tv Medicaid and the Role of States CSPAN March 17, 2017 11:18pm-12:04am EDT
medicaid increases spending to the states, increases funding. but it's not unlimited like the current system. so that cut is -- if you do what the house did and it becomes law, states get more money. they get more flexibility, but it doesn't go up unlimited like it does under the current system. and that's what they define as a cut. it's really more money. >> i hate to cut us off but i will say we have a fantastic panel on medicaid coming up moderated by my friend carrie young. we will get into more details there. thank you all. thank you for for watching. [ applause ] now from the same forum, republican congressman brett guthrie of kentucky talks about his state's role in administering the medicaid program. this is 45 minutes.
>> all right. we are going to introduce our last panel of the day that we have saved the medicaid discussion for our last even though as you see in each one of the panels medicaid comes up. it is sort of the elephant in the room in the current debate. carrie young, our associated editor at cq news for health care, is going to be moderating the panel. we also have diane roland, the executive vice president of the henry j. kaiser foundation, meg murray who's the chief executive officer for the association for community affiliated plans, jessica shumel senior policy analyst on the center for budget and policy priorities. and brett guthrie, republican congressman from kentucky. welcome. >> so we are all very interested in medicaid these days including what's going on on the hill. probably to save time and allow more time for questions we'll start by going to each panelist to talk about what you see happening with the current attempts to change the aca and
get a new bill up there. >> i think that the most surprising thing to many of us was that in the aca repeal and replace everyone expected to look at the expansion and the expansion states and what had happened and what was going to happen with that funding. but the current bill takes on a lot more of the overall medicaid program, which obviously affects about 20% of the american population and covers our elderly people with disabilities, children including children with special health needs, as well as their parents and now with the expansion some other adults. and i think that really does cause us to want to really look at what are we really changing and what are we improving and how are we moving forward. and i think we all anticipated a lot of changes to the medicaid program itself through waivers when the new administration came in but not quite such a capping
of the federal expenditures for that program. i think we're looking at where congress can move and what will happen with this legislation. a lot is at stake for some of our very lowest income beneficiaries and we just want to make sure that the safety net that we've developed as a nation to take on issues like the zika outbreak or the opioid addiction problems that we're dealing with right now is not going to be weakened but instead strengthened. >> well, thanks. >> you're right in the thick of it. >> thick of it. thanks. we spent the last year, actually, a lot of people say everything's being rushed but we spent the last year with the medicaid task force meeting with governors, stakeholders, a lot of people moving forward to see where do we need to go if we had the opportunity to work with medicaid. medicaid is the largest health insurance program in the world. it's bigger than the national health service. we're going to spend over a trillion dollars on medicaid by 2026.
how do we make it sustainable? how do we make it work? how do we keep the safety net in place? because you have a safety net that's not sustainable, then it gets a lot of pressure on the safety net. we started with looking at flat block grants. there's been a lot of proposals on block grants. and there may be some opportunity to have some choice in that for states. cbo estimates that no states would make that choice, they would actually choose what we looked at per capita allotments. and so when we started looking at it. i know some people have kind of phrased this as cuts in medicaid. it's not. it's actually putting it on a budget restraining growth. what the bill actually does, the bill has to pass the energy and commerce committee. every state gets the same allotment from 2016 that they had. so there's no changes in there are programs. what it does is it allows it to grow from 2016 forward at cpi medical. and there's some discussion even about -- for elderly population, disabled, maybe having more generate growth in that group. the other is in demographics
because if you put a flat cap on medicaid and you have -- i'm the end of the baby boom, so i'm 53. so by the time i'm 65 we're all going to be retired. the elderly costs more in the medicaid system. so if you just put a cap and you didn't account for demographics and hopefully as the economy improves you also have fewer people in medicaid but not because they were -- i'm talking about the traditional medicaid, not the expansion population. so we think that what actually the traditional medicaid program will be as it is today with growth for medical inflation and adjustment for demographics. we think that makes it sustainable. we're not bumping 2026 and spending a trillion dollars trying to figure out how to deal with the safety net. we think that puts it on a good solid pass. that's our view of it. the other is the expansion. i'm from an expansion state. we have -- a lot of us are from expansion states. moving forward. the way we deal with the expansion in the current version of the bill is expansion is maintained through 2020.
