natural disaster, and now, their needs are huge. but, i am afraid that is what the bill in front of us wants to accomplish, subjecting the rest of the country's medicaid programs to the same rigid, inflexible flawed, financing structure. mr. chairman, i know we have to go in vote, so i will stop right there. >> cannot entrust some of those issues though? >> after he gets through with the recess, sure. let us go and vote. >> a recess for 15 minutes. gavel]

sen. hatch: we are getting some interesting testimony, but it is not going to the problems that we have here in the senate. we will just have to see what happens. senator wyden has a few more questions to ask and then that will be it. sen. wyden: mr. chairman, i will and again,id man these are the kinds of questions that you and i agree should be asked at this hearing. sen. hatch: sure you reared sen. wyden: let us talk about

flexibility, put into context of the nation nations's senior citizens to read i watched all of these older people as a director of the center raise their families, build our communities, but growing old in america costs a lot of money so today, senior citizens have a guarantee that medicaid is going to cover the cost of nursing home care. this is hugely important because medicaid picks up the bill for two out of three senior citizens in nursing homes in america. that is a guarantee for nearly millions of older people. this proposal, that graham cassidy proposal, i call it the next version of trumpcare, and that guarantee. it turns it into a guarantee that effectively in name only the red this is not about

bending the curve or all of this hocus-pocus about state flexibility, we are talking about the types of choices that a state will have to make on the medicaid program and what it will do to impact those senior citizens on an economic tightrope there we had every month, balancing their food against their fuel and their fuel against the rent. tell us about what this proposal means for the nations in your citizens. >> thank you for the question, wyden.enator support forpublic long-term care except in the medicaid program. medicaid only does it in a very narrow way. about 21% of our spending in the medicaid program is for the 65 and older. so it is a very important part of where the dollars in medicaid go. as a result, when there is a cap

, if there were in every cherry -- ever cherry cap on the dollars a state can spend -- an arbitrary cap on the dollars that a state can spend on a they will look to people with disabilities to figure out where the expensive patients are. that is the elderly and the invalids. expandeds have flexibility for this care to make sure that they have the options. those individuals might lose their coverage. the other thing that states have been doing under the flexibility of the health care program is the spending -- is expanding community-based services. those are outlier costs and are an option under the medicare program. if you have cap, you will cut the high-cost cases.

>> i appreciate you saying that because i want people to walk out of here understanding that the nation's senior citizens who have counted on a guarantee under this program, they effectively are seeing that guarantee hollowed out. i very much appreciate your testimony. a question again on the state's flexibility issue. i feel strongly about state flexibility, it is the flexibility to do better, not to do worse. what i would like to have, is your opinion about whether as a result of this particular piece of legislation, and he state -- any state is going to actually do better overall. i would like to underline over overall." ter it seems to me that what this bill does is keep people coming and going, it is about nationwide repealing the affordable care act but also

about state by state, repealing the affordable care act. so, if you want, tell me whether in your opinion, as a result of this legislation, and he state -- any state is actually going to do better overall. i would like to hear your thoughts on it. >> i think overall, the answer is absolutely not. sen. wyden: not a single state overall will do better? -- i think overall, , as opposede a cap to thinking about how to do the kinds of things that schmidt doks about, about state can now with aggressive flexibility having better deliveries distance, accountable care organizations, those are things that states can do to

improve care and lower cost. what will happen under a cap is you have to manage so that you never go on dollar over the cap or if you do, you will owe the federal government more dollars. so you have to focus on quick, immediate steps to bring down your costs so that you are never at risk. or not be liable for the extra payments to the federal government. sen. wyden: i will hold the record open on your views on that, it seems to me like a threshold testing. we have been hearing all afternoon about state flexibility like it is some magical elixir, that if we have it, in this version, everything will be hunky-dory. you have pointed out it is not the case, because of the cap and we had >> and it is the medicaid directors themselves around the country, not in red states or lose states, but around the country who say that if you have flexibility without funding, it is not possibility at all.

