restructuring of new yorks medicaid system since the Program Began in 1966. And we have no waiting list. Id like to now turn to mr. Westmoreland. In mr. Archambaults written testimony, he cited numerous concerns about Medicaid Expansion. However, he ignores the fact that this program has also had a positive impact on the quality of life and health for millions of americans. He also ignores the fact that many of the positive impacts such as cost savings from preventative medical exams and Early Detection and treatment of disease will result in future cost savings to the states and the federal government. I am a strong supporter of Medicaid Expansion because i see the significant value of the program. Im interested in improving the program and not destroying it. So mr. Westmoreland, mr. Archambault claims that the Medicaid Expansion funding threatens the truly vulnerable. Can you clarify why this is not the case . I begin with first challenging the discussion as i did in my testimony of who is truly vulnerable. I want to be clear that not all people with disabilities, cognitive, traumatic brain injury, any of those discussions that have been ongoing, were traditionally eligible for medicaid. It was tied to a 75 poverty and receipt of ssi, and many people whom we would all consider to be disabled have never been eligible for the federal Medicaid Program until the enactment of the aca. So lets start with those people. Secondly, i would point out that there have been significant studies, economic and Macro Economic studies, some by Business Schools, some by economists, showing the states actually have significant budget savings and revenue gains by having the Medicaid Expansion in their state. So i think that its clear that states benefit on a financial basis, and that their citizens benefit on their financial basis in the ways that i outlined in my testimony. Mr. Westmoreland, both mr. Archambault and mr. Howard claim that Medicaid Expansion poses an unsustainable burden on state budgets. Can you clarify why this is not the case . Why have most states that have expanded medicaid actually experienced net budgetary savings associated with the expansion. Yes, lets start with the Health Care Expenses that as we discussed earlier there are fewer uncompensated care costs within the state. In addition to that, there is an influx of federal funds into the state to pay for services and those federal funds have a reverberating Multiplier Effect on the state economy. Finally, states are able to provide as you suggested preventative and Early Intervention services that might not have been available to uninsured adults before and actually lower the ongoing Health Care Costs for those people. My understanding that numerous studies have disproven the myth that Medicaid Expansion diminishes work incentives. Is that correct . Yes, maam. I yield back the balance of my time, mr. Chairman. Thank you. Now i recognize new member to our subcommittee, the gentleman from michigan, and reverend, mr. Tim walberg. Welcome aboard here to our committee. Thank you, mr. Chairman. Mr. Archambault, i appreciate the safety net illustration that we want to have safety nets. But we dont want to have safety nets forever for people. I remember i never worked over a safety net, but i remember working at the u. S. Steel south works and as third helper going out and being responsible to swing a sledge and take the plug out of a heat of molten steel. And had a fall protection strap on me. I appreciated that. But when the shift ended, i didnt want that strap, i wanted to move on. Thats a laudable goal, we find ways to make sure that people who truly need that safety net have it. We make sure that we dont waste it on others who dont and encourage them to move on in a very positive way. I would like to ask you for further response from your testimony and also miss maxwell, i would like for you to comment after mr. Archambault, your testimony references some of the waste and fraud issues that face our Medicaid Programs. Individuals that have passed away decades ago, individuals using high risk or stolen Social Security numbers and tens of thousands who had moved out of state yet remained on medicaid. What can we do to combat some of these problems more effectively . So there is a number of things that we would recommend and thank you, congressman, for the question. The first one is allow states to check eligibility more frequently. Under the aca there was a change that states could only redetermine eligibility once a year. Unless they were given a reason to recheck eligibility. We have found that states that are able behind the scenes to access data internally within State Government but also through Third Party Vendors, if theyre able to run those on a quarterly or monthly basis, theyre finding that these people individuals have life changes, just like all of us. And so whether they move or they die or whether they get a significant raise, we need to make sure that we find that sooner rather than later, otherwise were wasting money and i believe that there is vice partisan agreement on that, we need to make sure. The other thing is we need to make sure that the federal databases which we havent talked a lot about, the quality of the data in those is quite poor. If you talk to state leaders, they will complain constantly about how late the data is, out of date, and it is not flexible enough. So making sure that states are able to look for dual enrollment, for example, in the Food Stamp Program is moving in this direction, we should be doing it for medicaid, just to make sure were not wasting money as a result of individuals moving across state lines. Okay. Thank you. Miss maxwell, could you add to that . Thank you. I would love to. Would definitely echo what we just heard about the crucial need for better