january 1st of 2020. the people who have health insurance after january 1st, 2020, the current version or have medicaid in the expanded population stay on medicaid for as long as they're on medicaid at the enhanced fmap, the 90-10. states can maintain the expansion but if they put people in the expansion after 2020 in the current version they would have it do it at the traditional fmap. you have able bodies, most people in the expansion are able-bodied because otherwise they might be on traditional medicaid. you're incentivizing states to become health insurance able bodies adults at a greater rate than disabled and elderly. in kentucky federal government gives 70 cents for somebody who's disabled and they'll give you 90 cents, after the fmap for someone that's able-bodied. we allow them to stay on. cbo has estimated that people in the frozen population within three to five years will move into other health insurance or move forward. but that's how we deal with it
now because we always say we're not going to pull the rug out from anyone. and then you start dealing, so how do you deal with that population and the other versions of the bill, you do tax credits, refundable tax credits and things that we've been discussing do help people at the lower income buy health insurance and participate in the health insurance market. but not under medicaid. we're looking at it saying it's not sustainable the way it's designed. >> thank you, congressman. >> for those of you who are not familiar with acab, i just put my comments in context, i represent the safety net health plans that are non-profit and our plans cover about half the people on managed medicare including a lot of people in kentucky. so that's our view of the world coming from the non-profit move. our plans are owned by hospitals and children's hospitals. so we are very concerned about the bill and very concerned about the 24 million people that will lose coverage under this according to cbo and almost $900 billion hit to the states. so very clearly concerned about
that. but also just want to acknowledge that the bill does keep the entitlement, which is important. so we appreciate that and appreciate that plans -- states can still cover people under 100%, albeit at the regular match. and that's a paradigm shift from where we were in 2009. we definitely acknowledge that and appreciate that. two piece in the bill that haven't gotten that much attention i want to point out are two conflicts we see in it. the first has to do with continuous coverage. in the bill on the marketplace side there's incentives with carrots and sticks to make sure people have continuous coverage in the marketplace and that's important for beneficiaries as well as the stability of the industry. but on the medicaid side it's going tonight opposite direction. there's incentives to increase the level of churn in medicaid. at acap with our plans we've been very concerned about the level of churn in medicaid. it reduces people's -- the benefits people get and has implications for their health as well as ends up -- there's administrative costs when people go on because they usually do
come back when they go off and when they come back on. most people who lose their medicaid eligibility for whatever reason end up either still being eligible and they lost it because they didn't come in for redetermination or their income went up just a little bit but they tend to come back on in a couple of months. we're very concerned that on the one hand in the marketplace we're saying continuous eligibility's good, we want to incentivize it, on the medicaid side we're almost weaponizing churn to get people off of med sxaid get them back down to the regular match. so that's a conflict and we'd like to see that conflict resolved. everybody should be continuously covered. secondly, with the per capita caps we understand there has to be fiscal responsibility and that some of the caps and waivers do incentivize people to move more toward value and less away from volume. but we're concerned with the requirement for actuarial soundness for the plans, that there could be a conflict. the states will be getting a capitated payment but they are
responsible for paying rates that are actually sound to the plans. and in turn the plans responsible for paying enough to providers, that there's enough access. so if states end up pushing down on the actuarily sound rates it's going to cause our plans then to push down on the provider rates and eventually become out of compliance with our contracts for 3r50i6rd access. also our plans, many of them are regulated by the department of insurance. they have reserve requirements. so there's concern whether they'd be able to pay the reserve requirements. those are two things wefield feel are a conflict in the law and we want to make sure there are good -- oversight at cms that makes sure rates are paid on an actuarily sound basis. >> jessica? >> thanks. a little context coming from my recently we joined the center on budget, i spent the bulk of my career at the center for medicare and medicaid services,
and i think you listened to a couple of my former bosses this morning, vicky and andy. i won't belabor the point about the per capita cap issue that's in the bill. that's obviously a big concern of mine. i was fortunate when i was at cms to work on behalf of 70 million low-income kids, parents, seniors and people with disabilities. and from a personal perspective very concerned that what the per capita cap will do will make states have hard decisions to make in terms of cutting eligibility, benefits, provider rates and really preventing states from being able to adequately address public health emergencies like the opioid epidemic, zika, as well as account for maybe blockbuster drugs like salvoldi. und a per capita cap states will have the tools that are available to them under the current financing system of medicaid taken away and they