sen. wyden: i will quit while i am ahead. >> thank you, let me just a this can you response to senator wyden shekel question? let's let me say about funding. the idea that some states will not do better under the ram cassidy bill is salacious areas -- under the graham cassidy belt. basically, the individual market, they can use the money for that. and if they can use up to 20% of that money to support that per capita granted medicaid programs. they have increased flexibility in addition to more money coming in for this population that right now is not drawing down

any kind of medicaid expansion dollars. this second block grant, the replacement of the aca that is under graham cassidy, only 13 states get less money than they are projected to get under current law. so the idea that all of these states are getting slashed or there is a great redistribution of wealth between dates that are " state istes and "red not the case. the program is deliberate and slow, it takes 10 years, it takes a lot of flexibility that comes up with this extra money. -- youe lots ability have flexibility and as i said, those 13 states include the district of columbia. states, we are talking about more money, and more flexibility to be able to deal

with this population that was the target of the aca. -- dennisnow if davis wants to add to the medicaid program, but i think that is a positive change. >> thank you, mr. chairman. meant summitmissed up. make any comments you would like and then we'll come back to you, mr.'s with her. -- mr. smith. >> i am not sure what numbers he is talking about, you cannot have everybody getting more money under a block grant then at the end of the day redistributing the dollars very orically from high-cost extending it to states who are not doing it. there are no winners under this bill.

you have every state putting the bulk of their medicaid program, the vast majority of their medicaid program, the elderly, disabled, children, pregnant women under a cap. so that when cancer treatments come out and they are more expensive, the states will not be able to afford them at least without cutting something else. so that if there is another hurricane, they cannot afford to address that emergency unless they cut something else. that is not how the financing of the medicaid program works now to read it is important to understand the basic structural changes to financing for the vast majority of medicaid beneficiaries. >> thank you mr. chairman. again obviously, we believe that arkansas would be better off, or i would not be here today. and a number of other governors feel the same way. we feel there is great value in

this, in terms of the level of funding that is sustainable for both the states and the federal government, these dollars continue to grow over time as i mentioned previously, the i plus one is higher than the capital basis for elderly and disabled enrollees, it is higher than what the cbo has as their baseline. so we believe that it is sustainable and we also believe that while we have had progress, and both miss mann and i have in that position, we have both held that same job, encouraging state to adopt greater services in the home rather than in an additional place of care -- and institutional place of care. we recently hit the 50% mark

where long-term services and now, we-- as a nation are barely over 50% of the medicaid dollars for help going into home and community-based service settings rather than to an institutional-case setting. so we have a long way to go to be able to serve people in their home homes, in their own settings, to where they want to be. and that will again, help to lower the cost curve, as we know, those are more cost effective over time. senator harper, do you have the time? casey, [indiscernible] i am happy to yield to him. >> thank you senator, for that courtesy. for the record, there was a

reference earlier, several references to the governor's the letter that they wrote, the 10 governors, who are bipartisan. the first paragraph adjusted not considering the bill. that is significant. they ended with what i think is a pretty good summation of what we should all be doing. and i think we started this in the health committee. here is what the paragraph says -- we ask you to support bipartisan efforts to bring stability and affordability to our insurance markets. legislation should receive consideration under regular order including hearings, health committees and input from appropriate health-related parties. improvements to our health insurance market should control costs, table eyes the market, -- stabilize the market, and impact the coverage and care positively

of millions of americans including many who are dealing with mental illness, chronic health problems and drug addiction. i think that is a good summary of what we should all be doing and hope we can get back to that part of the predicate so that the bill doesn't pass. we have some work to do this week. ms., i promised i would come back to you with a question that i post to secretary miller with what happens to the medicaid expansion. i asked her about the impact on pennsylvania. in your judgment, based upon your ex areas, and i would like based uponain -- your experience, and i refer to your time as director of the center for medicaid services for doess, -- four cms, what that mean for the country, the winding down of the medicaid expansion? >> and you, senator.

