Medicaid Moving Forward

Medicaid Moving Forward
Hart Senate Office Building (Room 902)
Monday, April 3, 2017

12:00 – 12:10 p.m. Welcome and Introductions

• Sarah Dash, @AllHealthReform
  Alliance for Health Reform

12:10 – 12:45 p.m. Presentations

• Sara R. Collins, @SaraCollins_
  The Commonwealth Fund
• Gail Wilensky, @gailwilenskycom
  Project HOPE
• Sara Rosenbaum
  George Washington University

12:45 – 1:30 p.m. Question and Answer Session

PLEASE NOTE: This is an unedited transcript. Please refer to the video of this event to confirm exact quotes.

SARAH DASH: Good afternoon, welcome. I’m Sarah Dash, I’m President and co-CEO of the Alliance for Health Reform and for those of you not familiar with us, the Alliance is a non-partisan, not-for-profit organization, we have been around for 25 years and our mission is to inform policy makers and health policy leaders on the most pressuring health policy issues and get you guys the foundations of health policy, the evidence and the practice.

Today, we are here to talk about one of the most pressing health policy issues that has been making a lot of headlines recently, and that is the Medicaid program. Medicaid covers over 70 million people, as we will hear, and it is responsible for taking care of very, very diverse populations with an enormous range of medical needs from healthy newborn babies to children with very special healthcare needs, to low income adults, people with serious illness and disability and more. As we all know, recent legislation proposed the American Healthcare Act would have made major changes to the Medicaid program and certainly the discussion about the program is not over. Today’s briefing is going to examine the relationship between Medicaid coverage, access to care and health outcomes, as well as what might be next for Medicaid in the States and Congress and in the administration.

I would like to thank first, our sponsor for today’s event, our partner, the Commonwealth Fund. We are very grateful for their support of this briefing.

Before I introduce our panel, I just want to take care of a couple of housekeeping details. First, for those of you who need wi-fi credentials, they should be up on the screen. You can tweet to #futureofmedicaid and when the time comes for questions, many of you know the drill, but write your question on a green question card, or come to one of the mics on either side of the aisle or tweet your question to #futureofmedicaid.

Without further ado, I’m going to go ahead and introduce our panelists. We are still waiting on one panelist, but she will be joining us shortly. Our panel — to my left is Sara Collins, she is Vice President for Healthcare Coverage and Access at the Commonwealth Fund. Gail Wilensky will join us. She is an economist and Senior Fellow at Project HOPE. She directed the Medicare and Medicaid programs from 1990 to 1992 under George HW Bush and all the way to the left there is Sara Rosenbaum, she is the Harold and Jane Hirsh Professor of Health Law and Policy and the founding chair of the Department of Health Policy at the George Washington University Milken Institute School of Public Health. So, I’m going to turn it over to Sara Collins and we will go ahead and get started. Thanks.

SARA COLLINS: Thank you, Sarah and good afternoon to everybody and thank you to the Alliance and also the panelists for joining us today.

As Sara mentioned, a major focus of the American Healthcare Act was the Medicaid program, both the Medicaid expansion and also the traditional Medicaid program. The bill likely would have ended the Medicaid expansion over time, and it would have placed a federal funding cap on the traditional Medicaid program. In the wake of the failure of that bill, the question before us now on the panel and for all of you, is what is next for Medicaid? To set us up for this discussion, I’m going to focus on the Medicaid expansion, refreshing our memories about where the states stand on their decisions to expand the program and taking a look at the latest research on the effects of the expansion on coverage as well as other key indicators.

As of today, 31 states and the District of Columbia have expanded eligibility for Medicaid. Of those, six have used 1115 demonstration waivers, granted by HHS. These six states have struggled to reach political consensus on expansion and found agreement in alternative approaches, such as enrolling Medicaid beneficiaries and marketplace plans in the case of Arkansas and imposing greater financial responsibilities on beneficiaries including higher premiums and cost sharing. There are currently four states that are actively discussing expansion — the Kansas legislature has passed a bill to expand Medicaid, although the governor has vetoed that bill, the legislature is attempting to override it. Governor Deal of Georgia has expressed interest in expanding Medicaid. In Maine, Medicaid expansion is a proposition on the November ballot this year. In Virginia, Governor McAuliffe has submitted a budget to the legislature that would expand Medicaid with a Republican controlled legislature, considering it this week. Other states where expansion has previously been under discussion might be states to watch this year. They include Idaho, South Dakota, Tennessee, Utah, Wyoming, and a few other states.

Based on the Commonwealth Funds latest state scorecard, which we released in March, and numerous other federal and private surveys, it’s pretty evident by now, with three full years of experience in the Medicaid expansion, that it’s made a significant difference in coverage in states across the country. Uninsured rates have fallen in every state since the major coverage expansions of the Affordable Care Act went into effect, but they have fallen the furthest in states that have expanded Medicaid. There are nine states that saw declines in their uninsured rates of 10 percentage points or more by 2015, and they were all in Medicaid expansion states. Kentucky had the largest decline, followed by California, New Mexico, and West Virginia. Since 2014, coverage gains have been the strongest among adults with lower incomes and it’s in this income range where the differences between Medicaid expansion and non-expansion states, have been the most evident. Uninsured rates in expansion states among adults with incomes under 200% of poverty, fell by 14 percentage points over 2013 to 2015, compared to nine percentage points in non-expansion states. Coverage gains since the passage of the Affordable Care Act, have been associated with gains in access to healthcare, but these gains in access on average have been greatest in states that expanded Medicaid. If you look at the middle bars in this chart, the share of low income adults reporting that they had skipped healthcare because of costs, fell by 5.5 percentage points between 2013 and 2015. In states that expanded Medicaid, compared to a decline of about half of that in states that hadn’t expanded their programs. Likewise, fewer adults across the country report that they don’t have a regular doctor. But again, these declines have been the greatest in states that expanded their programs.

Let’s just consider the case of Kentucky and Tennessee. I use this example because these are border states in the South with similar demographic profiles, but which took polar opposite approaches to their Medicaid expansions. Kentucky expanded their Medicaid program and also ran its own marketplace, for a few years anyway, and also conducted an aggressive outreach campaign to encourage enrollment. Tennessee did not expand Medicaid and did not run their own marketplace. The states had similar uninsured rates prior to the Affordable Care Act. The uninsured rate in Kentucky, among adults with low incomes, fell by 25 percentage points. They fell by only nine percentage points in Tennessee. Kentucky also experienced the largest decline in the country in cost related problems getting care. The share of low income adults who said they had gone without healthcare because of costs, fell from 34% in 2013, to 21% in 2015. In contrast, Tennessee experienced no significant improvement on this measure. Likewise, many fewer adults in Kentucky reported in 2015 that they didn’t have a regular source of care, compared to 2013. And again, Tennessee did not see any measurable improvement in this measure.

