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tv   Alliance for Health Policy Discussion on Medicaid  CSPAN  November 26, 2018 8:33am-10:11am EST

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>> check out the postings. this year were asking middle and high school students to produce at five to six minute documentary answering the question what does it mean to be american? we are awarding $100,000 in total cash prizes including a grand prize of $5000. the deadline for entries is january 20. for more information go to studentcam.org. >> now a discussion on new medicaid rolls of the trump administration and how states are adapting. the alliance for health policy hosts this discussion with state health officials and several health law attorneys. it's one hour and 35 minutes.
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>> ready? good afternoon, everybody. welcome. thank you for joining us today for today's briefing on flexibility and innovation in medicaid. my name is sarah dash and i am president and of the alliance for health policy trip for those who are not the me with the alliance we are a nonpartisan organization dedicated to advancing knowledge and understanding of health policy issues. we want to say hello as well to those watching us live on c-span today, and if you're follow us on twitter will be live tweeting during debate and you can join the conversation using the hashtag all health life as well as ask the question over twitter at the appropriate time. this year's state medicaid policies have made national headlines and while states oppose had significant flexibility to tailor their medicaid programs within parameters established by the federal government, there's
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ongoing discussion about additional changes that even allowed this year and recently. and we're going to have a good discussion about those today. many states are considering changes to the medicaid program which includes perhaps most notably work in committee engagement requirements as well as expanding coverage to additional beneficiaries and establishing innovative care models to address the opioid epidemic, and other challenges. we are pleased to date of the panel of distinguished medicaid experts to talk about how states are responding to the administrations new priorities for the medicaid program as well as the role supports and shaping medicaid policy. we are particularly pleased to be joined by the leader of medicaid program in two states, west virginia and arkansas for leveraging flexibility through 1115 waivers to alter their
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medicaid program. before we get started i like to thank the commonwealth fund for making today's briefing possible and introduce rachel nuzum him vice president of the state health policy at the fun who would join as co-moderator. rachel, i'm going to introduce the panel and then we would turn over to get you started with some brief opening remarks. so joining us today, we are really pleased to have calder lynch to a senior counselor to the administrator of the centers for medicare and medicaid services. prior to this role mr. lynch served in several senior level health policy positions in state governments. most recently he served as the basket medicaid director under governor pete ricketts. next was her from thomas barker, parker and cochair of the healthcare practice at the law firm of -- he established and is a contributor to the firms blog medicaid and the love it confirm he served in the series a senior
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level positions at the center for medicare and medicaid services and the department of health and human services during the george w. bush administration. following his presentation will hear from cindy beane his commission of the west virginia bureau for medical services. she let policy implementation under the affordable care act which enabled approximate 165,000 west virginians to get health care coverage. commissioner beane manages and overseas project development, implementation of health policies and assures compliance with federal and state regulation while creating innovative healthcare services to address the needs of west virginians. we will also hear from cindy gillespie, the direct of arkansas department of health and human services. her previous career includes serving as as a prince of the multinational law firm dentin which led health policy and health insurance exchange teams and as an advisor to governor romney ron and health policy and federal programs. finally we'll hear from
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trannine, who worked at the pennsylvania health law project for six years books it on a wide range of healthcare issues dealing with eligibility and access to services in medicare and medicaid. we have a full panel and we really excited to what everyone has to say, and before i turn over to rachel, how may people and burning questions you want answered? a show of hands, how many people have burning question you want answered about medicaid and was going on in the states? there's got to be more burning questions the net. >> slow simmer. >> you're going to get to write a question step and asked the waiter so get ready. before that i'm going to turn over to rachel. >> thanks so much. thanks to all of you for being here. i'm the vice president for federal and state health policy at the commonwealth fund. i just want to take a couple minutes to lay the groundwork. i think for those who work in health policy, we don't need to explain why we're talking about
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medicaid but for others that may be wondering how much do we need to focus on this program? i just want to give context into how central of the role it is playing in our healthcare system, federally but also in the state level. there's been a lot of discussion now about medicaid as the largest insurer in the nation and affect it is the largest single insurer. we know covers the majority of births in the united states. also covers a large proportion of care at the end of life, and more recently it has emerged the importance of medicaid as as a provider of behavioral health services, about over half of the behavior health services in the country are provided and financed by the medicaid program and estimate is about 20% the medicaid you have behavioral health needs. this is a critical program that's serving a number of americans. the old adage about medicaid is that if using one medicaid program you had seen one medicaid program.
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that's probably never been more true than it is today. not since the programs inception in 1965 have we seen this much variation across the country. states have always been unique. states have always develop their medicaid programs to reflect their own communities, her own marketplaces, their own populations, their own financial and legislative framework. but right now we see a varied landscape when you look across the country. 25 states have have expanded medicaid. about eight are advancing expansions with the use of 1115 waivers like sarah mentioned. requirements are the issue of the day that a lot of people are focused on an interest in and were starting to see those. ten ten states have work requirt provisions submitted including in 1115 waiver. some of of those have been approved. what has been blocked. women are more about those and just about that but the use of
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waivers is not due in medicaid. i just want remind as that's been a guiding principle all along that states of both said this flexible to ask for additional opportunities to rotorcraft to program and design if the weather makes sense to them here i'm looking for to having a discussion about how those trends have happened over time and what we are seeing now in terms of those impacts. we i think the additional ways states considering such as the about initiative and perhaps more so this year than we are potentially seen in years in the past. why does this really matter? it matters because medicaid has been solely responsible or singularly responsible for some of the biggest changes in the rate of uninsured over the last couple of years. all states between use 2013-2015 saw a reduction in the rate of uninsured. we saw much larger rates of uninsurance obviously in the states that expanded.