won't be able to better address the challenges. another point i wanted to make and representative guthrie made it, is the demographic change. under the per capita cap model right now baby boomers are what we call young old. in the 50 to 64-year-old. and that's what the costs that will be used for the baseline of the per capita cap will be set at. but as they age and there will be more of them their costs are going into crease. the per capita cap formulation won't allow states to address the higher health care needs and costs associated with the aging of the population. and just wanted to also throw in a few other changes that the bill would make concerning. one is the bill would roll back mandatory coverage for children ages 6 to 18. vicky's talked a little about
it. we'll roll back the coverage and cost sharing protections that they currently have under medicaid. there's also a couple pieces that would affect seniors and people with disabilities. there is an enhanced federal funding for services provided in the homes that will need long-term care services. services that will help people get bathed and get dressed. and states are going to lose that extra federal funding through the house bill. and in a couple of states it's just going to make qualifying for medicaid even harder because the bill is going to look at home values differently when they make eligibility determinations for folks that need long-term care. so while the focus has been on per capita cap and expansion i just want to throw in those other little-known changes that are -- have just a significant impact on kids and seniors and
people with disabilities. >> thank you, jessica. before we go to a little baste discussion of what we're expecting to see with the states. we're expecting to see a lot happen with seema verma at cms but before that congressman guthrie we have to ask you what's your take on what's going to happen with house republicans on the medicaid date for the freeze. is it going to stick with 2020 or will it be 2018? >> i think the freeze -- because we're still talking about, it i think the freeze of people who are frozen going forward will stay. of course we're not expecting everybody to be permanently on medicaid but the freeze is permanent. the 90 -- 90%. but the enhanced fmap is anybody on it moving forward. we're not talking about stopping that at 2020. with people currently on it. the question is where do we put the date to not allow new people to come on to the system. some of it's driven -- we're discussing that now. but to move it closer to 2018 we hear people talking about.
i know my state meets every two years and does a budget. meet every year, do a budget every two years. some states meet every two years so you've got to be sensitive do states have to be able to adjust to that we don't want to force states to go into special sessions and things to deal with it. that's been discussed, i'm just being honest with you but i don't know how much further back we could go and not give states the opportunity to respond to it. >> we'll run through the panel again and briefly talk about what you're expecting cms to do in terms of regulation in changing medicaid. >> you i think we saw some very important clues in the letter that just came out from seema verma and secretary price. certainly i think one of the changes around the expansion population that states have asked for is to impose work requirements, to try to do more with reducing the coverage from the 138% of poverty down to just the poverty level, to try to do more with healthy behaviors, with some health savings accounts. so i think you'll see states
coming in and asking for some of those changes. and i expect that the new administration will be much more willing to go farther down the road. i think you might also see some states come in and ask for broader waivers around how they take care of their home and community-based disability and elderly population. this is an area where states have been very innovative but they've also been operating under some very limited funding that is now potentially some of to being taken away. so i think that's an area that will be expanded. but i think most importantly if i was a state i would try to be figuring out how to structure my program so that i could live with the caps that would be coming in based on what i was doing in 2016. and i think that's a very critical issue because what you do is if you trend forward from 2016 you effectively lomb in the
choices around policy other than the enrollment that have been made over the years in the different states. and so some of the states with much skimpier programs, much less room for innovation, some of the states that have paid providers very low over time really wouldn't have much room to grow. and i think they may try to do some things through waivers to maybe change their profile a bit but they could be locked into where they've been. >> like i said, it's going to grow at cpi medical. you're right. but some states who are at the lower end, starting at the lower end as they move forward. stuff we can discuss and look at moving forward. we want if to work. nobody out there's talking about a broad-based tax on everybody to make medicaid viable and sustainable in the future. we have to look at how do we put it on a budget. we're not cutting it. it grows at c pichlt medical. the waiver -- and on the per capita allotments, actually in the 1990s when they did welfare reform, which states renovated
and kind of drove that project. >> is that the model, congressman? >> that's something i'll look to because it seemed to be working. democratic president and a republican congress were able to do that together. and when they thought -- part of that originally was block granting medicaid that was original. i have a letter that's in the record that every sitting democrat member of the senate today, patty murray who's not there anymore, dick durbin, all signed a letter asking bill clinton to move toward per capita allotments. if you're going to put medicaid on the bunt that's the best way to go. i wouldn't say it the way to gene green said it he goes, well, if block grants and per capita are evils this is the less evil is what he said. i don't think it's evil to try to put medicaid on a budget. if you're going to put medicaid on a budget this is the best way to go. i mean, leaving it open-ended would be better for states to spend money but it's just not affordable or sustainable.