Ben Summers has been conducting a survey of low income adults in three states since 2013, to track the effects of Medicaid expansion. He selected Arkansas and Kentucky, both of which expanded their programs, and Texas, which did not expand. His analysis have found significant improvements on key measures of healthcare use and self-reported health status in Arkansas and Kentucky, relative to Texas. For example, compared to adults in Texas, adults in Arkansas and Kentucky had significant increases in getting checkups and significant decreases in visits to the emergency room. Ben also found that low income adults in Arkansas and Kentucky experienced marked improvements in affordability, including a dramatic drop in annual out-of-pocket spending, since 2013, compared to adults in Texas.

One of the policy rationales for repealing the Medicaid expansion that we have heard a lot about, is the contention that Medicaid provides inferior coverage compared to private insurance, and that having Medicaid is almost like being uninsured. But research hasn’t really supported this claim. For example, this study that the Commonwealth Fund did using the Commonwealth Fund biannual health insurance survey, found that Medicaid provided adults access to healthcare and financial protection that on most measures was comparable or better than that provider by private insurance and better than being uninsured. CBO estimates, estimates that by 2026, more than 70 million people will get their insurance coverage through Medicaid. As Sarah said, that many get their coverage now through Medicaid. And 15 million of them, through the Affordable Care Act’s Medicaid expansion. This quick overview that I just went through, suggests the value of this coverage in helping people get the healthcare they need, particularly large numbers of people with low incomes across the country. The program is really a cornerstone at this point in the U.S. health insurance system and it really should be a concern of policy makers to ensure its strength and viability over time.

In terms of what we might see in the next year in terms of Medicaid policy, some of the key questions are: Will more states move forward on expansion? Will CMS grant greater flexibility for states through the 1115 waiver process? And what will be the implications of that for enrollees? Will Congress return to pursuing policies that would place state caps on federal funding of Medicaid, such as block grants and per capita caps, and if so, what are the potential implications for enrollees? I will stop there and turn this over to Sarah.

SARAH DASH: Thank you, Sara. So, we may be non-partisan, but we seem to have a bias towards people named Sara today. Gail Wilensky is here. While she is getting settled, let me just ask, many of you obviously have been following the debate, but for those of you who maybe need a little bit of a refresher, can you just explain the difference between block grants and per capita caps? And I will let Sara Rosenbaum chime in on that as well, so that will help set the stage for the rest of the discussion, thanks.

SARA ROSENBAUM: Good morning everybody. Can you hear me? So, a block grant is a model of federal funding in which the federal government basically comes up with an aggregate cap on the federal contribution to state Medicaid programs. Many factors go into that aggregate cap. The Congressional Budget Office has very useful information on some of the factors that go into or could go into estimating an aggregate cap. The Commonwealth Fund has put out a short piece on how aggregate caps are built. But the point is, it’s an aggregate cap and it doesn’t necessarily relate to — and certainly over time, probably would not relate to actual population growth. A per capita cap is an approach to federal funding limits that would presumably tie to the number of people actually insured. So, as the number of people goes up, or goes down, the cap, the amount of funds would change. But as with an aggregate cap, a per capita cap also includes many factors that determine how it’s going to grow going forward. So, while a per capita cap might grow in relation to population, it’s not necessarily the case that it would grow in relation to changes in service intensity, changes in the price of insurance, or the price of healthcare and other changes that would affect spending on a per person basis.

SARAH DASH: Thank you so much. I’m just going to give Gail a moment here to get settled again. Gail Wilensky, we are thrilled to have Gail with us. She again, ran the Medicare and Medicaid programs under President George HW Bush and has many accomplishments besides that, as do the other panelists and I hope you will check out their bios in the packets. With that, and we have heard an overview of the current state of play from Sara Collins, and I will turn it over to Gail Wilensky. Thanks, Gail.

GAIL WILENSKY: For those of you who don’t know it, the Metro is shut down between Metro Center and Union Station and we have opening of the ballpark and so there are a gazillion people trying to drive around. But, I’m delighted to have been able to join you.

Fortunately, I had seen Sara Collin’s Power Point, so I know the points that she was making. I have a couple of observations that I wanted to share with you. The first is that it is important to acknowledge that Medicaid has been the ACA’s clear success story. And I don’t think we can ignore what we have been able to see. The Medicaid expansion actually accounts for the majority of newly insured, it has been able to do this without experiencing the kind of turn that we have seen in the exchanges, but on the somewhat negative side, the spending is running much higher on a per person level than was predicted. The second year, as expected, tends to be lower per capita spending than the first year somebody is on. Even so, it is way above what the expectations were. So, that’s one observation point.

The second, and this is something not actually related to the ACA, other than in a very peripheral way. The Medicaid current match structure really makes very little sense for anything other than to start a program. What you have with the ACA expansion is the highest match rate covering the higher income of the poor low income population. It started, as you all know, at 100%. It is in the process of walking itself down to 90%. Even so, that is way beyond the matching rate that exists for the base Medicaid population, which as you know is between 50 and 73%. It not only doesn’t make any sense to have different match rates for different parts of Medicaid, SHIP of course falls into this as well, but this seems to really have it backwards. You would think the federal government ought to pay a larger share for the poorest of the poor and not for those that are near the cutoff, in terms of Medicaid expansion. We understand why that happened, to try to lure as many states in as possible, but once we are on any kind of stable footing, that needs to be resolved. We need to find a match rate, probably somewhere between the base match rate and the new match rate, and have it apply for the entire Medicaid program. Having these three different match rates for different pieces of Medicaid SHIP makes no logical sense whatsoever.

The third issues that I want to raise is something that I have been commenting on now, probably longer than I would like to remember, but at least the last 25 years, which is that the states — we don’t usually give them enough credit for creative financing and creative thinking, but the states have shown themselves very able to find various types of financing strategies. The end result of which is their part of the money is less than what is statutorily required. It has gone through various versions. The first started just before I was running Medicare and Medicaid, around 1989-1990 with something called Voluntary Donations. It is in some ways, because it was the most egregious, the easiest to explain and understand. For those of you who didn’t recall this activity, it started in West Virginia, and basically what happened was the hospitals would put up the state’s share of the matching rate by donating money — that is the voluntary donation part — to the state. The state would then use that money as its match money for the Federal Government. It would get the federal match and the money would then go back to the hospitals, including their piece, which meant that basically the only new money in the system was that that came from the federal government. There are various other strategies that eventually was sufficiently egregious that it was shut down, but provider taxes frequently function in basically the same way. Tax gets put on a group of either the physicians or hospitals. That money is part of what is used for the match. The match comes in, the matched money and the base money goes back to the source either in its entirety or in large part. There have been more sophisticated ways which make it harder sometimes to shut down, involving inner-governmental revenue sharing. Since that is a legitimate activity between the state and the counties and the state and the city, that is harder to get rid of. Also, not having an upper payment limit that bears any relationship to cost, has allowed states to do this.