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a big reason to focus on medicaid is because actually having coverage does matter. this slide shows part of the study we did with ben summers and his colleagues that look at medicaid beneficiaries and their ability to access a personal doctor, how often they went to the emergency room and wasn't not they're able to get a checkup. she will help answer this question, we just extending a medicaid card or are we actually connecting folks to care which is the goal, and something that will be talking about as this panel goes on. finally, medicaid is a driver of innovation. it's not just about the way we cover and about discussions around our benefits and design and eligibility. medicaid as a program has a commence amount of leverage and mark about and it's also very, plays a very distinguished role in terms of finances for the
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sake in that system and for many state and local economies. so with that i'm going to turn over so we can get started with our panel. thank you. >> thanks, rachel. we'll turn over now to calder lynch. thanks, calder. >> good afternoon. thank you for the opportunity to be a today. i'm calder lynch, senior counsel cms administrator seema verma. i'm pleased about some of the working party urban medicaid and then engage with is the resistance panel this morning. let me begin by saying the work we're doing in medicaid is guided around three pillars that the administrator outline nearly a year ago last fall at the national medicaid directors conference and those of flexibility, accountability and integrity. i'll talk about some of our work about each of those focusing on the flexible aspect since that's the topic of today's briefing. i'll begin with flexibility. that's been articulated in a number of efforts. we're working on a number of
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regular provisions to provide states with increased flexibility and remove some burdens they face. much of that is been articulated through work around 1115 research and demonstration waivers which we heard about this morning. the first area of talk about before we move into community engagement is focused on the work done by states responding to the growing of opioid epidemic. a year ago we released guidance to states open new opportunities for them to quickly gain access to substance use disorder waivers authority to be able to expand access to residential treatment as well as buildup community-based treatment option for people facing substance use disorder. since that time we've approved ten states under the more flexible guidance that we released bring the total number of states with that waiver authority to 15. we have several more pending force. that's something that's important that we really worked to try to issue and be
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responsive to the national epidemic and give states that flexibility were saying something positive results already from early mentors of that authority in terms of reduction in emergency room visits and improvements in care for individuals. the other piece of talk about i think will hear a lot of today is the community engagement demonstrations. this january we released guidance to states in response to the strong interest that we've heard that states were interested in finding ways to connect nondisabled adults and beneficiaries to working committee engagement opportunity to medicaid. since the affordable care act was implemented the medicaid program expanded to over 15 million working age adults that have newly enrolled in the program. this is a growing interest and concern we seen from states. in response to that we worked really hard to understand those requests and to craft guidance and policy to better facilitate them. that culminate in the release of state medicaid direct a letter in january that outlined our
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commitment to that approach as well as the consideration states would need to undertake to design such a waiver including protection for beneficiaries can encouragement to align the program which what's exist already in the snap and ten programs come really encouraging partnership between state agencies and state partnerships to get help better serve individuals can be successful meeting the requirements and that line the things we expect to see in a demonstration for us to approve it. period strong interest across country contention the states amending demonstrations in response to the guidance. we have three that are currently approved, one that is implemented that was more about today and were learning about as we move this process about how this is working on the ground. we engaged states and a learning collaborative to learn from each other supplementation, to provide better guidance. we've had 18 states engage with us in this learning
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collaborative we've had several webinars, first in-person session, and getting them to some of the nuts and bolts about how to operationalize engagement programs effectively compelled to partner with other sister state agencies, your workforce programs to be able to connect beneficiaries to the types of resources that will have to be successful, how to build the right system to better support those initiatives to connect the different existing state data sources, , to be able to verify and play, in ways that reduce burden. a lot of heavy work is going into this to try to have good results for folks. we will continue that effort with the more current states web before can more coming through. the next i want to touch on is accountable because this goes hand-in-hand with a commitment to flexibility. we respond to their request to test new innovative demonstration designs. we want to make sure we have accountability.
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this is something we spent a lot of time focused on especially considering the growth in spending in medicaid, has gone from 10% of state budgets to 26% over the last 30 years as losing over $100 billion in increase federal spending in the last five years. a lot of interest in having accountable. that's why we are working specifically in the 1115 space to standardize metrics across waivers to have stronger valuation designs for states use when implementing these programs, to use consistent terms across all our demonstrations so that we can better transparency, better consistency and knowing the types of outcomes where producing. that's why early last summer we released the first of medicaid and chip scorecard to be in public reporting around both outcome and administer performance metrics with for some look at both state and federal administrator performance. we are seeing reductions in things like state plan
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processing times can manage to rate approval processing times and begin reflecting the interpublic dashboard that we can move for them. we'll continue to evolve an update that dashboard, add additional metrics to come new functionality is updated at least annually. you will see that reflected in future versions. the final pillar of what to touch on is integrity. with all these programs enhancements, investors were making we want to make sure the dollars are being spent on the half of eligible beneficiaries, for qualified services. we released and outlined companies of medicaid program integrity strategy that really focus on making the program a spinning top what needs to be spending it. that discharge includes looking associate state eligibility determinations and responses to which it audits, make sure the process done accurately and appropriate, look at state managed care which we see as managed-care growth continues to grow across the country, making sure those rights serving set up
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properly and being reported appropriate. and also looking how we can better utilize claims provider data. we know if every state and d.cd puerto rico reporting in much more robust data set to cms and able to begin utilizing that and looking at outcomes, integrity measures to understand of the program is performing. in 2019 will be can release our first analytic file to the research community to the understand better how program is performing. thank you. >> thomas? >> rank you, and good afternoon, everyone. my name is tom barker.
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i i am a partner at the law firm and i cochair our firms healthcare practice. i have a couple of slides i'm going to walk through. i'm going to give sort of a background on section 1115 and then i'm going to say a little bit more about some of the points that calder focus on some of the guidance that has issued and some of the history of waivers in this administration. just by way of level setting or by way of background, section 1115 of the social security act allows the secretary of hhs to waive quote in of the requirements in section if and the secretaries of judgment doing so would promote the objectives of medicaid. so what is section 1902? 19 '02? if you're ever on jeopardy and the clue is, this is the longest sentence in the english language, if you were to say
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what is section 1902 of us also did i come i come likely you would win. because section 1902a begins with the words estate plan for medical systems must, then it come if i'm not mistaken, list 83 requirements that a state plan for medical assistance must comply with. all section 1115 a is doing his allows the secretary to waive any of those 83 provisions. some some of the provisions, for example, benefits have to be available statewide. benefits have to be made available with reasonable promptness. beneficiaries have free choice of provider. payment rates have to be set through a public in process. all of those provisions can be waived if in the secretaries judgment doing so would promote the objectives of medicaid. section 1115 also allows the secretary to find her grants in medicaid that would not otherwise be authorized under
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allowable expenditures under section 19 oh 38 of the social security act. one of the key phrases in that sentence is it in the judgment of the secretary, so the courts have been incredibly deferential to the secretary over the years in implementing or assessing section 1115 waivers. generally generally speaking courts do not see it as their role to second-guess a decision that's been made by the secretary in granting a waiver. nevertheless, there is some case law that suggests that the secretaries discretion is not absolute. there are a couple of cases from the ninth circuit going back to the mid-'90s that suggest that estate has to at least provide some cursory level of review to a states request and, of course, more recently leo will talk more specific about the most recent example of a court setting aside
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and 1115 waiver based on the principle that the failure of a state to consider whether a state, a way to promote the objectives of medicaid can be fatal. we will say a lot more about that as we go on this afternoon. i would also say waivers crossed political boundaries. so i thought rachel made a really good point in her presentation when she said we are talking a lot about waivers now the rachels point was the waves have been around for a long time. and so at least as far back as the carter administration, where president carter and the secretary approved waivers of cautionary, caution cautioned s of medicaid. president reagan, if i'm remembering the history correctly, personally directed hhs to approve what became called or known as katie beckett waivers which we now are section