medicaid data. It hampers the ability to understand the program issues. But it is significantly deterred by us trying to find fraud, waste and abuse. In addition to that impact and protection, we also need to think about protecting the program from fraud happening in first place. In addition to the data, would encourage us to continue to work with states to improve enhanced provider screening, to make sure that providers that get in are the providers we want to get in and want to pay. Okay. Thank you. Mr. Archambault, an audit in arkansas revealed more than 43,000 individuals on medicaid who did not live in the state. With nearly 7,000 having no record of ever living there. More than 20,000 medicaid enrollees were linked to high risk identities, including individuals using stolen identities, fake Social Security numbers, et cetera. Something of interest to me in michigan has recently identified more than 7,000 lottery winners receiving some kind of public assistance. Including individuals winning up to 4 million. Those jackpots are something that encourage them not to be on medicaid assistance. Mr. Archambault, do these individuals get approved for and state enrolled in the Medicaid Program and is it the federal government or the states dropping the ball . Well, congressman, maybe a little bit of both to answer that question. And i think whats really important here is that there are some policy changes that have happened. The Affordable Care act removed an asset test for the Medicaid Program by and large. There is some that it still applies to. But as a result, these sorts of outlier cases admittedly but when an individual wins 4 million, takes a lump sum payment, they may not qualify that month, but the very next and the federal government needs to say if youre doipg this on a more regular basis, you can take that savings to pay for those efforts. That is not eainherent in the current structure weve set up. Thank you, my time has exp e expired. Thank you, mr. Chairman. As you know, i grew up the son of farm workers in the medically underserved community. I have seen firsthand what it means when a community is medically underserved and when they cannot access care and i can tell you this, it was not for medicaid, the Coachella Valley and regions like mine would not have access to health care from tha us on this dice and our families enjoy. If we repeal Medicaid Expansion, people will lose Health Care Coverage. They will stop seeing their doctors because the costs will be too high and theyll stop taking their life saving prescriptions because they are too expensive. In california alone, the nearly 3. 5 million individuals who enrolled in medicaid under a aca provision could lose their coverage. Thats millions of families losing access to health care. And if we repeal Medicaid Expansion, uncompensated costs will increase, straining our nations Health Care Systems, which will drive up coses for everyone. Because you see, when people dont have Health Insurance, they dont stop getting sick and our Emergency Departments do not turn someone away because they dont have insurance. Emergency physicians treat the patients. Like they should. So the hospitals have to make up the costs. And in 2014 alone, suitor Health Systems in california saw a decrease in uncompensated care by 45 in 2014. I am all hospitals in my district in particular hospitals are v seen a drop in uninsured patient bis half. So, we need to expand medicare even more. Make it more efficient. And more desirable for providers to see more medicaid insure patients. Fraud is bad. Cutting Health Insurance for sick patients is is bad, so, heres the possible common ground. Heres what i think we can both agree on. If we start with the premise that we want to cover more uninsured, economically struggling families like the middle class and more vulnerable families, then were on the same page, but if you read mistrust and millions will be harmed, including the middle class, so, the real question mr. Howard is are sick and injured people getting the care they need . Because anything short of this is negatiligence. So lets tackle fraud so that we can expand coverage to more struggling families. The question that i have, if you were to choose one thing that you can do to combat fraud, if theres one action that you can take that we can make the biggest difference in the system, what would that be . I think its around the providers. Making sure we have eligible providers who are in Good Standing and that those who are not in Good Standing and should not be providing services arent going across states to provide services. Thank you. The one thing, the one thing that will make the biggest difference. I would have to go back to the data. Without the transparency, we cant see whats happen ng the program and we have a lack of data across the nation and also data coming in from the managed Care Companies. Mr. Howard. One thipg you could change to make the biggest difference if fraud, what would it be . In fraud in particular . Engaged data transparency. Medicaid data should be on for all the states to look at. Thank you. What does the evidence suggest about how Medicaid Expansion is making health care more affordable . Is there evidence that Medicaid Expansion is reducing patients need the forego medical care due to costs . It is highly associated with the decline in personal bankruptries. Also associated with greater Financial Security for families who are newly eligible. So, these are middle class families having some Economic Security because of the Medicaid Expansion. What is the body of evidence say about how Medicaid Expansion has affected patients access to primary care and Preventive Care . People in those beneficiaries newly insured have much higher rates of traditional sources of care. Seen in primary care and using