The upshot, and this has been true as late as an OIG report that came out in 2016 for 2014, right before the match started, is that what we have assumed was the major constraint, that is the state’s share of the match, isn’t really doing the job in the structure that it was intended to do. One could question if the match was as small as 25%, whether it would have anyway, for the poorest of the states, but it is just not a structure that continues to make sense. As an economist — a public finance economist, I was actually always taught matching grants are a good structure to follow because it gets contributions from the person receiving the money and is a way to try to have a maintenance of effort. Good in theory, this has proven not so good in actual practice. Which is why I would like people not to be so dismissive of the notion of a per capita block grant. It fundamentally depends on the baseline that you use, the starting point, which is at the moment a bit awkward in the sense that 31 states, mostly blue states, have expanded, the other states have not, mostly red states. Kansas is trying — Governor vetoed it. North Carolina and Georgia are thinking about it, but we need to find what is a rational starting point and then we need to have a reasonable index to use, something maybe not quite as high as CPIM, the medical component, but definitely higher than the regular CPI, maybe somewhere at least to start at CPIM and then walk down a little bit as the exchange subsidies really want to do. If we were going to do something like that, and throw in the requirement of a few outcome metrics, five or six, we could have a very rational program. If you look at a Medicaid per capita block grant as a way of providing large amounts of revenue saving, then what I have just said really doesn’t hold.

SARAH DASH: Thank you, Gail. I will turn to Sara Rosenbaum now.

SARA ROSENBAUM: Thank you very much. I think we have sort of heard a couple of things now, one is, of course, from Sara Collins: Has Medicaid worked and does it work? And the answer is yes. I mean, whether you measure in terms of coverage, and of course, Gail echoes the same point. Or whether you measure it terms of access to care. Medicaid appears to do just what we want insurance to do.

The second point, which is the one that Gail is raising is: What should the financial partnership in Medicaid look like? What are ways to allow the program to do what it’s supposed to do, while maintaining some sort of control over program size and growth. And the third is, which sort of flows from the second point is: If the financial partnership is going to change, how do we change or do we change some of the structural aspects of the Medicaid program. I think it is absolutely imperative that we find answers to these questions. I first encountered the Medicaid program as a 24-year-old legal services lawyer in 1975, or thereabouts, in rural Vermont and have spent 42 years just extraordinarily moved really, by what this program can do and what it means to people. I think that this is not a program that we want to see live in a world of terrible uncertainty. It is a program that we should really spend some time reaching consensus on. Careful consensus. Its size tells us we need to do that. 71 million people and counting. It is the least costly way to ensure people. Its costs are appreciatively lower than buying into commercial insurance in the private market, assuming that you are going to buy coverage that does not leave people with breathtaking deductibles and cost sharing. It’s clearly a program that is able to achieve a mission and I think despite arguments to the contrary, it’s very hard to sort of overcome the kind of evidence that Sara presented and that other studies have shown.

The complexity in Medicaid is reaching some sort of new stasis, and that is because Medicaid, as far as I can see, plays five basic roles in the nation’s health system, and there really is no substitute for this program. Medicare doesn’t perform like Medicaid. Small discretionary grant programs clearly don’t perform like Medicaid, and commercial insurance can’t perform like Medicaid. It’s not built to carry the kind of burdens that Medicaid carries. The first mission, or the first role of course is the one that really was brought into focus by the Affordable Care Act and that is Medicaid as an insurance system for the working population and their families. The normal mechanism by which Medicaid achieves that level of coverage, of course, is through enrollment in managed care plans and I actually suspect, I’m not sure, that that — sort of the initial bump up, substantial bump up, was because states and plans had a tough time, just like in the commercial insurance market, in figuring out exactly where and how to set rates for newly insured population that includes some — a lot of young healthy people, young healthy workers, but also older, sicker people entitled to alternative benefit coverage.

Second, the program is really — and part of it is that I’m at a school of public health and so I think about this, but Medicaid is a central strategy at this point for dealing with the highest priority issues in population health, whether that is infant mortality and maternal mortality. Whether it’s services for children with developmental disabilities who need to be able to be integrated into school in community settings, whether it’s long term services and supports for people with chronic conditions, whether it’s the opioid epidemic, Medicaid is really in many ways the most flexible means we have for dealing with population health priorities. It has played that role now in the eyes of Congress and a series of administrations for decades. It of course is a partner to Medicare, I think it’s the thing that many people forget about, but it really makes the Medicare program work for lower income Medicare beneficiaries. It is a first health responder in times of crisis, whether it’s naturally occurring crises or man-made crises. It is a program that has been there to insure people in terrible times, and it is capable of handling surges.

Finally, Medicaid — and I think this is something that we had to go through the expansion for, in order to fully understand, particularly in the expansion states, it is the financing system that anchors health system delivery reform in medically underserved communities. We have 65 million people living in medically underserved communities and Medicaid is the primary insurer. And so, it plays sort of the ecological role, and therefore, when you are doing Medicaid reform, you have to think of all of these issues. And even if you just wanted to pick one issue, you have to think about the spillover effects in other areas. So, it is a very difficult program to sort of get your mind around and any sort of reform effort has to be put into these contexts.

There are two big areas, obviously now, that I think most of us who spend a lot of time with Medicaid are watching — one, as Sara Collins mentioned, is this issue of the 19 remaining expansion states, will they in fact come in for the expansion? And will they come in as straight up expansion states? They have the option to simply adopt the expansion, or will they potentially come in for expansion under certain circumstances that is under 1115 authority, which I’m sure we will talk more about. And some of the conditions being talked about are ones that might be applied through 1115, are ties to work, work requirements, premiums with a lockout period for non-payment, open enrollment periods in Medicaid as opposed to enrollment as the need arises system. An end to what we call retroactive eligibility, which is a long-standing part of the program. A slimmer benefit package, time lines for coverage. These are some of the issues that have bubbled up either from current demonstrations or from past requests that haven’t been acted on yet.

The other big issue that everybody is watching is this issue of sort of broader Medicaid reform. How do we want the Medicaid program to run? Some of the points that Gail raised and this all-important issue that is of particular interest in the expansion states, which is new strategies for delivery reform. How do we use Medicaid and the broader Medicaid coverage to shape delivery of care? How do we get greater efficiency in care? How do we integrate mental health and physical healthcare? How do we integrate health and social services more? And particularly, this is the case for populations for whom Medicaid is a huge buyer, with really the ability to influence an entire sector of the healthcare system. We have known that this is the case for a long time in maternity and pediatrics. It is clearly the case for mental illness and addiction. It is clearly the case for long term services and support.