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1915b, waivers of the genesis of those was the so-called katie beckett waivers that come again if i'm remembering correctly, arose because president reagan received a letter from a family saying that her daughter had to live in a nursing home in order to qualify for medicaid. president clinton approved a waiver that i remember reading about back in the early '90s for the state of oregon that really completely transform oregon's medicaid program. president george w. bush approved waivers for florida that expand the use of managed care in medicaid, and also allowed states to impose a global cost cap and rhode island and in vermont. in the obama administration, some degree of the medicaid expansion of the aca was implemented via waivers and the obama administration was also quite aggressive in approving delivery system reform waivers
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as well. and, of course, the trump administration is also very aggressive. i'd like to turn to that now. so calder mentioned a lot of the guidance that's come out. some of what i'm going to say duplicates his comments, although one thing i didn't hear calder mention, to me at least as an outsider it all started with a letter that administrator verma and secretary price's sent to the governors april of 2017 announcing what they called a new era in medicaid, and they said in that guidance that they would give priority to waivers that focus on improving program management, community engagement pics of the concept of community engagement goes back to the spring of 2017 just a couple months after president trump took office in that letter. the western information bullet to states that came out in november of last year that came just a couple of months after administrator verma is speech to
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the medicaid directors that calder mention in his presentation to calder mention the community engagement requirements the came out in january of this year, at administrator verma made some announcement just a couple of weeks ago, made some announcements or sort reiterated the administration position at a medicaid managed care summit a couple weeks ago. couple points, it seems to me that cms has been quite aggressive in approving humidity and take a waivers to fight the medication respect administration seems to be continuing forward with the concept of community engagement waivers. cms is also using waivers to combat the overweight epidemic. i think that's worth focusing on a little bit, so there's this court in the medicaid program called the imd exclusion which essentially prohibits medicaid from paying for services in an
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institution for mental disease,, for individuals between the ages of 21-65. that exclusion, that imd exclusion really historically cms has been very, very reluctant to waive it legally it's not quite as easy to waive it as it is, as are other provisions in medicaid. but this administration has been quite aggressive and approving waivers of the ind exclusion, at least to the extent that it's to do with the opioid crisis. cms clearly has some limits, the massachusetts waiver we saw that governor baker wanted to waive provisions of the medicaid prescription drug rebate program and cms rejected that waiver. there are some limitations. i'm going to wrap up their come happy to take questions after we're all done speaking. i'm going to pass this down, if
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i make. >> before we hear from cindy beane, and i just ask, could you just elaborate a little, what kind of falls under community engagement specifically, if you could elaborate on that? either calder or thomas actually. >> with our guidance outlines a number of activities states can count towards community engagement requirement including work, volunteering, education, training. states have some flexibility. what we encourage states do is look at the activities that count under other existing working committee programs or add additional activities they think appropriate for the population they're targeting for the medicaid waiver. but will have a lot of flexibility in on that at the state level. >> thank you. okay cindy beane from west virginia. >> high.
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i'm the commission of west virginia medicaid. i've been there in my position for about four years and before that i was a deputy commissioner at medicaid, so a lot of history with west virginia medicaid. we have gone through a lot of changes of what i want to do is highlight the west virginia footprint and all the changes that cms is made available for us to do a program to meet the needs of west virginia. .. and west virginia, medicaid has quite a large footprint in our health care system. so when the decision was to
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whether or not we were going to expand medicaid under the aca. one of the things taken into consideration we need a healthy work force in west virginia. our economy is changing and at that time of expansion, we were starting to see the rise of the opioid epidemic in west virginia, 20,000 have a primary diagnosis and 50,000 members have a seconddy diagnosis and when we expanded medicaid in west virginia, we used one of the flexibilities that were offered and used modified 1115 waiver in order to get people on the rolls. our actuary predicted 90,000 on the rolls, we were very successful, we had over 100,000
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on the rolls within a period of six months. what we found there was a lot of pinups in the end and individuals without health care and found individuals one of the things we found were individuals that had a health care need that were no longer able to work. a hair dresser testified she had a knee replacement, and got the expansion. >> that's how expansion worked in west virginia. and speaking of the opioid epidemic, it's been mentioned here, and the opportunity for sud. and this is devastating for west virginia, we lead the average in overdose death. the national average is 19.
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we were giving full continuous services for sud and we were first under the trump administration for the waiver to provide continuous services for sud in west virginia, from an assessment, to actual inpatient treatments and ind's so we can have short inpatient stays and expands our use as medication assisted treatment, which is an evidence-based treatment for sud. so in west virginia as soon as we applied for that waiver we got lots of calls from individuals who previously were going to perhaps a methadone clinic paying cash. i remember one call i took from actually a grandmother who said, you know, crying on the
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phone, thank you. i hear you're covering this now. i didn't how much longer i was going to be able to hang on. my car is breaking down, but i'm paying the methadone clinic for my grandson and this is the best he's been in five years. i'm getting him back and i don't know how we would have hung on. so those are going on in west virginia and how medicaid is making a true difference in the lives of west virginia. with the waiver and the new administration it's always been an emphasis is increasing accountability. so with the evaluation, we have partnered with our university, west virginia university to really do a robust evaluation of our waiver, and we're doing a comparison study with regards to our waiver, its impact and actually doing a different study with another state. so, we're also trying to get
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another state to come on board, but that's where we're at right now. >> and neo natal syndrome, babies exposed to drugs in the womb during pregnancy and it's basically the withdrawal of those babies. and so, a baby with neo natal syndrome abstinence syndrome is not for bright lights and noise. we had one of the nurses at one of our nicu's inundated with these children and started a place called lilly's place and it's actually a place where these babies are weaned off or withdrawn in a setting that's more conducive to the baby. how can we get this approved.
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we worked for months and got a state plan approval for that and the first state to be able to do that and we're very excited about that, that program. another think that west virginia has taken advantage of. the health home to integrate your physical and behavioral health and gives a team approach to that individual, follows up making sure they're following up for appointments. we have two health homes running in west virginia. our first was bipolar hepatitis c health home. we also, due to different factors, lead the nation in hepatitis as well. so we went from actually a 25% screen rate to 100% screen rate for hepatitis for our individuals participating in our health homes. just some quick statistics for our first health home. this was our bipolar health
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home and we started out in a pilot area so we had a six-county pilot and compared it to a six-county pilot in another area of west virginia and see the dramatic results what it took to see the dramatic approach in health home. and this shows you compared to the cohort, the decrease in hospitalizations as well. and lastly, one of the flexabilities that west virginia uses, we are about a 78% managed care state. we actually-- our managed care companies have brought to the table different mechanisms for flexibility, such as value-based payments. we're looking at some different employment supports and incentives through managed care agencies and value added services that they can offer our members as well. so, in west virginia, we take a multi-prong approach to do
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whatever it takes to meet the needs of the members. >> all right. thanks so much, cindy. and now we'll hear from cindy gillespie from arkansas. thank you. >> thank you. i was going to give just a brief overview. i'm going to put in context and mostly talk about what we're doing for the work engagement community environment, but as cin cindy beane just showed, and said earlier, every state is different. we have one of every three residents is in medicaid. we are-- have a lot going on in addition to the implementation of working community engagement requirements. while i'm not going to spend all the time on this i want to see how every state
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simultaneously major shifts are underway. they're back against each other. you're never doing one program channing in isolation. so right now, for example, we are focused on really shifting arkansas's medicaid program in many ways to have a more client centered approach to service delivery, across all populations and when i say all populations, we are focused not just on them from the standpoint of traditional versus expansion populations or behavioral health and intellectually developmentally disabled, but also, our foster kids, the youth we have in juvenile justice, these specific populations we're doing direct medicaid programs toward them. to put it at a very high level so you can see the way we're going at this. first, we want to be sure to integrate a lot of the nonmedical programs that are available in the state into the case plans and the work going around our bizes in medicaid.