Preventive Health services. Thank you very much. My closing statement is if this is leading to increase in expansion for economically struggling middle class families, then you know, im in. But if the ultimate goal is to create a facade and amplify a problem politically to then justify policies that will hurt the middle class and decrease Health Insurance, then im not in, so lets tackle fraud so we can expand more Health Coverage to my l class families. Thank you very much. Thank you, now, were recognizing another new member of our committee from i think ucla, former state assemblywoman, state senator, mayor, congresswoman mimi walters of california. Supporters argued Medicaid Expansion would increase jobs. Has this happened . Predictions have been off. Whether enrollment or jobs. In particular, iowa, tennessee, where there were predictions of gains in Health Care Jobs as it related to expansion. The opposite has taken place. Where theres been a loss in Health Care Jobs. During the conception of the aca, supporters argued that expansion would stop hospital closers. Has this been the case . So, it has not stopped hospital closures in a number of states. Hospitals have still closed. I think its important to realize the supporters claim its a Silver Bullet to stop has not been true. Finally, Medicaid Expansion was projected to lower emergency room use. However, you pointed out that the evidence suggests that emergency room use has increased after expansion. And that many emergency room visits by medicaid beneficiaries were deemed to be avoidable. Can you explain what might have led to this yoult come . Sure. And my experience is not just influenced by the aca, i live in massachusetts and worked on romney care and have studieded it closely. Wup of the things that becomes apparent is both in the expansion population and traditional medicaid population is folks are not getting coordinated care because theyre showing up to the ers at a higher rate than those privately insured or uninsured. As a result, these are the questions we need to ask about. The effectiveness of the program, the quality of care that individuals are getting. Theres been a number of surveys looking at how many of these visits are avoidable and unfortunately at least in massachusetts, those surveys found that 55 of medicaid visits to the er were unavoidable. Thank you. I believe my time has expired. Recognize thank you. Thank you, mr. Chairman. The Affordable Care act has been a blessing for so many people in our county. 12 million more americans have access to health care. Governors across the country submitt eted letters in responso the and the expansion medicaid within our states. Something weve seen in these letters . Yes. Okay. Even some republican governors appeared to have positive things to say about the expansion of medicare in their state. For example, the letter from my home state of illinois stated that our, that the governor stated that our medicaid population quote now stands at 3. 2 million, almost the states population and it went on to urge Republican Leaders in congress to carefully consider the ramifications of changes, the governor of nevada stated in his letter to mr. Mccarthy that quote, i chose to expand medicaid, the program to require managed care for most enrollees and to implement a state based health exchange. These made Health Care Available to many nevadans who never had coverage before. Can you touch upon how the residents of states of expanded medicaid under the aca have benefitted such as illinois and nevada . Sorry, didnt understand the last part of the question. I sided illinois and nevada, but can you briefly touch on how the residents of states that did expand medicaid have benefitted . Lets begin with 11 Million People have medicaid coverage who didnt have it before and many of those people are in serious need. I would point out and ayee wigrh you, that of the governors who wrote to mr. Mccarthy, none requested appeal. 16 of the states of republican governors and ohio, mr. Kasich, one of your former colleagues, was most passionate who believe it was a moral duty. Thank you for that. Can you touch on how i also wanted to mention there are other principlexamples of state have had positive outcomes for their residents and beyond providing benefit to an additional st Million People, how has it helped statesmanage their budgets . Has it had a positive impact . As i suggested earlier, there have been Business School studies and economic studies suggesting the states with expanded medicaid, who not only met increase in federal funds coming into the state, but also enjoyed revenue increases because of effects providing those funds in hospitals. I would also point tout to you that there is a longterm study to be done. Of how productivity might be impro improved. Thank you u. Some of the letters i was referring to seemed to raise concern by republican governors the changes to the Medicaid Program would produce destabilizing cost shifts to the states. For example, governor baker of massachusetts in his letter to mr. Mccarthy said quote, medicaid is a federal and shared state partnership, proposals that states may be provided with more flexibility and control must not result in substantial and destabilizing cost shifts to states. So, is there a valid concern of a major cost shift under the republican proposals youre seeing such as prop proposals t caps on spending. Should states be concerned about major cost shift sns. States should be very concerned. The first question is what level will the block grant and its formula be set at. The major questions for states to be set on is how the evolution, the increase of funding in the future will evolve as compared with the actual cost of providing Health Care Services to the number of people who need them. States will be left