first of all, it is not winding down. basically is20 is one it goes away. -- on1 million people generate first 2020, it will go away. notral people covered will -- the states will not have any ability or legal authority to get more dollars to continue that. that expansion has been and/or misleading valuable to those states who have done it, the states have lowered their uninsured rate to record lows. but more than that, people have been getting care. , keeps asnyder dashboard in michigan of how many people got mammograms, how many people that colonoscopies, preventative care. in louisiana, a dashboard for their tension says that they got

for hundred 33,000 people covered under the medicaid asked tension and they can tell you how many people got preventative testing and were found to have illnesses and got treatment for those illnesses. real people and real services. in addition, it has lowered uncompensated health care costs, helped hospitals deal with their funding, and you saw hospitals being most effective in -- being less effective and then expensive states. all of that goes away if the expression goes away. >> one of the points you make which is of paramount importance to me, is of the guarantee of medicaid. you could have a family that has, and we saw this and some of the reaction of folks around the country, families with high incomes, good health care but who still need medicaid because their son or daughter has a profound

disability of one kind or another. all kinds of families benefiting from that guaranteed to read the last thing i will say is on page three of your testimony, you mentioned that if they take away that guarantee, and you talk about the other side of medicaid, meaning the original medicaid program is health. you say that the consequences of this major change in financing fall solely on those enrolled in a traditional, medicaid program. newborns and other children, very low income parents, pregnant women number 3, low income seniors number four, people with disabilities, number five if you would like to add to that in 15 seconds? >> that is irony in this. a lot of the criticism about the expansion, even though there are people who are at 10% of poverty, 50% of poverty, is that the resources should go to the traditional medicaid program and

yet, this bill would cut those resources and impose a arbitrary cap. so those people would not have that guarantee for funding and the states will not be guaranteed that they will be able to afford the treatment that those individuals need. >> thank you, mr. chairman. i would like to submit first for the record that some of the emails that i have gotten in the last several days. so, i will leave this with you. mr. chairman, i also want to emphasize again, that i wish we were having a markup on the children's health insurance program which you and ranking member -- which view, and ranking member, myself and others among a bipartisan bill that is very important to 9 million children. ending thischip week along with the community

health enter funding. and i have 70tor members of the senate on a letter indicating that we want to make sure that community health center funding is done by the end of this week as well. we also have a very important effort that is going on right now and the health community with a bipartisan effort with senator lamar, alexander, senator kerry, thank you miss miller for being a part of those discussions. those things are what we should be doing, a bill that roles all of them together. hearing what we are about today over and over again in terms of the affordable care act is the part of the aca that is of the individual marketplace , where less than 10% of the people are that have gotten, in fact it is 6% in michigan, who have gotten increased coverage through the individual marketplace. in fact, we have situations where premiums are too high.

no question about that. but it is been used as a smokescreen, in my opinion, to hide what is really going on here, behind the curtain. which is a gutting of medicaid. .eniors and nursing homes three out of five seniors in michigan and nursing homes. alzheimer's patients, they got their nursing homecare through medicaid. children's, families. now, we have a cbo score that literally just came out that tells us the facts, which is that in addition to medicaid coverage going down and coverage in the insurance system going down, that justin medicaid, in , 2017-2026, there would be a cut of $1 trillion. i have been operating in using

numbers that were not $1 trillion. when trillion dollars in coverage to seniors in nursing homes and children and families. one trillion. i think that is really the goal. that is what folks are going for. we can fix the individual medicaidithout gutting and taking away individual coverage for people. i would like to talk about one of the areas of individual coverage, which is mental health , something i care deeply about. i know that senator mccaskill, you and i have talked about our interest in community-based services for mental illness and opioid addiction. in the first really introduced, i know -- the patient freedom act, you actually included protections for mental health and substance abuse. even though you were creating the possibility of eliminating the essential health benefits.