So, these are the big areas of high profile policy reform. There are sort of two basic reform pathways in Medicaid and we have three very different views going on right now about those two pathways to reform. One is the legislative pathway and one is an administrative pathway, because of the uniqueness of 1115 of the Social Security Act. And within the legislative pathway, over the past few weeks now, we have seen two competing visions. One is a quick strike system that takes a lot of money out of Medicaid. Close to a trillion dollars. And basically, uses potentially a follow on administrative structure, potentially follow on legislative reforms, to rebuild the program. So, all the financing changes and none of the structure changes.

Then we have the strategy that actually — for Governors, in a very interesting letter, to House and Senate leadership sent, and their vision is a vision that sort of turns the first vision on its head, which is very careful introduction of the kinds of financing reforms that Gail mentioned, with also a clear choice on the part of states to remain in a current financing structure, but with some limits. But allowing states also to move into more aggressive financing reform, coupled with very sweeping legislative — with structural changes in the program on basically all aspects of the program. And so, we see these two very strong competitors for a reform vison.

Finally, there is the question of 1115, which obviously can work by itself or it can work in connection with some of these other reform efforts. And I will close here by saying that I think quite frankly, 1115 has been way overblown. 1115 is a 1962 demonstration authority. It was enacted in order to create authority in the Secretary, of then, HEW, now HHS, to introduce important changes, test those changes, evaluate those changes and determine whether certain changes are such that Congress ought to consider building them into the statute. Now, in fact, we have used 1115 quite well. One, actually, were a series of demonstration begun — actually, a long time ago, broadened under the Clinton Administration and carried over by the Bush Administration, to think about essentially giving Medicaid to people based on income. Whether a slimmed down package or a broader package, using income as the test. The two other big areas in which 1115 was used, tested, evaluated, were long term services and supports, where 1115 played a crucial role in essentially restructuring the Medicaid statute, ultimately, to give states a lot more leeway and enable beneficiaries to live in community settings.

Finally, managed care. The Balanced Budget Act amendments of 1997, the managed care changes that were quite sweeping, built on many years of testing managed care for Medicaid beneficiaries, first allowing some smaller changes and then allowing states to do demonstrations with larger compulsory managed care reforms and finally introducing a new series of state options. 1115 is an authority in the secretary to make wholesale changes in the Medicaid statute. 1115 is a pilot and testing system and the question now is: Where do we want to see pilots? Where do we want to see tests? What kinds of evaluations should we expect, does the policy matter? Before an idea goes forward on a massive scale. At what point is it proper and appropriate for states and the federal government and Congress to expect that in fact, certain kinds of issues will come up in the legislative arena, as opposed to piloting and demonstrations. So, why don’t I stop there.

GAIL WILENSKY: [inaudible] 14 years for Arizona?

SARA ROSENBAUM: Well, there is the question of whether certain — and this is an issue, whether certain long term sanctioned demonstrations finally get a legislative sanction to go forward. But that was one state. You know, now having proven its medal.

SARAH DASH: Great, thank you so much. We are at the question and answer portion of the briefing, so while you all want to think about your questions, you can stand at the mic’s, you can fill out a green card and somebody will come around and pick it up and we will try to answer it. Or, you can tweet to #futureofmedicaid.

While you all are getting organized, let me kick it off with a question. So, we have heard about successes of Medicaid, particularly with respect to — in this briefing, expanding coverage under the Affordable Care Act. We have also heard about some challenges, some cost challenges, some distortions in terms of how the federal match works. This is a huge program. What is the biggest problem we are trying to solve in terms of Medicaid reform. In your own words, what is the problem we are trying to solve, and then on the flip side, what is the biggest opportunity for the Medicaid program? And I will let any of you kick that off.

GAIL WILENSKY: The problem that we are trying to solve is how to be sure the major source of coverage expansion under the ACA, Medicaid, goes forward on a rational, stabilized basis. I mean, that is generally the issue. And to assume that this one piece of Medicaid would continue along with SHIP at a 90% match rate, where the base Medicaid program is at a different one, doesn’t make sense. And trying to integrate at whatever level the Congress is willing to support, those various rates is one of the issues. I know that what Sara said, in principle and in law, is correct about the function of the 1115 waiver’s. I was teasing her about Arizona as an example. Arizona was the last state to come into Medicaid. By waiting so long, it decided that it should try to avoid some of the most common problems, which is having a lot of people show up either at the ER or without ambulatory support, and so they put in a modified structure to basically give people ambulatory choice opportunities. They stayed on their 1115 waiver until the Balanced Budget Act, because the Congress didn’t want to shove it down and there was not a legislative vehicle handy. So yes, in principle, the 1115 process should be used to try out ideas, see how they work and then legislation should move from that, sometimes it happens, sometimes it doesn’t. It is a very important function. It obviously can be challenged in the courts and on occasion it gets challenged as to whether it’s beyond its bounds. The real opportunity I see is to think about Medicaid — the Medicaid population, and the population right above it, say to 200% of the poverty line, or to 225% of the poverty line, as basically extensions of each other. And to try to make it easier to move money rather than people. One of the issues that Sara Rosenbaum and I have talked about over the last couple of years, is the frustration that as you cross from 138% of the poverty line, to 140% or 150%, you are basically forced to change your whole delivery system, which you may just have finally gotten to understand and to work, because many states seem to take pride in the fact that their people providing care under Medicaid were different from the people providing care in the exchanges.

One of the options that has made sense to me, is to basically let people use whatever subsidy money they are entitled to at that area of low income. And either buy into Medicaid, which seems to have been able to handle the expansion better than many of the private plans. The ones that did seem to handle it better were basically companies like Sentene and Molina, that structured their plans to look very similar to their Medicare Managed Care plans. And of course, I would give the option the other way as well — we need to think about this more as a continuum and have opportunities for people to move their money rather than to be forced into a different delivery system that makes no sense.

So, I think that the observation that on a comparative basis, Medicaid seems to have handled the bulk of the expansion reasonably well. We don’t want to force a disruption of that, but as a matter of fairness or appropriateness, I would let the option go both directions. I just don’t think it would actually be used very often. But I also think that we are going to see a lot of use of both the 1115 waivers and the 1332 waivers that were built into the Affordable Care Act, because they will provide the opportunity for many states to try those.

SARAH DASH: Thanks Gail. Sara or Sara, would you like to comment?