holding the bag for both medical inflation and the number of people who have no Health Insurance. What about for those that are receiving health care through acas Medicaid Expansion . Are they at risk, particularly if they block grant the Medicaid Program . First, id suggest my colleagues on this panel would point out those, suggest those people should be the first to go. Off of the health care rolls and they would return to traditional medicaid populations as theyve existed over the last 20 or 30 years. So, i would suggest that people who are Medicaid Expansion are those likely to be on the chopping block to begin with. Secondly, no expansion expeerps the growth thats almost inevitable, if the states are left holding the bag and they dont have a guarantee of federal fund, theyre going to be cut iting back on even. Thank you, i yield back. Another new member of our committee. Mr. Costello of pennsylvania. Thank you, has the number of criminal investigators increased or decreased over the years . The number of criminal investigators specifically . I think right now, we are below our ftc. We are still trying to hire more. How many more do you think you need to hire. Well, we would hire as many as you would let us, but we need, 1700 is where were pegged for. The entire oig. True or false. For every dollar, 1. 70 is returned to the health care and abuse program. True. Has that been a consistent return . Zm around 7 and same for the fraud units. They have a similar roi. Youve conducted a review of state medicaid agencies presented with allegations of provider fraud. Did you find that state agencies properly suspended payments to those providers . They did not make full use. They did not. Although in a number of the cases where they did not suspend, they cleared the provider of wropg doing. Very good. Since your work on the issue of Program Integrity, has found the claims of matching dollars is inadequate to safegua federa dahl l dollars, what more could cms be doing with watch something. Given that cms and states share risk, we should they should share accountability. Prevention, helping statds implement the enhanced provider screening, helping them drive down proper payment rates and of course, the data to be able to understand the program and to tech fraud and more importantly, the data helps us hone in and really target our oversight so we can get this tricky balance right between trying to have really strong Program Integrity, but also not put an undue burden on its provitders. Going this shift this question. But feel free to respond including whatmention ed about the issue of enhanced data matching technology. If you have technology and you have data, knowing that we have the data, knowing were an advanced society, it would be yez year to detect eligibility to cut down on those who are ineligible from being accepted. I see in your written testimony, in the first ten months of operation, pennsylvanias Award Winning Enterprise Program identi identified more than 165,000 individuals receiving benefits including those in prison, even millionaire lottery winners resulting in nearly 300 million in taxpayer savings. What can we do in order to pivot to real time identification of something that doesnt seem quite right, rather than just relying on the one moment if time annually to beef up Program Integrity here. For them to be able to keep a piece of that savings up front and more than they get to save now, given the funding formula that we have. The other one is let them check more frequently. If the federal governments data is not timely enough. We know who were doing business with. In one case, we found the state Medicaid Agency thought there were 63 owners. They told us there were 12. So trying to coordinate this data, so all the programs know who were doing business with. In addition we recommend the data be improved. While we are a tech knowledgically advance ed socie, the Medicare Program is not. There is a lot of work to do to get good data systems that are more flexible and more agile. It rules for substantial improvement in data systems and this committee lerted the Effective Date of that. I think its a valuable addition to be able to find. I agree with my colleague that is the data systems need to be improved inning andrea i think the rule does that. Thank you all for your comments. Thank you and now, recognizing another new member, the owners of carters pharmacy. Is that a place where we might see someone like ellie walker and o p, ie . Very much so, but understanding a small town medical care. Buddy carter. Thank you and thank you for being here. We appreciate your participation. I want to preface my questions by apologizing if i ask you something you arent prepared for and if you doebt know the answer, just simply tell me you can get me the answer, that will be fine. I understand looking at your bio last night, that you have some expertise on the 340 b program. I do. I dont to get into that, but i have a hospital in my district that was participating and receiving moneys from the program and they got back in it as i understand, there are two Different Levels you can be at as a Sole Community provider and disproportionate share. Both covered entities. They got back in it as a theyre losing over 300,000 a month. Now, that is significant for them. Im sure for anyone, but for this hospital system, its very significant. Now, he also is telling me that the formula that is yusz used for that, that medicaid participation, the medicaid rate is also in that formula to determine what there are a Sole Community or in the disproportional share. And what im hearing is that those states are put at a disadvantage and that we arent eligible for that. Is that true . Is that the case . Im going to have to take your offer to get back to you on that. Thats fair enough, but my