kentucky specifically on the waivers. we would like to get more flexibility within the law. on the reconciliation bill it limits what you can do without becoming a filibuster level of votes. zbluf a waiver pending now. >> he has a waiver pending. so what ind did -- i was looking at what vice president pence did as governor and mitch daniels before, and it's treating the expansion population different than traditional medicaid. in kentucky it was asking for no changes on traditional medicaid but the expansion population they were looking at let's treat it more like traditional insurance because these are the people we would like to progress where they go into the workfo e workforce, they get traditional insurance. some are in the workforce. a lot of the working poor are in the expansion population. they were looking at -- i think they were looking for premiums based on income, the high-level premium would be $15, low would be 1. and then they were looking at work requirement and they were saying you'd have to work 20 hours a week and it could be work, it could be volunteering. it could be in what i was
pushing technical training, school training, doing something out of 9 house every day to go and improve yourself so you can have a fuller life. that's where you want to move forward to. i would assume as you said after the letter last night. we met with seema verma with kentuc kentucky. so i think it would be positive to them. they struggled against it. even though indiana had it, we had trouble for kentucky getting it last fall. but i think that we'll be able to move forward with that. >> thank you. meg, you have some specific things you're looking for from cms now. >> well, one of the things i think we'll see a lot more of is managed care for long-term care services, especially if there are caps because certainly that's one way then to control the costs and -- >> just on that, a lot of times in the general public people don't really understand how much of long-term care is medicaid. >> at least 40%. >> 50. >> medicaid's 50%, over 50% of long-term service, long-term care. >> right now in terms of managed
care about 44 perts of all dollars in medicare are in managed care. that's grown over the last couple years. i would expect we'll see -- i know virginia and pennsylvania just got approval for managed long-term care and massachusetts will be looking for it. other states, i think there's maybe 20-some states now that do some form of managed long-term care. so that's one that i think we'll continue to see. actually with or without the caps. states under pressure even without the caps. >> one of the important things to remember about medicaid's role in long-term care is the nursing home institutional care is a required service but all of the home and community-based services are optional and that the option of the state. but that's really the only place anyone can go since medicare doesn't cover those benefits to get those services. so that's one of the areas where medicaid really makes medicare work for about 20% of the lowest
income medicare beneficiaries. but it's also an area that i worry if the state is really constrained in its spending that that since it's an option would be a place they might have to cut rather than expand or they could try to do better in managing it but at the end of the day those services are ones we really ought to look aught you hon airprovided through both medicaid and medicare. >> remember it's growing at cpi. we're looking at the rate of growth in medicaid, not cuts in medicaid. and you're right. those are optional services. i think what we -- we spent a year talking to governors and state legislators and they say if we could have flexibility within the program then we can manage the things you're talking about, manage it better where we can provide more. so i guess the assumption would be they're just going to have to withdraw everything but mandatory. and i don't really agree with that assumption. i think they're going to still provide the services they want to provide, they're trying it provide. they're doing now great restraints to their budget. they can't. they have limited budgets and
they can't borrow money like we do at the state level. they're still making it work. and we want to give them the flexibility to make it work. i understand your point but i think they can be managed is our expectation. >> and jessica, you worked on some of the policies. >> yeah. i'm biased to say what they could do. because i think the ranks that have come out in the past couple years are great, right? but i would just say that from my perspective i'd worry as diane rightly pointed out the letter that came out early this week really does provide a road map of what the new administration is thinking and i would just be concerned about rolling back beneficiary protections that you see in the managed care rule, for example, or there was a rule on improving access and making sure there was, you know, a sufficient number of providers participating in the medicaid's fee for service program, and i just would worry that changes would kind of roll back the progress that we've made from a
beneficiary protection standpoint. because at the heart of all this i just keep always telling myself, the beneficiaries are central to the program. and we always talk about money and how much it costs but really it's making sure that beneficiaries have the services that they need, can improve their health and well-being and also their financial security which medicaid providers. and i just wanted to point out to the thought of what diane had said. home care services are optional. but in 2013 we had a really -- hit a milestone for the medicaid program where medicaid for the first time in the history of the program actually spent more on long-term spending -- long-term care spending in the home in community settings versus institutions like nursing homes. and i would be worried that the