SARA ROSENBAUM: I think that with Medicaid, the biggest problem we are trying to solve now, and it’s actually, we have gone through sort of periods where this is the biggest problem in Medicaid is less sort of specific and operational, although I certainly do agree with Gail that the financial structure of the program is paramount and it becomes sort of part of the overall problem. But I think the problem that we are always trying to solve with Medicaid is aligning the dependence on the program and the role that the program plays with political views about the program. By that, I mean that Medicaid is part of the DNA of the healthcare system at this point. Its functions are so important and unfortunately, a lot of those functions are not immediately visible to us and would disappear only if the program were really mortally injured in some way. I can remember a year back, 20 years ago, when the ability of all of the District of Columbia’s children, who need special education, was imperiled. Their ability to start school on time was imperiled because of the billing and recovery mechanisms in D.C. Medicaid that had the city behind on recovering funds and it was, you know, so serious, that when the school year began, the question was, would these children be able to go to school? So, I mean, these are the kinds of things that you understand if you understand Medicaid. You see that everybody’s ability to live in communities, that the child welfare system, the special ed system, that entire delivery systems all depend on Medicaid. And so, we are at one of those moments right now where I think our biggest problem is this perception problem, this gulf between what Medicaid does in the world and some political viewpoints about Medicaid. So, that’s the problem.

The opportunity in Medicaid is what I have always felt the opportunity was in Medicaid, which was that it represents the best handle we’ve got for addressing those aspects of population health needs, that involve the healthcare system. Many population health needs do not involve the healthcare system, they involve other remedies that are not the subject of today’s discussion. But when it comes to healthcare, Medicaid is the way in which we have chosen to finance healthcare for low income people, and we have ended up making this decision for lots and lots of reasons. And I think in this struggle over how to reform Medicaid, we see, particularly in the Governor’s letter, a tremendous understanding of the importance of Medicaid to local healthcare delivery and it is a matter of reading and listening to states very carefully at this point, who are, in the end, the force for healthcare delivery and shaping federal health policy to enable states to move more actively, in more holistic directions.

SARA COLLINS: Just to put a finer point on Sara and Gail’s overviews of what is important, the political log jam in the 19 states that haven’t expanded yet, is really having an effect on overall measures of system performance in those states. In our Commonwealth Fund state scorecard, we ranked — we had 44 measures of health system performance of which on coverage, access to care, access to preventative care, are part of that. And in the top — we do this every few years — and in the top quartile, every single state in that group has expanded their Medicaid programs and this year, three states that hadn’t expanded their Medicaid programs dropped out of that into a lower level, into the next lower quartile. It’s a program that exists as a key part of people’s overall health systems in states, and so the getting through the politics and the political opposition to it, is going to be really important to state’s overall performance going forward.

SARAH DASH: Great, thank you all. So, we have someone at the mic. We will go to the mic, and then we have a lot of great questions on the cards.

AUDIENCE MEMBER: Hi, my name is Carl Polzer, I’m a long-time health policy analyst and I have worked for one of the speakers and alongside another, but I won’t specify which ones, so they won’t be embarrassed.

My question is, really as this focus shifts from the legislative to the administrative on the work requirements and other types of requirements that are states are either reupping their Medicaid expansions or proposing new ones, these seem to be the most controversial new requirements. They may seem very attractive to a conservative economist, but I think there is some practical issues. Would it make sense to put state employment offices in emergency rooms? I mean, people do have a lot of time to fill out forms and to take training there and decide what they want to do with their lives. Would it help to have a civil rights office there? Because people, when they go to work with illnesses, they might need protections. Like, if they show up with hives or drip bags at McDonalds or other places, they might get a job at that wage. And then they might need sick leave. Like, most people at that wage don’t get sick leave and there is no legal requirement for it. So, that would be an opportunity for a bipartisan agreement, so you could trade work requirements for sick leave. Then finally, I’m a consultant now, and I have cards and I know there are there a lot of non-profit entrepreneurs in here and business guys and lobbyists, so after the meeting we can talk about the hospice population. Because there is great possibilities for temp work there I think. I really think that some of them could really work quite effectively right up until the last minute. You can save money on vesting on their pensions.

Anyhow, you need to think through the practicality of some of these requirements and just how deeply you can apply them. I would just like some discussion on the work requirement.

SARAH DASH: Thanks. So, we also have a question here about the work requirements and I think — let’s dive into this for a second. This intersection between employment and Medicaid and sometimes it’s a little bit of a chicken or the egg. Either you’re healthy, so you can work, or you have to work so that you can get health insurance. Let’s just talk about that. What can we expect to see out of the new administration? Is that going to come under the form of 1115 waivers? And what is the likely impact going to be?

GAIL WILENSKY: I think it is likely to come through 1115 waivers, or already indicated that. I was part — actually, so was Sara, of an interesting conversation a few days ago on this issue and a couple of points were made that may be able to be helpful in the situation. The first issue is whether or not the people that actually could work after you exclude all of the obvious candidates, including pregnant women, people who have young children at home, et cetera, narrows down the group considerably. Childless adults who don’t have major kinds of health problems or people whose children are in school. The question is, whether we would want and the states would want to cut off healthcare if someone doesn’t do any of the options, which usually includes training or education in addition to working. But another strategy that seemed to go after the same end point was the proportion of people likely to receive food stamps and whether or not the work requirements in food stamps might be a better way to look at making sure there were strong work requirements. Because the notion of cutting off someone’s healthcare because for whatever reason they aren’t following through on the work activity or efforts they are supposed to be doing, seems not very likely and the work requirement for food stamps may be able to have a much better handle on something that a state might actually consider. So, I think that the spirit is understood of why this was raised. It is possible a slightly more sensible strategy to produce a similar outcome might be able to be developed.

SARAH DASH: I want to get back to a point that was raised earlier about the connection between Medicaid and the health of the population and Medicaid’s role as a program and a very — it’s sort of many populations, but a very low income population, medically underserved communities and this idea of a wraparound between Medicaid, work, transportation, those kinds of things. What has been happening in terms of Medicaid’s role in this overall continuum of helping to improve people’s health and what can we expect to see going forward?

SARA ROSENBAUM: Well, first of all, I think it’s important to note, and of course it goes to all of these issues, whether it’s work requirements or time limits, uh, or other conditions on eligibility, basically. One of the striking things about poverty in the United States is that while poverty is everywhere, we have many, many, many communities, urban and rural, where poverty is highly concentrated. And so, in those communities, Medicaid becomes not only a means for purchasing healthcare, but it becomes an absolute staple of a local economy. It is able to support a healthcare economy that in turn supports other sectors in the economy and it’s also a program that supports certain kinds of entities, anchoring entities, whether it’s a rural hospital, whether it’s community health centers or a rural health clinic, that themselves off an array of services. And so, you have this interaction between Medicaid and local economies and local healthcare economies that makes the program a logical program for building out as an intervention. There is a very interesting report from the National Academy of Social Insurance that came out early this winter, looking at what states are trying to do to build new approaches to delivering healthcare onto people who are enrolled in Medicaid that utilizes both certain kinds of healthcare providers and that expects healthcare providers to have formal affiliation agreements with other kinds of entities including schools, including job creation programs. Including social services. And so, one way to think about getting at this dynamic from the earlier questioning, is to maximize the opportunities that states have to think about healthcare delivery as part of a continuum of services that are targeted on communities that just are working with few resources. There are fewer jobs to have. And so, if you look at what a rural hospital does in terms of its local economy, what a health center or rural clinic does in terms of its local economy, these are huge issues to factor in, along with the fact that you have the kind of anchoring healthcare in a local economy that then attracts other forms of commerce. So, it’s less than thinking about things like a work requirement as a condition of eligibility, having this sort of more sophisticated thought process about Medicaid as part of an economic engine system. I think it would get us further.