in this new bill, there is not the case. fore is no protection mental health. >> can i respond to that? let me say one thing about the $1 trillion cut to medicaid. it is repurposed into the federal law congrats. the money is still there, it is just not called medicaid. in regards to mental health parity, -- >> i will stop you because i agree, mental health parity is -- i was proud to author that -- ision in the bill understand that it is still there, that is not what i am talking about. what you are saying, is that parity, if health you offer insurance, you have to offer the same kind of insurance for mental health. but because it is not included as an essential benefit, you know longer have to offer it. >> that is not true. what is said is that any law

before 2009, still applies. if they offer insurance for physical health, they have to offer matching insurance for mental health. that is in the bill. >> and benefits, offering that, what is difference -- i will agree with you that mental health 30 provisions are there. but with this bill, insurance can and coverage of mental health and opioid of these services just like any other essential health benefit service. is that correct? >> it is correct. >> then it is not the same thing as parity for mental health. because you do not have to offer it in insurance and. also, what is a person in this situation supposed to do, who can no longer get the treatment that the need for substance abuse, opioid addiction portland to help services, and what would it cost for someone in that situation?

i would like him to answer please. we have the five-minute rule and we are all getting tired -- >> mr. chairman, if you could just have a chance to answer the question of what a person in the situation, who no longer has mental health -- >> let them answer the question. >> i think it is a good question. one of the things i worry about is that under medicaid expansion in pennsylvania and our individual market, with this proposal, -- we have had 175,000 people in pennsylvania access extensive use treatment. moving to the block grant and reduced funding, i worry about whether or not those individuals getting the treatment will in the future be able to continue. sen. stabenow: thank you. mr. chairman: where is the money coming from? how do we pay for this? want to helpe all

in any way we possibly can but there is a limit to everything you read senator portman? sen. portman: thank you, mr. chairman. i am glad to be back. i support hearings, and i think we should have had more hearings with regard to this particular bill and for that matter, health care in general. i would agree with what was said earlier about them move -- many for more regular order to one of the facts as i understand it is that as an example, with regard to expansion in medicaid which we did in ohio, which is important for substance abuse treatment, is that the money continues to flow. you are worried about what will happen in pennsylvania, i would hope that you and your governor and others continue to provide that funding mental health and for substance abuse treatment because it will be needed. the one thing that i will talk about here today, i am still undecided on the bill because of the numbers. the numbers may have changed, let us face it, even over the

weekend. there may be some adjustments made to the formula that were even done by dr. cassidy. certainly in my state, this 10% matches onerous. it is onerous to the point that ohio, our legislature is not interested in providing that 10% match. moving just from 5% to 10%. with this legislation, you do not have to put up the match to get the money. so, i am looking at the ahs numbers here, and dr. cassidy, in the year 2026, it would be 49 million under this. under this, it is about 9% more, this is hhs numbers and omb numbers. another words, you would be able to get your funding without running up a match, a 9% increase.

other numbers that i have seen show that i would be about a 3% reduction over the 10 year. -- 10-year period. if i was governor and he told me that i have the flexibility to cover these low income folks in medicaid isay -- incredibly important, absolutely essential to have but let us face it, it needs reform. the reimbursement is such that many providers do not want to take it and they are not required to thomas medicaid recipients will not have many choices that many around this diet have -- this dais have. with regards to what happens with any vote that we have, we ought to have a honest conversation about that. i believe there needs to be more flexibility and i believe that

both democrats and republicans alike believe that. more flexibility to get people into private plans who are on medicaid right now and to cover them. if they have more options they can go to different doctors, is a not a good and? i would ask dr. cassidy, my right about the numbers, that actually ohio under this provision would get more funding based on the hhs and the omb analysis? the first bill, we learned over the weekend that inflation rates are impressive -- incredible as projected for the individual market. get them ready as soon as we like and we keep that from being a big drink for states that have already expanded -- a big drain. smithly, mr. comes up with imaginable ways --