space, the home and community-based services space would be the first to go even though the services are much less costly to provide than institutional care. and quite frankly, that's where people want to get care. they want to stay in their homes, and they're just -- you know, respond better and are happier. and so i would be worried that anything -- the caps would, you know, affect that. >> jessica, what would be the pressures on governors to make that decision? it is a popular approach. it's a program people widely support. why would that decision -- >> i think diane raised it already. the institutional care services are a mandatory benefit. and the new bill, the house bill doesn't change any of the services, at least to my knowledge in looking at it, any of the mandatory services. states would still be required to provide that care and under a per capita cap model they would have to make hard decisions about where that money's going toward. >> i'm going to ask congressman
guthrie, i want to ask you this one specifically, what you're hearing from your governor, and then i want to hear some input on how are governors viewing what's going on? what decisions are they facing? >> so our governor has asked for block grants. he's asked for block grants, give me flexibility, let me manage the program. if you can treat somebody cheaper at home than institutional care you need to have flexibility to do that because i agree, that's where you save the money. i know there are certain things we can't do with reconciliation we could do otherwise that we need to have that kind of flexibility. so our governor wants ultimate flexibility and let me go manage my program. that's what he says. you know, it's different. it's been public. we have different governors. even republican governors that have views of the expansion and views of not. and the comments are up here all appropriate. you're going to look at the largest health care program in the world and we're looking to make changes to it. we should bring up concerns and considerations. i mean, you can't put a handful -- if you put the
smartest people in the world in one room and they try to write a program they're not going to get it exactly right. bringing up those points, how do we make sure long-term care doesn't crowd out home services where people prefer to be at home. so those are things that these discussions are important. you hear critical mass -- i would say particularly -- during our medicaid task force we would hear from democrat governors saying we've got to figure out how to make this sustainable. i won't say any came up and said we want allotments. but they said we've got to make this sustainable for our state. republican governors, governor kasich has been a little more on keeping the expansion. to really kind of -- has coalesced to where we are in our bill. they give us per capita allotments you that get more for the disabled, more for the aged. you've got children who don't cost as much but have to be covered. four categories plus expansion. that's five categories.
and then let us -- of course every governor wants maximum flexibility and flexibility to manage the program is where we are. that's kind of what you're hearing from governors. where we are in the bill is kind of critical mass and what we heard from the governors. and there's some outliers on either side. >> anyone else want to weigh in on -- >> i was just going to say i know the governors -- it came you earlier today, complain about the waiver process. and i think there's a lot of validity in that, especially for things that states have been doing for so long like managed care in particular. it came out of the medicaid task force. i'm not sure if you introduced the bill that would basically say if you've been doing managed care under a waiver for a while you should be able to keep doing it and not have to come back and sit in that chair at cms. we would certainly support that right now since the bda was passed in 1997 you can put most populations into managed care just with a state plan but for some of the big dollar populations you do have to get a waiver yet we know that we have
evidence that it's working well and also for children with special health care needs you have to get a waiver. so we think that should be changed and support your bill to make cha chanthat change. i think that's an example of something we know works and should be made easier for states. >> so if i may just jump in on the waiver process, you know, there is in the summer of 2015 cms has gone in somewhat as a fast track waiver and states that have long-standing wabers that use them for managed care that would be something that would be under consideration as a fast track. the other point that i just want to make out, 1115 waivers, medicaid waivers are experiments. and they're supposed to be tailored and testing new things that are happening in states. and each state is different. and because they're experiments they're also supposed to be evaluated. and whatever changes are be made are supposed to further the objectives of the medicaid