SARAH DASH: We have had a couple of questions — I’m going to turn to the population that is covered under Medicaid, the long-term services and supports population. So, we have a couple of questions about that. One question is that with two-thirds of Medicaid spending in states going to seniors and individuals with disabilities, an aging Baby Boomer population and little stable private long term care insurance to speak of, what is Medicaid’s role in covering that population and then a related question was, could somebody please expand on the influence of the per capita cap and block grant proposals on Medicaid services for people with disabilities?

SARA ROSENBAUM: I’m happy to start. One of Medicaid’s greatest achievements, I mean, where you see the power of Medicaid compared to any other payer, is what it is able to do for people whose disabilities are serious, whether they are young, whether they are working age, whether they are elderly, whether Medicaid is functioning as a companion to Medicare. Whether Medicaid — we forget about one of the most interesting and important amendments, relatively small, but significant that Senator Grassley championed over a decade ago now, to make it possible for families with children with very serious disabilities, to essentially buy up to — buy Medicaid to compliment employer coverage in order to get the benefit of home and community based services that employer plans just don’t cover. I mean, it’s just not where employer coverage goes. I would be horrified and dumbstruck if most Medicaid spending didn’t tip toward this population. These are the population who really need a lot of healthcare. Most Medicaid beneficiaries are healthy, working aged adults, or relatively healthy, and children of course who we hope are healthy. And so, like with any insurance, it is normal to think that Medicaid is going to skew in its spending toward high-cost, high-need people. That’s the way insurance of any type works. In terms of federal funding limits, obviously as Congress goes back to and thinks about introducing limits on funding, these will be the crucial questions, which is to make sure that funding limits don’t spill over onto the costliest populations, for example, you know, a per capita cap is population sensitive, but badly structured. It could also incentivize states to eliminate potentially a lot of optional eligibility groups that have their eligibility based on disability, but to the extent that per capita spending falls behind where it needs to be, a state may feel that it’s just carrying too much financial exposure to maintain optional coverage for long-term services and support populations. So, this is a crucial issue for the disability community. A block grant of course is even more problematic, or at least has problematic implications because of the concern on the part of states that if they are too overloaded, as they would see it, with people who have very, very high cost needs, their own financial exposure is huge and this is obviously in a country where such an emphasis is now placed on high value, on life and on insuring the best possible quality of life, regardless of severe disability. This is probably the number one issue we have to grapple with in Medicaid.

GAIL WILENSKY: Some of the legislation has talked about having carve out or different growth rates allowed for the aged and disabled, versus the non-aged and disabled populations that are on Medicaid and obviously, it’s not a trivial issue, but recognizing that this is a different population with different needs. So, we will have to see if there is — the next round, what it looks like in terms of that level of detail.

SARAH DASH: I’m going to go back to something I thought I heard you say, Gail and maybe you could clarify. You said that if there were a different financing structure that was different from the current FMAP, that we could have a more rational structure. But I believe what I heard you say is that, if it comes with significant revenue cuts, or if it’s seen as a vehicle for significant cuts in funding, that that is problematic. Can you talk about that? I guess what I’m trying to get at is, why are per capita caps and block grants the answer, if you will, to some of the distortions that you mentioned? Like, the higher FMAP for different populations and the creative financing and so forth? And then is there a way to address those issues without significant financial cuts to the program?

GAIL WILENSKY: Well, let me go back to the basic point I tried to lead off with. The two big questions are the starting point and the growth rates. The starting point now, I think, will be very difficult to step back very far from where we are. Maybe some, for the expanding population, but most of the bills that we have been talking about outside of the major [unintelligible] legislation, if you look at what the governors have talked about or you look at Cassidy Collins, assume the start keeps most of the new money in, and the big question, and I think it is going to be hard for many members of Congress to try to claw back a lot of that expansion money, we saw a lot of the pushback that was coming on. The question is, how do you try to balance the states that have expanded from those that don’t, in terms of coming out with an acceptable starting point for the per capita block grant. And then how do you try to allow it to grow? The issue as to how you want to look at the distribution between what the state had been doing in setting up the block grant — the initial starting point — is one where you can take account, if you want, of various base income levels in the state. That is a very serious point about where do you start. It is understanding that once you do that, it becomes, where is the growth rate? And of course, the reason that the per capita part, to my mind, is so critical as opposed to just a fixed block grant, is the state would be completely at risk for any kind of economic downturns or any kind of changes that affected the number of people who you would expect would be using this program. So, I gather there seem to be some states that make noise, like they just want the option to have a full block grant, but I don’t understand why they would. That would seem to be a level of risk that no governor should want to take if they understand what it means in terms of going forward in a recession or following a major epidemic, or something that would clearly impact the relative population.

SARAH DASH: Can we talk about accountability for just a second and then I will get to the question at the mic. We have a couple of questions on this. So, this notion of flexibility and accountability. What are states accountable for right now under the Medicaid program and what, if anything, should they be more accountable for?

GAIL WILENSKY: I have talked about not just dismissing a per capital block grant in Medicaid without any merit, which I think is just not correct. I would, in exchange for the substantial increase in flexibility that that provides, put on not an unreasonable number, but some — five, six, seven — outcome metrics that states would have to report on, relating to this population. And the reason – – and this has bothered me greatly for a long time, is that aside from various surveys that groups like the Commonwealth Fund or Robert Wood Johnson, or other foundations sponsor, there is precious little information about what actually happens to the health outcomes of the population that is covered by the program. And for me, the quid pro quo would be substantially greater flexibility, substantially fewer occasions of “mother may I” kind of requirements coming in for waiver requests and in exchange, some credible metrics about what happens to the population that is affected.

SARA ROSENBAUM: I have to say, from my perspective, I think actually states are accountable at this point for an extraordinary — really an extraordinary thing. And in some ways, the move to managed care has driven this point home, which is — at one point when I — when I first began to work in Medicaid, states were accountable for determining eligibility, and getting a car to an eligible person, if the person qualified, and obviously claims payment. So, sort of a third-party claims payment structure. Today, much because of their own choices, they sought this power and they have the power now and they are using this power tremendously. States actually have taken onto themselves the responsibility for making sure that poor people get healthcare and medically vulnerable people get healthcare. Now, do we have the measures that we need to know whether they are getting the kind of value both in terms of health outcome and in terms of cost, in terms of quality, out of the arrangements they have developed that we would like. This is not my area of expertise and my breath is constantly taken away when I’m sitting with people who do this kind of work. It’s just how complicated it is to come up with these kinds of measures and then the data systems to collect the information that would tell you what performance looks like. But I think that what we haven’t embraced enough, at least here in Washington, is the tremendous responsibility that states have taken on, that looks nothing like the responsibility looked 30 years ago. And the question always to me, is less whether the responsibility is enough and more whether they need tools that they don’t have at the moment to do a better job. The flexibility to use Medicaid financing to do certain things that are slightly off the beaten path for a commercial insurance plan. Frankly, I don’t see the value in giving states more flexibility to take people off the Medicaid program. My tendency would be to think hard about where they need flexibility in order to be more effective and efficient in the delivery of healthcare itself.