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we see that they do not work together well, and to help people move out of poverty and to get to better health, we have to integrate those programs so we're focused on that. we're focused on improving communication. there has not been an effective outbound communication program with medicaid beneficiaries over the years and we've realized the need to make that a core part of being able to be effective. and a more client centered approach. in the past, arkansas has been working through the provider to get to the beneficiary. instead it's beginning to look at the individual beneficiary and what programs and services do they need and then finally, probably most importantly, expanding the services available. cindy's presentation, we did not have a robust spectrum, for example, of substance abuse services available as of july of this year and we now do.
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those services, it's important for medicaid make those successful. so a brief look back at arkansas expansion. this is a look at what our waiver looks like. arkansas expanded, they called it the private option. beneficiaries were enrolled in plans available through the exchanges, through the marketplace. into qhp. the goal was to increase access and coverage in the state and that was achieved in the four years of that demonstration. the uninsured rate was cut in half. in 2017, we began to amend this waiver. one element of the amendment was to focus -- to increase the focus on assisting those individuals in the waiver access services that could help them move towards economic security. and so we, as part of that, we
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were going to refer individuals on expansion program to services available for education, training, job search, et cetera. there were other elements in the-- in that amendment and we worked with that through the year. we did not see the referrals working and interestingly, doing the referrals, we began to have a lot of discussion with our fellow agencies that provide education services, training services, job services, et cetera. and realized that they, in a state with low unemployment, and a very-- unfortunately, we do not have the labor participation we need, that they were having trouble finding people to use the services. and the next year, we amended the waiver under the trump administration and put in the working community engagement for able bodied enrealos under 50 years of age without
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dependents. it applies to only anyone in a qhp. anyone who is medically frail and is not enrolled in these, we have income eligibility limits. quickly to move through this. if an enreal en enrollee is ove they're not subject to the work requirement. if they are, they're exempt from reporting if they meet certain, certain other conditions. if they immediate -- meet an exemption, and the exemptions, if you have a dependent child in the home, caring for an ip capacitat capacitated -- incapacitated person. working 80 hours a month.
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in behavioral health treatment. if you're in substantial abuse treatment. a long list -- if you have a chronic disease. there are a long list of exemptions available to for someone and they're not at risk of losing medicaid if they meet these. if they're required to work report activities, then we have a risk of losing medicaid coverage for the rest of the plan year if they have three months of noncompliance during a plan year, for those of you who have been following the way the affordable care act was implicated around qh p's, a lot of this is founding familiar. you lose coverage until the next plan year when you can reenroll. always type -- the state validates the exemptions. this is part of what calder was talking b we validate the
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exemptions where we have the data available. if we have data that shows there's a child in the home we give the exemption. if the income data working more than 80 hours a month, and given minimum wage, they're given the other exemption. other exemptions, pregnancy how it works. someone who is pregnant is exempt. if they're notified they're pregnant, they're exempt through the pregnancy. and when they have the child, they notify us, and then they're exempt for the child. they notify us they're in treatment. notify that they're continuing or now out of that and have moved on either to another exemption or moved into,
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hopefully into work. >> a couple of unique elements. the demonstration has been built on the use of qh p's as i said. those who are in a qhp usually have a broker, an agent, a commercial -- they have these commercial insurers, someone to work with them to help with employment, education and traj training. a key part is to use the fact that these individuals have an insurance carrier who cares about ensuring that they keep their coverage. the other thing to be aware of, we use a lot of proactive outreach tools, not only us, but the carriers use them, our department of work force services. we have had an extensive use of social media for the first time in arkansas, i talked about wanting to begin doing more
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where we communicate more with clients. for the first time we're doing outbound communications with clients. that has been part of the way the whole program has come together. all total, we have sent over 160,000 letters, 60,000 letters, 150,000 phone calls. there have been people knocking on folks' doors, e-mails going out in the hundreds of thousands. the carriers have been date it mining claims and calling people and the department of work force services has been reaching out. it's been an extensive effort. what i want to mention here is technically how that outreach effort works. >> when someone is found to be enrolled in medicaid and into the expansion category. the first thing that happens is they are given to our outbound education center, and they reach out in the first ten days, the individuals enrolled, before they even are assigned to a carrier and they educate
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them on the fact that they have a working community engagement requirement and try to see how they can help them meet it, whether with exemptions or whether with referring them over to services that can help them. they're then given to an insurance carrier who works with them. and so, there's always at least 45 days to 60 days before the person goes actually onto the qhp and their requirements start and it's in that period that we work with them to get them ready to be in this new world of having a working community engagement requirement. all of it is about trying to get them to the services that can help them with education, training, work, et cetera. so, they're-- they do report their activities on-line through a portal. it's a self-service portal around medicaid in general. they usually have an on-line account or we will help them get an account set up.
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there's been confusion, i think, in some of the coverage that has gone on about the on-line portal. if an individual cannot use the on-line portal, they can, just like they do when they apply for medicaid, they also come into one of our county offices where we help them and we've also set up, they can call and there are people who will help them report over the phone, the insurance carriers provide those. so there has been a way for people to be able to get to that kind of coverage. final note here, this has not been an effort just by the medicaid program. we're working closely with career education and with our work force services agencies. they have also had some assistance from the trump administration, as you will see here, that's allowed them to use tanif to support these abbictivitie activities.
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and you have in your pacts, we started in june and we're in the last month out of the 250,000 people in arkansas works, we had 73,000 subject to the work requirement. 53,000 met the requirement for month and 1400 had their third month of noncompliance and rolled over. we have a period this year we're taking existing beneficiaries and rolling onto the program. that's were the numbers are as they are, we're moving larger groups through and finally, this is what closures look like for us. just because there's always a lot of question about it. in september we closed about 15,000 cases at the end of the month. 41,000 were for noncompliance with the work requirement. you see a lot of these are for people's income going up. it's for people who, they have a higher income. they have moved out of state. they might be incarcerated. there's a lot of reason people's income medicaid month
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to month. and some move out of the home. so we're tracking this and inmrementing the program. at the end of the day i think the main thing i want to say, we're the first to do this and we're trying hard to implement the program aimed at our goal which is to help these individuals who are on the program access the services available to help them move up the economic ladder. thank you. >> thank you so much, cindy. okay, we will now hear. from the national law program. thanks. >> thanks everybody for being here. thank you to the alliance and to commonwealth fund for having us and the great work you do. i'm talking about medicaid flexibility and recent litigation and give my major points upfront. flexibility can be good and medicaid is flexible.