program. so when you look at state tailoring each program based on the conditions in the state, the fact that they are evaluations and the fact that they oftentimes have a lot of money associated with them, so you want to be a good steward of taxpayer dollars and make sure that things are being spent, the dollars are being spent on things in accordance with federal law, those things take time. and when you look at waiver applications such as kentucky or indiana, they are complex. they have different accounts and premiums and tracking. and just you know, it takes time to make sure that you know, your you're evaluating, you have everything in place to make sure that beneficiaries understand and there's some type of ability for the federal government and the state to make sure that what's happening in these waivers aren't harming people because that's not furthering the objectives of the medicaid
program. i know i'm probably channeling and yea little bit when -- >> andy slavitt. >> andy slavitt with the process because i work so heavily on it. but there are people's lives at stake with these waivers. and you know, it's just a little concerning when people just want to rubber stamp everything and do it quickly. and you just want to take time to make sure things are being done in appropriate ways, that people's care is being provided and that the money spent in accordance with federal law is a good use of federal tax dollars. >> the expansion population is a good example of the previous use of waivers. many states came in for years and said we'd like to cover adults without dependent children, they're really poor, a lot of them are critically ill but they were not part of the original categories when medicare was enacted in 1965. so that they used waivers to
come in and try to provide coverage which is part of the use of waivers, we learned who that population was. and i think one of the positive things even though the expansion has been repealed in terms of the federal matching is at least there's a recognition now in your bill too that that group is a group because of their poverty and often because of their chronic illness deserves to be another eligibility group at the state option at least. >> i'm sure we have a lost medicaid experts watching this but for those newer to the program those are policy waivers that have been used for decades. the basis of romneycare. these are pretty effective tools. i want to get a sense, how many people want to ask questions before i go on and hug the panel. okay. i'm going to ask one more, and then i'll turn it over to you all. what's one thing that -- we've talked so much about the politics on the hill and we're going to continue. i'm going to be chasing congressman guthrie and his colleagues for days and days on
that. we talked about the politics, talked about some of the sense of disagreement. what's one thing that's interesting about the program that's been overlooked? it seems as you delve into it it's one of the largest health care programs. it's a dynamic program. so quickly one thing that's been overlooked maybe. >> you know, we've spent so much time really moving through it and trying to think of what we -- i know we've talked about different things. jessica talked about it. we want to make sure there are not disincentives within the caps. like i said, it restrains the rate of growth but if there's incentives to put people in more expensive care because it's mandatory and it takes await incentive to put people into home health, it's where most people want to be. they want to be home. it's just so nice when you're home because it's convenient for the family that's home. so if there are things that we've overlooked in that i think we need to make sure either through -- if it's something we can't do because it's a policy issue not a budget issue we need to figure out how to work on
those things and be open. and i think we have been open to people discussing this with us and it's not -- this is our belief and we're just down this path. we've really tried to be open and had discussions and tried to move forward. but in the end, unless -- and i haven't -- on either side of the aisle that say we're looking for another half trillion dollars in revenue and we have to figure out how to deal with this to make it sustainable and we're already at $20 trillion worth of debt and we're looking at 20 trillion in deficits the end of the decade. medicaid has been stretched. this is one step in getting health care spending. and i think in a responsible way growth at medical cpi -- medical cpi. we're looking at maybe some of the elderly population may be enhancing that. that's some discussion we're having as we move forward. >> how serious was the discussion about enhancing thaelderly -- >> it's serious. we're just trying to figure out how do we do things as the baby
boomers age and the stresses on states, how do we not -- it's all consumed by one group of people at the expense of others. we're trying to say how do we get enough money. somebody said you can always use more but we make sure -- we need to make sure there's enough. that's what we've tried to get to, what's between more and enough and it's actually going to make the system work in a way that we think's responsible. >> i think one thing that has been overlooked, it's one of the problems with the per capita caps is unlike the waivers where you typically have five years to reach budget neutrality, you can have up-front funding. and i know in oregon they've done that and some of the other states. some of the that money up front goes to investments in delivery system reform but also to address the social determinants of health and that is one concern we have, whether there will still be room in the caps for that to happen. we know that especially with housing for people that are coming out of nursing homes that they don't have places to go for housing and just we need some