question is twofold. I couldnt speak. Please include that in your answer. Im going to move now to a sk you the video you showed there, now, understand, i spent ten years in the Georgia State legislation. All in health and Human Services, so i understand about medicaid and you know, we did the hospital tax in order to draw more dollars down. You bring up a valid point about how my question is about the video you shows. Now, i am a strong believer that medicaid should include the age line of disabled. In fact, i think that if and if youll help me, that most of the cost of the Medicaid Program can be attributed to the abd. My question was why didnt this passion this patient eligible . It would have seemed to me they wouldnt have had to wait on the waiver. Thank you for the question and i think its important to know that we are talking about a couple of dichbt things here. There are some services that she could have access to under these programs, so for skyler, cant just call a neighbor to baby sit. You need to have certain skill ket seths to be able to watch her given her condition, so this would allow access to those services. Im one who believes that medicaid should be taken care of that group. Once you get past that, we can have a discussion and debate. I honestly believe as a health care professional, they should be covered. That is my point. Exactly. Good, thank you for that. New patients are going to cost 6,366 per enrollee in 2015 and that this is a 49 increase in what they have projected before. Why is that . Why are they costing more . Congressman, may be because in these new expansion programs states have raised their reimbursement rates to providers to get newly eligible population in the system. Thats my understanding. It would appear to me if the again, i get back to the age, blind and disabled, if they were already included, they are the most expensive. And why are they im sorry, i know im running past my time. Just baffles me why it has gone up that much. Okay. Thank you, mr. Chairman. I yield back. Okay. Thank you. Now recognize mr. Collins for five minutes. Thank you, mr. Chairman. Ill be directing this to you, mr. Howard. Some background. Im western new york, new york, as we all know, is one of the highest state in medicaid per capita spending and total spending. While new york only has 6. 5 of the population it accounts for 11 of the National Medicaid spending. According to a 2014 report from medicare, and the chip payment and access commission, using data from 2011, new york spent 44 more per medicaid enrollee than the National Average. All kinds of complex and fragmented funding streams that make it very difficult to provide adequate accounting controls for the program. So the question is this, in 2012, a report from the hhs office of the Inspector General revealed that new york had systematically overbilled federal taxpayers from Medicaid Services for the mentally disabled for 20 years. New york state Developmental Centers, which offered treatment in housing for individuals with severe Developmental Disabilities had received 1. 5 million annually per resident in 2009 for a total of 2. 3 billion. They were compensated 10 times higher. So the simple question is, how could these overpayments go unnoticed for 20 years . Congressman, it is because there is simply no financial incentive for the states to go back and police their symptoms in a way that would result in a decrease in federal funding. The state of new yorks settled with hhs i believe for 1. 63 billion for over payments, i think 2009 through 2011. So to some extent the problem was remedied, the reality is the ratchet only goes one way. Congresswoman clark pointed out earlier, that Governor Cuomo has had quite a bit of success which i noted in my testimony in bringing down the payment rate for the growth rate for medicaid. I think if someone who had an r by their name had suggested what is effective for new york state, a cap on growth of the most nondisabled part of the program, held to 30 effectively below the historical payment rate for the program there would have been compromise of poverty, and we would be throwing people out of the program. Miraculously, new york state providers found ways to significantly decrease their spending by hundreds of millions of dollars. I think the belief that significant flexibility or block grants or per capita caps ignores there is significant opportunity for efficiency in health care and until we give states Better Programmatic and financial goals to seek out that efficiency, we are not going to be getting the best outcome for every dollar were spending on health. Well, you know, being a new yorker and bringing this up i would have to say, you know, while we they apparently negotiated a significant settlement, it did not reimburse the federal government for 20 years of egregious behavior, which i would say was deliberate. You cant be charging ten times the National Average for 20 straight years and try to, you know, prove that this was not intentional. So, you know, we talk about rs and ds, i wonder if there was a d behind the president s name and d behind our governors name if that settlement would have come closer to reimbursing the u. S. Taxpayers. But what i think was grand theft auto. So another question about new york, and by the way, the reason i come at this the way i do is county executive of erie county, largest upstate county, were one of a handful of states where the counties have to pay a share. By the way, on dish and igt for upl, the counties pay 100 of the federal match. The state pays nothing. And in the case of erie county, my county, second, third poorest city in the United States, city of buffalo, 110 of our property taxes went to medicaid. We couldnt raise enough property tax to even pay our county share of medicaid because of