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and slashing coverage is a bad use of the flexibility from the point of view of policy. sometimes bad policy is also illegal. so that's the summary. if you want to do a nine minute power nap, go ahead. so i just want to start making point that's already been made, which is that we are all in agreement that medicaid is already flexible and that's by definition and statute. there's no arguing that, you can see the flexibility on the slide. nextability is not a dirty word, but we always have to ask ourselves, flexibility to do what? and that leads us to the kentucky example where you see a bunch of the flexibilities they requested, which added together leads to 100,000 people losing coverage. these are not innovations. they are things that reduce spending and reduce coverage. now, we're on the hill and i want to say to those of you on the hill, the design of your
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statute does not say to states, here is federal money and go make eligible whoever you feel like making eligible. your statute says to states, here is the deal you can take or not. and here is some federal money, if you make eligible, quote, all individuals, closed quote, who are eligible. that is the deal that medicaid offers states. that's not what is happening here. so let's talk about federal standards a little bit. we've been talking about section 1115, which requires-- it has many requirements, it's not a carte blanche to do whatever you want and i want to talk about two of the most important requirements. one is that it must be experimental. an innovative type of pilot program. i want to start with the basic proposition that not all innovations are a good idea. we can all imagine things are
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innovative and might raise suspicion. so, if you have a group of people who are living in poverty and rely on transportation support to get to the doctor, and what you do is, you just take away their transportation support. we can intuitively understand what that's going to lead to. i'm not asking you to rely on intuition because we have wavers of things like premiums and we have 40 years of studies telling you what happens when you charge premiums to people who are lower income. it won't be surprising to you that they drop off coverage and/or afraid for applying for coverage. the second requirement, 1115 demonstrations must promote the objectives of medicaid. lucky for us, the statute defiance what that means which is to furnish medical assistance and services. you look at that in kentucky, it looks like barriers to people actually being covered and furnishing care and we can
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use the transportation example again. it's literally, the opposite of fu furnishing services to stop transportation services. we can think of the work requirement, terminating people who do not comply with the requirement. termination, not furnishing health services, not what the act says. so your take away from this slide should be. these are not, you know, leo's standard, these are not standards that some court made up. these are in the statute passed by congress. and states and most particularly hhs is not huing to those standards. sometimes people say how do we know -- i'm sorry, how do we know what the legislature meant, you have clear language, the purpose of needy parents
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promoting job at work and marriage. personally i don't think that's the congress's finest hour, but the statute, you have snap and r with work requirements, it's in the statute. what does it look like in the medicaid statute? it's not there. okay? so again your take away is, when congress wants work requirements, it knows how to write work requirements, it has added to the medicaid statute umpteen different times over the years and never added work requirements, including the times when it added requirements to the other program. last year we had legislation to do work requirements in congress that failed. what does that tell you? most recently as of last year congress says there shunting work requirements in medicaid, number two, if there are a bunch of people in the legislature trying to pass a law let us do work requirements. what does it tell you about the
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legal status of work requirement. so, we have a policy that does not comply with medicaid law or 1115 law and unfortunately, the lawyers are involved. party is over, everybody out of the pool, it's no longer fun. let's talk about kentucky first. right, so in january with our partners, we filed a lawsuit against hhs over the approval of the waivers in kentucky. in june those were vacated, in other words, shut down by the d.c. federal district court. and the reason was that hhs failed to consider the administrative record in the case. in other words, the evidence in front of them about whether these wavers were good or bad. where that case is now is that they reposted that same application for public comment and presumably they will be soon reapproving that same
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application and we may have a version two of kentucky. we also have arkansas where we saw litigation in august. that litigation will be proceeding in front of the same judge as the kentucky case. the briefing will be running from november to january, meaning after mid january at some point you would expect a hearing and at some point after that, some kind of decision. the key difference, of course, is that terminations in arkansas began in september. so, i want to talk about that for minute because i know that's what a lot of people are interested in and i want to talk about it in two ways. i want to talk about the data and how you should think about the data. so data first. the data is bad. it does what many of us predicted, including really respected policy experts. 8,462 people have lost their health insurance thus far two months into the termination's beginning. that size, the important things for you to know about that size
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there are not enough people in that cohort who are not working, not students, not parents, not with a disability to have a number that large. so by definition there are workers, students, people with disabilities, et cetera, in that group. very concerning. 507 people have recorded clien compliance with work, volunteering or some combination there of. that 507 number, however, does not distinguish people who were already working and people who are newly working. we suspect the majority are, in fact, people who are already working, not newly working. additionally, of the people who are newly working, it doesn't give us a baseline as to how many people every month are newly working, because every month, people on medicaid, some amount of them get jobs. so if, let's say, there were actually only 200 people newly working, but the average is 175
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a month in arkansas get work, that means only 25 got it through this. the upshot of this, that 507 into um is actually closer to 100 and now we do a simple comparison. we have 8,500 or so people who lost their health insurance and we have some number, i think closer to 100, who may have gotten work through this process. and so obviously you have to ask yourself does that pass your smell test? they are justifying that based on outcome. 8,500 people who did not have health insurance and you gave them health insurance, what are the health outcomes for that compared to the psychosocial benefits that people get from working. in addition the state spending a lot of money, making a lot of effort and a lot of red tape to do this. so that's where the data sits and i'll close by talking about how you should think about that data. he think i may surprise you a
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little bit here. i think there's been a lot of public discussion, including in the media criticizing arkansas for their implementation. there are big mistakes in the arkansas implementation. this was designed and approved with hhs with an on-line portal only system for reporting your hours. that's how this was designed and approved and was, until very soon after the problem started. so just understand when we are talking about a low income community in a rural state, that this was not designed in a way that was going to likely be successful for a lot of people. we have solutions like, you can drive 20 minutes to a place where you can then use the jn line portal if you're able to do an account successfully, if you know how to navigate it and you have to do that every month to report in some cases. right, again, big issues with
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implementation and i actually want to say we shouldn't be thinking about this in terms of arkansas did a bad job, and i think of the icarus, put on wax wings and tries to fly towards the sun, the wax melts, he falls to the earth and dies. and i can take a narrow lesson which means don't use wings made out of wax or say to yourself the sun is 20,000 degrees fahrenheit, don't fly at it. the problem is arkansas's implementation, there are good things and bad things. cindy talked about some of them and they're really true. the problem is design. if you fly at the sun of wings of wood, paper or metal, the same result. this population includes people who are homeless, have serious mental illness, people of
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victims of domestic violence aren't allowed to come out of their house and communicate. people who moved five times. and people who park part-time, shift work. seasonal workers, four months off and eight months on. right? it includes tons of people who are self-employed, people who are paid cash and many of them, right, a huge number of them are legally below the threshold for you to be required to file taxes. there's no reason why we would know about many of these people and their work status, much less volunteer status and tracking real time on a month to month basis. so the headline is not arkansas is doing a bad implementation job. the headline, it's a bad idea. it's an idea that's not legal, is bad as a matter of health policy and is not something
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that's feasible to do considering the population we're talking about. >> okay. well, thank you, leo. so on that note first, i just want to say, this is what the alliance is all about and, you know, that it takes a lot of courage to kind of come up and sit on a panel where there are such extremely different points of view. and different ideas about the intentions and implementation of programs so before we get to the end i want to thank our only polices for being up here. so let's kind of stick to this question for a moment. i want to turn to cindy gillespie and say if you have anything you want to respond to as far as what leo said and i'm curious, you thought there were some good things. i want to see if you want to elaborate on that a little bit before cindy responds. sure, so i think one of the good things is we know from the
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data a little bit more than 70% of the people are being identified for exemptions without-- without having to do anything through a data match, right? so that is 70% of the population who doesn't have to deal with all of the problems of figuring out how to report themselves. right? that's a good thing. that's not necessarily something that every state would have done or will do. and that is dramatically reducing the scope of the problem and without that instead of talking 8500 people we might be talking about 30,000 people. so that's a good thing. i think some of the policies that arkansas has put in place with respect to self-attesttation are also better than policies we've seen in other states. so i think there are a lot of things about the implementation that are better, but i sort of think about it in terms of, you know, there are reasons why somebody might disagree whether
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they prefer the firing squad or the electric chair. there are details that matter, but at the end of the day huge numbers of people are getting terminated and some of them are literally going to die. to me, that's the story. >> okay. cindy. >> okay. you know, you said it well when you said the data at this point, it is early data, okay? and there's a lot that's going on here. i think maybe most importantly is to step back and let me just remind you why we did this. people keep saying that we did this in order to reduce the rolls. the rolls in arkansas, in december of -- december of last year, all right, ten months ago, we had 330,000 people on the arkansas works rolls. by the time we started this in june that was down to about 270,000.