SARAH DASH: Thanks. I just want to point out, in Sara Collins’ slides, we saw that in the states that did expand Medicaid, there were improvements in access to care and improvements in sort of measures of financial risk for the individuals. So, I’m wondering if, Sara, if you would like to comment or any of the other panelists would like to comment on — and again, now we are back to talking about the expansion population, but what more is needed to help to get those numbers even better in terms of access to care? And then health outcomes? I want to link that to something that really struck me in the state scorecard, which was that the state scorecard found that life expectancy or measures of pre-mature death had increased in two-thirds of the states. We have all kind of heard this. I mean, we are dealing with a population in health crisis, it seems to me. How is this linked to the Medicaid program and what tools do states need to make that link between Medicaid, having a Medicaid card and improving access and improving outcomes?

SARA COLLINS: A couple comments on Ben Summer’s work in Arkansas and Kentucky and Texas, and he did look at a large number of access measure. So, cost related problems getting healthcare, medical bill problems and one striking outcome on affordability was a 30% relative decline in out-of-pocket spending for people enrolled in the program, relative to people in Texas. So, major changes that stem from the protections in the Medicaid program that are actually very different from people who are buying coverage through the marketplaces and states that haven’t expanded Medicaid, particularly in out-of-pocket cost side and the premium spending side. But the other areas that are really important to look at in the work that he’s done, is the access to care amount people with chronic health conditions. The glucose testing for people with diabetes and really importantly the changes that he’s finding in these states three years out, on self-reported health status. So, a significant decline in reports of being in fair or poor health in Arkansas and Kentucky, relative to Texas. Now, this is a — self-reported health status is self-reported health status, but as actually studies have found, highly indicative of mortality in someone’s life. So, impending mortality. These are not to be dismissed as measures that are not measures of health status and trying to hold Medicaid to a higher standard than we even hold private insurance coverage to improvements in health status. Everyone goes back to the Oregon study, the Medicaid population, which ended up being a randomized study of enrollment in Medicaid and what effects it has on people’s access to care, but also some small measures of health status as well. And not finding significant improvements in health status in that population. I think what one has to keep in mind when we are thinking about measures, is to allow for a significant amount of time to go by before we can see actual impacts on health status.

I will give you one quick example of a study done on Medicare beneficiaries who had been uninsured for most of their 50’s and enrolling in Medicare at 65 and what their experience was after that. There was a huge increase in utilization among this population. Once they got access to Medicare. And it took a good seven years for that trend to flatten out, so it equaled utilization among people who were already enrolled in Medicare and the people that benefited the most from getting coverage at 65 in Medicare after having been uninsured, were people with serious chronic health problems. So, heart disease. And those measures did change, but took several years for those to change. So, I think the caution and trying to look at health outcome measures in Medicaid, is not to hold it to a much higher standard than we do other forms of insurance coverage. And that these access measures that we are seeing early evidence of, really point to possible improvements in health status down the road.

SARA ROSENBAUM: I think it’s important for people not to claim more than we know. The Oregon study was to me, somewhat disappointing that even in the areas where you thought in the short term you would see some impact like the hemoglobin testing or high blood pressure, the hypertension — I mean, it’s not obvious that you wouldn’t see some impact in those areas. I don’t have any problem with people saying, we think it will take longer, but it would be much better to say that, FMAPs data, you know, eventually we will shed some light, because at least has two years of coverage between the two samples and a lot more information about what is actually used. But we shouldn’t make claims on the other side about what’s done. What we can see, which is hardly surprising, given how much money gets spent, is that people — an ability to access in a way they didn’t, and their out-of-pocket expenditures were less, it would be like, well, I should hope so. But will we see something on the effects? On the health outcomes? It will take more time and don’t make other claims, which easily get made. I mean, that is not unreasonable, it just needs to be — that is the positon people want to take, it just ought to be sold as that and not something else.

SARA COLLINS: I think also just to — I completely agree. I think also, just thinking about what these measures might look like on health status. Is it a one-time decline or a one-time drop in an outcome measure? Or is it a flattening out of trend? So, it’s a tricky area to do analysis of the outcomes of insurance programs and I think the thinking about what is a reasonable measure will take a lot of effort.

SARAH DASH: Folks waiting at the mic very patiently, go ahead and ask your question.

AUDIENCE MEMBER: Thanks, Sarah. Mike Miller. I want to go back to something Sara Rosenbaum was talking about and drill down a little more within the essential providers. Talk about rural hospitals specifically, because I know that’s something that a lot of members are very concerned about. And if you and the others could talk about sort of the current situation with rural hospitals. In my experience, going back in some states in the last few years, there has been an attrition where rural hospitals are slowly being forced to close or convert to non-in-patient facilities or things. Both what is the trend line projected, given the current status quo of everything going on, and how all the different options for Medicaid could impact that either — you know, continuing to enable the rural hospitals to survive or possibly the opposite. Thank you.

SARA ROSENBAUM: Thank you. Yeah, I think this issue of, you know, access to care in rural America goes through these sorts of wafting and waning periods of time. Certainly, a small part of the population lives in rural areas, but they are very important part of the population and right now, a lot of the kinds of health trends we are seeing in the data that Sara Collins alluded to, are data that as — I mean, you can’t watch television now for five minutes without seeing reports about the declining life opportunities and life itself for people in poorer rural areas. It’s in these areas, whether it’s a hospital or a community clinic, that you know, the loss of any capacity is critical. It of course, has been a factor in the Medicaid expansion discussion now for years in Kansas, where of course as Sara Collins mentioned, that both houses of the legislature voted to expand, whether they will override the governor’s veto is not yet known. But driving that decision was the crucial role that Medicaid plays in essentially the healthcare ecosystem and it’s why I feel so strongly that to understand Medicaid simply as the public equivalent of what say, employment based coverage does for those of us presumably in this room, is not to understand the Medicaid program, because of the concentrated nature of poverty in the United States. Here in Washington where there is of course, relatively speaking, a high degree of affluence, we see the effects of concentrated affluence in healthcare and good coverage and good purchasing power, because we have so many parts of the city with generous levels of healthcare. That comes from creating the economic circumstances that allow good healthcare systems to flourish. If you go to the poorest communities in the city, of course you see the opposite and that is equally true if you go to poor rural communities. And so, getting to a point where people appreciate how sensitive healthcare itself is to Medicaid policy, I think is maybe the highest challenge we have. I was saying before to Sara Collins, that we had done a study, which ended up not coming out, because of the demise of the American Healthcare Act, but we were about to release a study that showed — that had the Medicaid reductions of the level anticipated, gone through in combination with the reductions and subsidized healthcare for people who were in the marketplace along with an anticipated loss, potentially grant funding. One in four community health centers in the country was reporting to us a reduction of 5,000 patients or more. And it was all over the country, but it was actually of course the health centers and the states that had expanded Medicaid, where they had been built up in both urban and rural areas. I mean, just unconscionable loss of primary care capacity. And that is really Medicaid talking at this point. Of course, it comes from Medicaid as an insurer, but it also comes from this phenomenon of Medicaid as a source of financing to stabilize healthcare.