the way new york state runs this program. We had to supplement it with sales tax revenue. So thats why i get a little emotional when i find out the state has been cheating for 20 years, especially the way they handle the counties. But also, as i understand it, in a 2009 report, new york state ranked last in affordable hospital admissions, last. So our outcomes are so poor, what is going on in new york and we only have 20 seconds, but just quickly, i think there is consensus that the amount of spending we put on health care does not automatically correlate to better outcomes. So if you look at a scatter plot of state spending per enrollee, it is all over the map and outcomes are all over the map because there is an increasing body of research that says Health Behavior dictates longterm outcomes. We have to think about health differently. I couldnt agree more there is no correlation between spending and outcome. Thank you very much for your testimony. Now recognize the chairman of the full committee, welcome back, mr. Walden, recognized for thank, mr. Chairman. Thank you for conducting this oversight hearing. I want to thank our Witnesses Today for your extraordinary testimony. It is very valuable in the work were engaged in. I want to focus on data and high risk. Especially to both the gao and to the hhs oig. My understanding is for 14 years running, medicaid has been on your high risk list. What is behind that . Is that because cms does not collect the right data to begin with . I think there is a couple of things behind it. One is the nature of the partnership itself that by the time the federal government is reviewing expenditures, the expenditures have occurred so that prevention ability is always challenging. The second piece really is about data, you simply cannot run a program this large when you cant tell where the money is going and where it has been. And we need better data. And so have you made recommendations to cms to collect better data and have they ignored those recommendations or what is the issue there . We have a report coming out in a few days that might answer that question a little more fully. But i think feel free to go ahead and share it today. The ig has been focus ed on this area for quite some time. We have followed evolution of the National Data and continue to push cms to create a deadline for when they think that data will be available specifically for Program Integrity reasons. So one of the issues that has come up in the press is this issue of wood working. Everybody is trying to count numbers here, and i would like what you said about lets get to the quality outcomes, but off that for a minute. There is this issue of wood working. How many people are eligible before that are being counted now as if theyre new eligibles. My question is, do we know that answer . And, second, are there states that are getting reimbursed at a higher rate as if we were paying for newly eligibles and what would be a 95 rate now, when, in fact, those individuals were actually always eligible and should be the states should be compensated at a lower rate. Do we know any data surrounding that, how many people are actually wood working, have states been reimbursed at a higher rate when they should have been reimbursed at a lower rate . I cant speak to the working numbers specifically, i can tell you that ig has the same question you have and we have work under way to answer that exact question. Are states pulling down reimbursements for beneficiaries as if they were in the newly eligible category when they should have been enrolled in traditional medicare, medicaid. And that work will be forth coming. Do you have a timeline on when you think you may have answers for us on that . We have four states were looking at. The next two states, the next couple of months will be out, and the other two probably later in the year. Can you reveal what the four states are . I can if you give me a minute. Okay. We did have we did issue some work that looked at this question. And we did identify some issues where it appeared that people were not accurately categorized by whether they received the 100 match or state expansion match or that regular f map. We did identify problems there. And one of the recommendations that is still outstanding in this area has to do with the fact that cms adjusted the eligibility differences but then did not circle back and correct the financing that occurred. So we think those two things need to be related. If you identify an eligibility issue, either way, if the matching rate is off, it should be corrected. Cms is starting to look at that, but it could be a big number. We dont know. But it is an important thing to get right. I remember i spent about 4. 5, 5 years on a Community Hospital board at a time when the federal government decided to go after every hospital on the ledge, billing misbehaviors, going back, i dont know, eight, nine, ten years. And the threat to the hospitals was we will use the rico statute because you have engaged in criminal practice because of multiple cases. And it strikes me that they are willing to do that there, everybody had to settle because. It just strikes me that they were willing to do that there, everybody had to settle, nobody wanted to go after that path. We know the government sometimes gets it wrong, we never go after the government with rico. What is happening with these people ageblind disabled and we dont have the resources or the data, thats what youre telling me, is it . Yes. I have the states. They are kentucky, california, new york and colorado. Kentucky, california, new york and colorado. Your timeline again to probably conclude your analysis . The first couple probably in the next month or two and the final two will be later this year. All right. Be sure to let you know. If we could help