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we didn't do this to reduce the rolls. our rolls are going down. the economy's improving there. we have other efforts that are going on around keeping our rolls accurate. we have a lot going on. we're not doing it to reduce the rolls. we're doing it because we have a number of people that are in the program that we see not getting help from anywhere. we started with a group of 30 to 49-year-olds for a reason. the 30 to 49 years old-- when you're 30 to 49 years old, you don't have a child in the home, aren't caring for incapacitated person, not engaged in the community any way, shape or form. all evidence out there is that it does, in fact, lead to a healthier life when you are
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engaged. if you can get your education and skill training up, you see that that is one-- one of the reasons that people talk all the time anymore about social determinates of health most of which go back to poverty is because you really have to move people-- help people move up the economic ladder. our programs in the state are-- or too siloed. the work programs in one place, education programs in another place and to help bring those people together we have to bring the programs around them. so our experiment, a demonstration, as you said is an experiment. so our experiment is based on the idea of compassion. we want to identify that subset of people within this population and between us, our insurance carriers, we are working with the homeless advocates. we're working with every group we can out there, begin to help
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those folks move to access the services that are available and paid for by the-- through all the other federal programs that flow to the states. so, that's our goal and i do think it's important to understand what the goal is because, as you said, we are collecting data. we will continue to collect it. we will evaluate the program as we're supposed to because we're trying to learn how to make that difference and how to pull these things together. the other thing is, it's often talked about, this is the first few months of a new program. we are the first to do this. it's often talked about like everything is black and white, and the way that this is being run. we have set up, in addition to the fact that, yes, there is an on-line portal. there's a self-service portal. medicaid beneficiaries in
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general, we're hoping to move towards the self-service portal. you apply for medicaid on-line or you call someone and they apply for you on-line, it happens on-line. our portal is on-line and that's how you change your circumstance, that's how you do this. if you we have other ways for people who can't do it themselves to reach someone who can help them do it. we have a good cause exemption. this is a new program, right? and people are learning as they find out, oh, wait, this has to happen. so, we have a way for people to call, have someone else call or e-mail on their behalf. come into an office, whatever it is, come in, tell us what's going on, and our folks will work with them. so, if, in the case as you're talking about, we find out afterwards that there was a reason somebody wasn't able to get to us and get their exemptions, we granted.
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we're trying to implement this. i love the way the director of the county says we're looking, if there's a judgment call to be made err on the side of the client, that's the approach they're taking. we're in the beginning stages and i think that the team there is doing a great job. they are doing it with compassion. and i'm very hopeful that we will continue to see success. we have individuals who are accessing services, who are getting training, who are going from making zero to making $24 an hour. we have success stories, i'm hoping a year from now we will have hundreds and hundreds of those. you have to start. i don't believe -- i did like what administrator said, i don't think it's compassionate to leave people in poverty and our goal is to help them. >> thank you, cindy. we've already gotten a couple
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of questions on green cards and they are on the topic. so i'm going to let rachel ask those and switch gears. we've had robust discussions and we have only have about 20 minutes. if you have a question, write it on a card and we'll pick it up. >> i wanted to bring cindy in, in your west virginia example you highlighted a classic good news/bad news situation. you over achieved your goals in terms of finding folks that were eligible in enrolling them. obviously with that comes some costs you weren't expecting so i think as we talk to states, but also to federal folks, there's a lot of interesting concern about, you know, doing a really good job at outreach and enrollment. how are you sure you have the resources to bring those people into the system and how have you seen those costs balance
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out? have you seen savings or more balancings of expend turs when you look at reductions and other costs? >> so in west virginia we did our enrollment far exceeded our expectations. we've leveled out now around 165,000 individuals on expansion. at one time we were up to 185,000. like arkansas, we have seen a movement. our numbers are down and have leveled out. we've seen people, our economy in certain areas of the state is picking up and we've seen people obtain employment and get off the rolls, but what we did is found efficiencies within the program initially, there was a lot of pentup demand. fortunately, for an expansion state for those first couple years, those were 100% federal dollars. so we're now to the point of where that match is going down.
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so we're currently at 94 and in 2020 we'll go to 90. but with that, what we have found by finding other efficiencies, we found some efficiencies on the pharmacy programs and other services, and we basically have revamped our program in order to pay for these additional individuals on the roles because it's important for west virginia and its economy to have a healthy work force, so, west virginia, we have historically been a coal state. coal is not like it used to be, and our economy is changing, and we have to get our work force healthy and in order to basically have our economy be more robust and so, it's very important for west virginia to continue those individuals on those roles. yes, it was a concern and, yes, we had to find efficiencies in other parts of the program in order to continue to pay for
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the expansion population. >> thank you. we also have a question around providers, and if you could call talk about how the innovations that are being discussed affect the way that patients interact with their providers. we have talked about the patient-centered approach and is there anything to do to see medicaid patients or for innovations that are dealing with the so-called dissocial determi determinates of help? is there anything to help physician's offices or patients to connect to the resources they need? we talked about work and community engagement, but perhaps other resources as well? if you could comment on that. i don't know if you have a comment on that and perhaps we'll ask others as well. >> i'll jump in quickly and say this is an issue we know states
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are very interested in. we've heard this consistently that there's a desire to understand how different issues are impacting the overall cost of care so we're working with a few states, and some different approaches under 1115 or other authority to think through that more. we hope we can have some examples we'll begin sharing and learning from soon, but one of the things we really want to make sure we're focusing on this, we're linking those investments to outcomes. that they're linked to value and if we're beginning to think about paying for new things in different ways at that we're measuring the impact on cost of care and outcomes and we're monitoring and of course, correcting over time. so look for more of that here soon. i think we're working with a number of states, but something we're very interested in. >> so in west virginia, the health home model that we highlighted that, really encourages the extra person in the office that can do the care
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management, outreach, call that member and make sure they're being adherent to the medications and the physician's office, individuals, especially in the bipolar homes, they're not the easiest clients, sometimes not compliant with medications and have the additional payment to go for the office for those supports and our managed care offered in different areas, where there's a particular need, ob-gyn office that has a lot of high risk pregnancies, and pregnant women suffering sud. and hook those women up to treatment during the pregnancy and also, making sure that the babies have ongoing support as soon as those babies are born, and hooked up right from the start for additional services.