flexibility to address those kinds of issues. we have a health plan in california, cal optima-a that uses its own reserves to set up housing for homeless people so when they come out of the hospital they have places to stay so they're not on the streets and back in the hospital. so by investing a little bit up front they hope to get -- >> i know we're talking medicaid but there's $100 billion in state innovation grants in our bill for states to use those for those kinds of programs. >> that's one incentive, is it enough money and is there enough flexibility is another question. >> i think one of the things most overlooked in medicaid is the need to also shore up the administrative capacity at the state level to actually manage this complex program. and that when we've looked over the years -- >> shore up -- this is a program covering about 70 million people. >> at the state level it's often been a place where as state budgets are constrained the staff to manage the medicaid program has been cut back
dramatically. there have been real challenges there in trying to find the appropriate stat to deal with the very changing administration of the way you administer medicaid benefits. there have -- often someone who's been a civil servant for a long time, you may not be the best negotiator with meg and her plans around set rates or whatever. so i think really looking at also perhaps providing some better tools to the states to manage their per capita caps or whatever is coming is an important place. the other thing that's important to remember is we keep talking about it as if medicaid is a one size fits all program but it's already a very, very diverse program and different states are in very different places. and i think as we look at in going forward is there a place where we'd like to see more states able to move, that they may not be able to move. especially as they deal with an
aging population. and many states have -- you know, there are some states that have over 50% of march their medicaid beneficiaries who are over 65 and another group that's disabled. that's a state that has a different management challenge than one that has most of their beneficiaries under age 21. >> and those points you just made is what kind of drove us. because you remember when we started block grants, big word, more of the allotments because you can do them by category and make sure you're not pitting seniors against young people because they're funded within their category. that's a good point. that's what we're attempting to address. >> that's the old joke about if you've seen one medicaid program you've seen one medicaid program. >> that's true. >> i want to leave this open for questions. who is -- >> brian hewlett from jeffries. question for jessica and the congressman. you talked about home sxar how the personal care services
provided today could be at risk. if you don't mind just giving us more details on what is in the bill based on what you've seen. and congressman, considering this is a -- we're talking about long-term care being 50% plus of medicaid, it has been a money-saving service, shifting people out of nursing homes from a republican perspective, thinking about the fiscal side of things. do you think that there's an appreciation for this unintended consequence as this bill has gone through different committees and it goes to the floor, you know, that this could actually be raised, the effective cost of delivering care at the medicaid level. >> sure. and just before i answer your question i just want to jump into what i think has been overlooked, which is i think that the strengths of the program have been overlooked and the flexibility that's inherent to the program. you know, people have been saying oh, it's not flexible. but it really is in fact. and you don't even need these medicaid waivers to do a lot of the delivery system reform activities that some states have
been doing. medicaid is there when people need it. and in different public health crises, natural disasters, you know, i have been fortunate to work on various demonstration projects where they were responding to sandy, for example, hurricane sandy. the recent flood crisis in flint. my colleagues -- my former colleagues who are just amazing to work with really learned about lead. and as a health policy person i, you know, didn't know all the ins and outs of different lead pipes and when it starts at the county and who does what. so i just want to weigh in there that medicaid is a very flexible and nimble program and i just think that's being overlooked in the current discussion. to your question about what's in the bill, so the affordable care act created community first
choice program and what it is is an incentive for states to kind of augment their personal care attendance services. and these are services that help people as i said get bathed, get dressed, stay in their home, get ready for work if they're able to go to work. really important quality of life services. and what the affidavitable cafft did for bump up the match for states by six percentage points. if the state has a normal match rate of 50%, they would be able to get 56% off of any of the community first choice services. and so what the house bill would do would be to roll back that extra six percentage points. so states would no longer have the incentive to provide these services and then use the additional funding to probably
reinvest in their program either through providing a more comprehensive set of services, doing new things, maybe even providing a higher provider rate for these attendants because they're they're not usually paid they're they're not usually paid very well. captions copyright national cable satellite corp. 2008 captioning performed by vitac