you do your job the way you want to do it, what would that be . I hate to keep saying that. Its got to be the data. We absolutely need the data. The same . I would agree. If there are specific items related to data, please get those to us, i will be happy to work with the cms administrator to get you the data. Its important for us for all our Decision Making and we know we have people on lists and cant get access to care. We have to get the waste and fraud out. Thanks for your testimony and mr. Chairman, for your leadership. I have one more question of mr. Howard. This relates to trying to find other ways of saving money and effective medicaid. It has to do with alternative payment models as a way to reduce costs, that means physicians and hospitals are paid to take care of the patient opposed to a fee for service, every time someone shows up. Sort of like paying a carpenter based on how many nails he puts on the house, he will put a lot of nails in the house, otherwise alternate patient model that checks on their medication, counsels them, to keep them out of the emergency room and keeps them out of the emergency room. It amounts to 30 billion in 2015 with an error rate hovering around 10 . Studies like the oregon experiment shows medicaid coverage does not necessarily result in Better Health outco outcomes. What do you think of these alternative payment models sh showing the skin of the game is theyre doing all they can to keep the patients healthy . Absolutely. Experimenting with models is healthy. You talk about fraud, waste and abuse is a big problem and estimate s for people like donad is 20 of care is ineffective and wasted. There are providers we know doing an excellent job. If we had data transparency we could encourage more competition across these payment models. Could you get us information how you get those things . Absolutely. A followup comment . A couple comments, mr. Chairman. The first is heres something we can agree on in a bipartisan way, getting you folks the data you need. I will echo what mr. Call den said, whatever specifics you need and that staffing. If we freeze you, it will be a problem. I want to make a couple comments about the Medicaid Expansion. First of all, i keep hearing people today say we want to make sure people with chronic and severe diseases like the videotape we saw, get service. Thats absolutely true. Then people on the other side talk about ablebodied adults. I would point out 85 of people getting the Medicaid Expansion are working. They might be ablebodied adults but they have jobs. They were uninsured before either because the employers didnt offer insurance or it was too expensive. These people are going without healthcare and as mr. Westmoreland said that increases the cost for everybody because of the costs of uncompensated care. If theres ways, i was just talking to miss brooks about this, if theres ways we can find efficiencies in the program, all of us are for more efficiencies and were for delivering healthcare in a more Cost Effective way not just medicaid but insurance, too. We can work in a bipartisan way to make this happen. To say, we shouldnt give the Medicaid Expansion because these people are quote ablebodied adults is not understanding whos getting it. I want to close with an email i got from my best friend in South High School in denver, colorado, we are not Spring Chickens anymore. Heres what my friend, laurie sent to me a couple weeks ago without solicitation, she just sent to it me. I just want to add my story to others you are hearing about the Affordable Care act. I was laid off during the recession and lost a lot of my retirement stability. Then, at age 54, i looked for a job for three years without success. I had no Health Insurance. Finally, i fell back on my journalism skills and landed work writing for several neighborhood papers. This has worked out fine but only because of getting insurance through the aca. I make very modest money so i qualify for the expanded Medicaid Program. What a godsend. Since im not yet medicaid age but too old for the job market, i dont know what id do without this help. This is the people were talking about. We have to figure out how were going to give healthcare to the 11 to 12 Million People who have gotten healthcare because of this Medicaid Expansion. Thats what were talking about. Thank you, mr. Chairman. This will bring to a conclusion this hearing of the medicaid oversight committee. I remind witnesses you have 10 days to submit questions and ask the witnesses to respond prom promptly and this subcommittee is adjourned. Subcommittee. Watch as President Donald Trump delivers his first address to a joint session of congress. This congress is going to be the busiest congress weve had in decades. Live, tuesday february 28th at 9 00 p. M. Eastern on cspan and cspan. Org and listen live on the free cspan radio app. Tonight on cspan3, a look at the role of journalism in disclosing classified information from the government. Later, a confirmation hearing for President Trumps pick to head the centers for medicare and Medicaid Services. Investigative Journalist Bob Woodward took part in a discussion about the pg papers and how their publication in 1971 changed the medias relationship with the government. Speakers also looked how coll t collecting and disseminating classified information has changed. From georgetown, university. This is an hour and a half. Good morning. Im Sanford Unger and delight to welcome you here or welcome you back for those with us for my conversation with daniel el elseburg for the publication of the pg papers 46 years later. I think dan will be with us again today and with us in the audience and making his presence known as we go on. He is the person who made it possible for us to be here. We are live on cspan. I think its cspan3. It will