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so there are unique things that the agencies can do to give offices additional support because it's not necessarily always the payment. it's additional support that they need to help me and it's the medicaid member. >> i'll just add a couple of quick ones and it really builds on what cindy said. a couple of things that we're doing in arkansas, we've had like you, the help homes-- patient-centered medical homes and it's been successful, voluntary, but over 80% of the practices are in. we're expanding that this year down to practices with 500 or less patients which will really allow us to move this more into the rural areas, so that's been a tremendous benefit. in exchange of information that goes on between providers in that-- in these pcmh's has really helped improve the quality of
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care delivered in many areas. the other thing i'll mention, even though this is not new in the rest of the country, it's new for us. we are beginning next year, managed care for the first time in the state around the behavioral health population. managed care is not just-- it is not popular in arkansas, i think would be the way to say tso this is our first foray, really, into managed care in the health space. so the behavioral health population, high need, will be in what we're determining or terming organized care, but this year began with care coordinators. so care coordination for the first time around this population, which is allowing us to finally have that connectivity about what's going on between the behavioral felt and the rest of the medical treatment, and so we're very excited about that shift in change. >> okay. thank you. we've got a number of questions, a vast majority of them actually that are really
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focused on the resources that are required to really connect the people that need the services and then given different states and different areas within the states to the different area available. how much more critical that is now kind of in the face of using some of the wavers and the inability to reach out to someone and requirements that leads to them coming off the rolls. so i was wondering, calder, if you wanted to talk about it and then tom and then turn to the stage. what helps are you taking or how are you thinking about as you're situating these new approaches, ensuring that appropriate steps are being made especially in areas where broadband is not exsistent yet and i know we've talked about it in arkansas, but otherwise? >> sure, i think we both
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recognize that these are wavy understakings, and all of 1115 demonstrations and take a lot of thinking through and planning around effective implementation. and we've identified key steps that states need to go through in order to have thought through the issues that we're recognizing are emerging through this. and they center around three key issues, those are procedural operational challenges, what needs to happen with the eligibility field workers, the processes across the state governments. the necessary capabilities. the we've heard the conversation about the work that arkansas has done due to date linkages to be able to minimize some of the administrative work that beneficiaries need to do and having an effective communication strategy so that folks juan what the requirements are in the
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communities, working with the natural partners that are exist. and part of the learning that i talk about in my opening comments, helping states, what are the benefits across each of the steps and each of the three areas and letting them share with each other, the lessons learned and best practices, because we're finding those to be the most valuable occurring, and we brought those together in baltimore. there were exchanging and policies. and i know that cindy can talk about the work that they've done. they are going to be unique and taylored to some of the unique aspects of each of the individual states. >> i'll start. you know, one thing that we are learning, as he said, we're taking this from the standpoint of how do you -- we continuously keep asking
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ourselves what can we do to improve communication, what can we do to improve communication? and i think that's important for any state that sets out to do this, it is to realize that it should be a process of continuous improvement, continuous improvement. when we read something in the newspaper about-- when someone raises an issue and says, well, this person did not know. we go how could we have gotten to them? how do we get to them? where do we reach them? we are in a -- i think that's what's incredibly important is not to say this is the plan on communications, make it static and then go. it is just to keep reassessing. we will be doing focus groups and learn from focus groups, we will reassess, we will add to, we will continue to add to and continue to add to. the more this has gone on over the few months, the more the
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community has become engaged and i think that's incredibly important. the organizations that work with different populations. we've been doing training sessions with them, webinars, the medical community. the carriers have been able to let the pharmacies know if someone has not been responding. there's all kinds of way to try to touch someone. we've even had the laundromat society association in arkansas, willing to put posters up. try to think where people will be. we've worked with churches and worked with others. so communication is not static. communication is something that you just keep layering on and layering on and layering on and i think that that's an important lesson to learn. >> and cindy, let me ask-- did you have a comment? okay. in terms of there are several
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questions i'll try to kind of summarize them, if somebody, you know, does have their coverage terminated, you know, what's next? like, is there outreach to help them how to figure out how to get back on, any kind of outreach to help them, for example, stay healthy enough to work or, you know, otherwise engage in the community, so there were several questions along those lines, if you could comment on that? >> be happy to. >> so if in addition to the-- you know, you have required noticing you have to do around everything in this program, so we do all the required noticing, but communications, part of it is we have been layering on additional communications and one of those is when someone does lose their coverage with noncompliance. we reach out to them and let them know partly where they still have receive health care, if they need health care services. if they think that this has been done in error, if they
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would have had an exemption, if there's something that was going on. we tell them how to reach us, and that's what i talked about this good cause exemption. we try to make sure they know where there are services available to them and try to make sure that they know how to come back and communicate with us if they think this was in error. and this is different from the appeals process. ins just come talk to us, give us a call and let us look and see what's going on. and then on top of that, as you know, we said, they can come back into the program in the next plan year, the timing around the first one means they will be able to go through open enrollment, which will start in november, to start coverage again back in january. and/or at any point during the year next year, if they lose to come back that way. >> thanks. okay. so we have a few minutes left for questions. i want to turn to tomorrow and
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leo who haven't had much of a chance to weigh in. if you talk broadly kind of what is next for these court cases? what can we be looking for, should we be looking for in terms of process, timing, outcomes, that type of thing, you know, as we know there are several other big court cases that might affect health care in the near future. what are you looking at and how might they affect medicaid in general? tom, you want to go first? >> so i'll defer to leo on the community engagement lawsuits, the arkansas case, the next steps in the kentucky case. i would say that there is sort of a-- this is quite apart of the subject of waivers. there's sort of a burning issue in the courts right now over whether or not the entitlement to medicaid is enforceable via the federal court system. there are a couple of cases
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surrounding the free choice of provider requirement in the medicaid statute and there's a split in the circuits on that issue and that sort of typically would tee things up for a supreme court decision. the whole question of whether or not the medicaid entitlement is enforcement in the federal court system is an issue that i think is worth keeping an eye on over the next year. >> thank you, leo, do you have any thoughts? >> sure, i think, the litigation will move forward in arkansas, will very possibly happen, start up again in kentucky. i think there will be some other new states approved. there will be some-- there are a couple of states that are approved that haven't implemented yet. those may start and may also one day lead to litigation so i think it's a top that's going to get richer over the next year, it's not going to stop being a topic of conversation.