GAIL WILENSKY: The politics of trying to come up with a rational resolution of the issues for rural health have been quite extraordinary during our political pass. One of what I thought was a very promising program, started in the 1990s, called the Each Impeach Program of Central Health Facilities. And was an attempt to allow communities that couldn’t afford their full-fledged hospital in that area, to become something that they could support, which was a small holding center that would keep people temporarily either before they would get moved out to a rural referral center, or they could go home. But it was a very limited number of beds and a very limited time they were supposed to hold them, which seemed like a really good transition type of structure. But then politics entered in and everybody wanted one of these and they wanted to increase the number of beds they could have and they wanted to increase the amount of time they could keep them. And basically, what had started as a really thoughtful way to try to make a conversion in the short term holding and then move them out to some place where you would actually prefer that they get care that had any sophistication and complication attached to them. Similar kinds of events where if you make the differential payment a very attractive — you just see a bulldozer coming through to expand who can qualify for Central Hospital status. It doesn’t matter whether there is one that you can practically spit at nearby, somehow those tend to get swept in. So, I mean, it is a problem that thoughtful decision-making ought to be able to help resolve particularly in an age where you have so many ways to communicate and the kind of capacity telehealth could provide to people who are in very limited facility areas or when they have more critical needs to move them out to a place that is like a rural referral center, rather than where they are. But the ability to actually keep it focused and not just blow a hole, so other groups that want the additional money, that is usually attached, stay out, has alluded my observations of being able to happen. But I don’t question the problems that you have described in some of the very — the smallest and especially small, poor areas.

SARAH DASH: Thank you. We are nearing the end of the briefing, before I turn to the panelists for one last question, let me just remind you all, you have a blue evaluation form in your packet. If you could fill that out before you leave, that would be fantastic. We really do want to hear your ideas for future topics that we should be focused on.

Let me just ask each of our panelists to comment on perhaps a slightly provocative question, but just to end it on a broader note. If you were talking to somebody right now who is a beneficiary of the Medicaid program, should they be optimistic going forward? What should we tell them about the future of the program as it currently stands with what we know right now? What should they be looking for elected officials to do?

SARA ROSENBAUM: I actually have gotten this question. I do some volunteer work in my community with families who need the program. Use the program, use subsidized insurance. Of course, I live in Virginia, so I’m sorry to say that I really haven’t dealt with many adults who need the program — or, use the program. Typically, what I’m having to do is tell people they don’t qualify for the program. But, their children do and I will tell you that the panic level was very high over the past month. It is really hard for those of us in this room, I think, to fully appreciate — unless in fact you have had, whether it’s through patients or clients or volunteer work or a family member, or whatever, it’s hard to overstate how important the program is to people and to the community providers that serve people. And what I found myself saying to people was, I don’t think it will come to this. I don’t think it will come to this. And that is why I said that I felt that the biggest problem the program faces today — and it’s always been a problem with Medicaid, but it’s particularly acute now, is the gulf between what this program means to people and the healthcare delivery system and what the political discussion looks like around the program. And it’s why I continue to think that along with Gail, with whom I have worked for over 30 years on this program, that the answer to Medicaid’s future lies in careful, thinking through, what you want this program to achieve, what tools we need to achieve it and how to manage its costs. And those are the same questions we would ask about any insurance.

GAIL WILENSKY: The expansion of Medicaid has played such a major role in expanding coverage to the previously uninsured. I find it hard to imagine in a political context, in a political environment, having that ripped away. But of course, it’s easy for me to say that, my healthcare access isn’t dependent on that. But we saw the kind of pushback from governors that expanded, from Republicans who were concerned about what this would mean, that along with the strong pressure from Democrats on the issue, seems very unlikely to occur. One of the very fortunate outcomes with the election is that we are closer to our usual positon in the sense of having, especially in the Senate, a very closely divided Senate. That puts a break on having ideas that aren’t fully thought through with their implications, able to go very far or to do very much. They either have to satisfy the budget reconciliation rules, which are quite stringent, or they need bipartisan support, which is critical to not have a redo of what we have seen with the Affordable Care Act. It was truly astounding to me, to look at what had been contemplated and hoped for, which is after six years of trashing the Affordable Care Act at every possible moment, Republicans looked like they wanted to recreate a similar political dynamic on their side. It’s like, have you learned nothing about what it takes for stable legislation? I think that there are sufficient impacts that it will put a break on doing bad things.

SARA COLLINS: I think one of the most interesting aspects of what we have been through the last couple months, is the focus on beneficiaries in the Medicaid — who have enrolled in Medicaid expansion and just hearing how much this coverage has meant to them. I know from our survey data, we have been hearing high rates of satisfaction with Medicaid among people who are enrolled — who got coverage through the Medicaid expansion. Ninety percent of people with Medicaid coverage are somewhat or very satisfied. And when you compare it to private coverage, the people who got plans through the marketplaces, more than half of Medicaid beneficiaries rated it as — say they are very satisfied with their coverage and that is a much higher number than you see in marketplace plans. The other striking finding in the survey data that we continue to see for the last three years, are people telling us, who have Medicaid coverage, who have used their care, 70% saying they wouldn’t have been able to get this care prior to enrolling in their plans. So, I think that these numbers have been known for a while, but I think the debate over the American Healthcare Act really brought those voices into the open and maybe people not even realizing that they had Medicaid, that they had this new expanded coverage and not just totally — maybe not linking it to what is actually was. So, I think just from policy maker’s perspective, I think that the voices were heard pretty loudly in this debate. I think it did have an effect on what the ultimate outcome was, and I think going forward, people who enrolled in Medicaid are people that policymaker ought to be speaking to.

SARAH DASH: Please join me in thanking our panelists for a great discussion.

[Applause]

Thanks again to the Commonwealth Fund and please fill out your evaluations on your way out.