imaginative ways to do this. -- innk there will be your state, $49 billion under the current law and 47.5 under our law -- under our proposal. you can weigh the match to the tune of 2.2 billion dollars. $53.7 billion. >> they were lower. why was that? they just did a change. >> the change was made because he were going from a phasing in of the formula from a six-year. of time to a tenure period of time. -- from a 10 year time frame to -- from a six year to a ten-year timeframe. >> i have another question, we talked a lot about this, in

ohio, i was concerned about losing that ship program. the chip program. what concerns me still is not to include those between zero and 50% of the poverty line. why do we only include 50% of two 138 and? why not include those between 0% and 50%? asthe money can be spent long as the focus is on the lower income and working income. chipis bar -- per regulations. it is just a means of distribution. >> but in ohio, we cover those people. cassidy: you still can. it does not prejudice how you use the money. >> thank you, mr. chairman. i think we have heard a lot today about how you can cut all

this money and continue to ensure people. cbo, withw from the their truncated scores, that they should be able to do, that millions of people will lose their insurance if we passed this bill. someone couldhat have a principled position, senators santorum may have had this position in the past, i do not know, a position to say that the federal government should not be in the business of health care. i have heard people say that for eight years and i have heard ohio, say friend from that medicaid needs reform. the problem we are facing as a country, not just in the states, mr. chairman, may i answered for the record that all of the money colorado is losing as a result of this help? i say, it has been amazing to watch supporters of the bill waving the flag -- a map around of who the winners and losers are. editor paul said it very well, it is a transfer from democratic

states to republican states. that is obviously what is going on here. in a world where kickbacks -- many people should be appalled by the kind of discussion. in any case, the problem we face is that i have a people -- a bunch of people in colorado who make too much money for medicaid but cannot afford. private insurance. it is a huge problem in america. and and another problem is that if people lose their medicaid, they will have an even harder time buying insurance than middle-class people who cannot afford it because we have not created a kind of transparency around health care that other countries have, and we have not created a kind of incentive structure that would drive down costs, which is what we really need to do, if we are concerned about preserving entitlements and doing something useful for our budget. this throws a bunch of people off medicaid with absolutely no

said justin about how they will be covered, which means that they will once again be uninsured people showing up at emergency rooms across the country. in colorado, mr. chairman, a lot of rural hospitals had 14% bad debt as they called it, before the aca was passed. that number has dropped to 2%. it represents a huge savings that if those folks are never on out.aid, it would be wiped we would be once again chasing our tail around this lace reared i appreciate my colleagues' like -- my colleagues love for federalism. my colleagues on the other side who have voted 60 times in the care, inrepeal obama seven years were unable to forge a consensus among themselves about a theory on improving american health care. so what they have done is left

it to the states. an admirable thing to do from the federalism perspective, suggesting that there might have been other reasons. but in doing it the way they have done, mr. chairman, you and i talked about the instability miss of the individual market of bill. let us talk about this ability over the next few years as every state in america will be forced at exactly the same minute to create an entirely new health care system in a two-year. without knowing what the funding levels are going to be for months and months, with part-time legislators, full-time legislators, what does that look like for america? and who are we by the way, to set the agenda for the 50 state? it will be a great bone to the health care consultants in america but not great for the american people. miss, thank you? >> i do not think it will be -- i do not know if it will be a big load to health care

consultants because states cannot have enough funding to figure out how to do this. >> so there is no money in this program to set up the program. >> to help us figure out what to do? no. and i think in a two-year. , i have no idea about how we will figure out what this new system is going to look like. getting legislation passed in pennsylvania is not an easy thing to do. >> really? it is so easy here. do have a full-time legislature but we would have to bring all of our stakeholders together, said route what the new system could look like, but all of the pieces in place to help i make it happen. states had four years jury the aca and they knew what they wanted to do. here, we do not know what the new system will look like and and two years, i am not sure we could do it in five.