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these are-- one thing i would say that i would probably disagree a little bit with tom on is the notion that there is sort of a lot of history for courts to draw from in these cases. there's not a lot of waiver cases. it's not like free speech where there are options by the supreme court and-- >> i don't disagree with you, i agree with you on that. >> misunderstood, sorry. and i think less in medicaid cases and there aren't many that are at sort of a high level that would be binding on every court. so the court that heard the kentucky case really didn't have a lot of clear precedent and sort of making it up as it went along. i think that courts are going to have to-- as the judge did in kentucky -- take a look at does what the state's doing match the records in pt fro of the state. how does it look compared to the statute in the state and i
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think we'll see courts struggle how to do that. i think the issue of preference r deference will be a talking point. the courts should defer to the secretary. that is a very condensed description of a wide body of law which basically says that sometimes the court should grant deference, other times it should grant deference -- shouldn't grant deference and even as we saw in kentucky rational means to support something that the program is about. ...
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just to wrap up, can you share your positive vision, what innovation for development d.c. as most promising for medicaid? if you could just be qaeda briefly shut that, that would be fantastic. >> i think we actually heard great examples from both on the stage. some of the interventions with respect to su d a really important. the issues around social determinants of health are really important. the notion we can better connect our clinical systems some of the other social and nonmedical support systems is really important. it's a big challenge. it's a statutory challenge in the sense how do you medicaid pay for certain things when the losses here's what you are allowed to pay for. that's a challenge that cms is working with states to try to solve. it's the challenge for states to
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implement. they have to get providers on board with the new screening. you have to get providers on board with new types of treatment that are important. for example, informed care for communities of color, communities that are victims of sex trafficking we have to really address a lot of trauma that's been there. we've been talking about probably the lightning rod a lot. there are a lot of positive things. the only thing i will close is the interaction, and the interaction is when you take away coverage you destroy continuity of care for individuals for going to be locked out for a nine-month timeframe. that does not promote continuity of care, doesn't help. when you look at what to work with social determinants of health, whether it's new screenings or new ways of doing therapy or new connections, it's always the addition of the new valley. it's not the taking, if something. >> thanks, leo. cindy gillespie.
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>> i will say that i agree with most of what he said except right at the inn. and i agree standpoint of i think that is from medicaid and for the population research probably the most important thing is how do we begin to work with thickly those who are second, third, fourth generation poverty, how do we really begin to break that? and you break it by figuring out how we are going to, in fact, help the whole person and not just help their medical, but how do we deal with this issue of all the social determinants of health and how do we pull back together. >> thank you. >> i think one of the benefits of the aca's that brought to the medicaid agency was that medicaid agency can't expand and do these things alone just in the file of medicaid. now i work closely with the justice department because individuals coming out of the
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jails and prisons are now on medicaid. i work close with the bureau of children and families, in order to basel ii get those, what i think the next step is to blend some of these findings together, ohio together with these are pure for children's and families looking at the skids, foster care kids are kids that are involved in that system, our just a simple system. there's a plethora systems several to work with the social determinants. they're willing to work with the medicaid agency. we all have her own data pools. we are currently working on basically getting those feeds, so people know what is that whole person because it is important if they are homeless and they can't get health care, access to healthcare, they might have a medical card but they don't know where to go, how do you outreach that person. that is the key. wikis are medicaid agencies to realize we can't do it alone. we've had his partnerships with
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public health, children and families and justice. >> i completely agree with the comments on social determinants of health. i think that's a huge shelter medicaid. my other comment is i do think, and i realize that cms is thinking about this right now, but i really do believe that medicaid needs to think about how the new therapies, gene and cell-based therapies, for example, that into the overall medicaid prescription drug rebate program, and how the drug rebate program could deal with value-based purchasing arrangements for these new therapies because it's a completely different paradigm and they don't work the same way that traditional drugs work in the drug rebate program. i think that's a challenge that needs to be addressed in the next couple of years. >> we really excited to see the
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work on all these fronts. obviously we talked about the working committee engagement requirements and what that is driven to try to dress is what is seen as a growing an emerging problem when you look at work participation rates across the country, particularly among childless adults a fallen pretty considerably over the last few decades and we are now at a point worthy of the lowest rate of unemployment in nearly 50 years, wages at the fastest rate they ever have in the month of august and states are looking for opportunities to help reconnect individuals back into the workforce and back into their communities. this is one aspect of that. we heard the medicaid program has historically had come this is a purpose and that's true but it's also important to remember before 2014 childless adults were not eligible for medicaid. the program has evolved and were having to a fault with a two-out address the needs of the population that is the serving. it's not a policy that radical
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in the fringes. kaiser health tracking poll last summer showed 74% of adults support the policy of the worker community engagement as a requirement for eligibility. the devil is in the details, we work with states around the supplementation but the valuations will do what the results are and we're committed to making sure those are thorough and with good data to understand what's working so they can be emulated and best practices can emerge. >> great. thank you. that is all the time we have. please join in thinking our panel for today's discussion. thank you. [applause] >> thanks to the commonwealth fund and to rachel for making this possible. please fill out your blue evaluation. it really does help us, and come back to our next briefing. thank you. [inaudible conversations]
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>> tonight on "the communicators", nyu professor and author scott galloway talks about the power of the largest tech companies in the u.s. with his book the four. >> if you think about who really knows you, is it your wife, is it your kids, is it your therapist or friends? i would argue the anti-gw knows the real you is google. google knows if you're about to get engaged. it does the trick of
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contemplating divorce. google knows what ailment you have, what ailment you are worried about having exposure sell to. google is the real you. if there is a real modern man got it is google this is everything, all of your intentions and how those intentions will likely translate into action. these organizations know where we are, know who we are connected with, , no hard feelings, nor intentions but we have yet openly invited them into the brightest and darkest corners of our lives. >> watch "the communicators" tonight at eight eastern on c-span2. >> now, , dan coats director of national intelligence calls on the private sector to step up their efforts to combat cybersecurity threats saying everyone must do the part to protect the nation's infrastructure and democratic system. he spoke of the cyberscoop cybertalks conference. this is 20 minutes.
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♪ ♪ >> good afternoon. given those lights i can't see anyone. you can probably see me, although as long as you can hear me i guess it works. i appreciate the opportunity to speak to you. my understanding is its closing in on the end of significant conference dealing with a very significant issue. and so i'm pleased to have the opportunity to come and share a few thoughts with you. my understand is that everything has been conducted in 15 minute increments. goldie said i could have an additional five minutes so i make it run off. when i i was at the house of representatives and moved on to the senate, i was,

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