in two years, i do not know how we could possibly do that. in the meantime, we have individual markets that are going to be significantly destabilize, because this bill will throw the individual market into a house -- into chaos. >> there is a $2 billion implementation fund included in the bill. which two, the cbo score you quote the us say the states could elect to continue their current medicaid programs. i just wanted to point that out. >> to give you credit, you have been very effective here in this committee. and you are a doctor. >> i appreciate that we are now relying on the cbo score which you have come weeks ago. mr. chairman: i agree. >> it says that millions of people will lose their insurance as a result of this terrible is the legislation. a request that these messages

from the citizens of delaware be committed. mark twain once said that it is not so much that people do not know that bothers me it is what people know for sure that just is not. senators tothat the think back on something they heard from us on this panel and from the other witnesses, things you heard that just ain't so. i will be brief. it is not about impugning anybody's integrity. --t you just heard, and so what have you heard that just ain't so? >> we are talking about in this proposal, making drastic cuts in medicaid, that is what we are talking about, but we are doing it under the guise of obamacare failing. when we talk about obamacare

failing, we are talking about the problems with stabilizing the individual market. we all agree that there are problems with the individual market and we need to stabilize it. >> a lot of them are self-inflicted wounds, if you do not mind my saying? >> they absolutely are. the very people who want to get rid of obamacare are the very people who have helped it trouble in some cases, and i think that is fundamentally -- there is nothing in this bill that will stabilize the individual market, it will do the opposite. we need to be clear about what we are doing, making major, major reductions in the medicaid program. >> miss manners? -- ms. mann? >> let me had on three points. there has been a discussion of that 10% match, it was not a 10% match for a while but it cap the states from expanding medicaid. for the most part, besides the politics, the uncertainty about

whether the 90% would still be there, that is what kept a lot of states from jumping into a medicated tension. if you look at the answer into his of the funding in this new bill, you have zero funding in 2027, you have hope that something will come about at that point but that uncertainty makes it pale in comparison. we are concerned about states meeting their match. on the traditional medicaid side, the expansion of the state -- stateher than expenditures rather than expansion, this bill produces state's flexibility, and a very prominent way, that states have used to be able to finance their medicaid programs. it reduces their reliance on that considerably. finally, the myth that we can have a certain amount of money and if you're concerned about ifs album, you can fix it,

you're concerned about that problem, you can fix it -- i understand from the cbo that their analysis says that every state can replace their medicaid expansion with block grant dollars and there would be not a penny last to do insurance -- a penny left. >> thank you. mr. woodruff? >> the absurdity of the allegation that you can take hundreds of billions of dollars out of medicaid and continue to ensure the same number of people in insured now, and secondly that we can expect the states to create a new insurance system in two years, when they had such a difficult time doing a much is your system in four years, under the aca. >> for the record, i have never aen a doctor, i have been flight officer, studied some a,nomics, got an and the

state treasurer, chairman of the national governors us is nations. -- governors association. one of the reasons that welfare reform worked, is because we launched it right in the middle of one of the greatest economic expansions in the history of our country. employment went down, revenues went up and we were able to make sure that people were better off getting off welfare and going to work. what we have coming at us right -- a digital army margin of growing. treasurer theas most money we spent on medicaid was mothers with children. it is not so anymore, two thirds of the money was and on medicaid is on our grandparents, our uncles, old people with dementia and people in poverty. veterans are 2 million. i am a veterans. ahead and pull the rug out of the states, we need

to take -- hit the positive button and say, we should try this together. i close with this, mr. chairman. fast, travelravel far, go together. this is an issue that bags for us to travel together. mr. chairman: senator cantwell? cantwell: we have the cbo score which is pretty illuminating and detail i should say, with risk asked to medicaid on page seven. i noticed that it states would worry about additional possibility under the per capita cap. a few states would obtain additional possibility and it goes on to say however, the funding of this room would grow at the time of the rate of the c attractively to the states

who expect a decline in population and would have little effect on enrollment and medicaid. it would not be attractive to take who are experiencing population growth, and they would not be adjusted for that growth. so, i do not know if this is the people designing this who did not want to ask you, who did not think that increasing affordability, increasing access to care, bringing people up, and now they are proposing something that is really about just being think you willou have lower populations and not cover people. i am interested, because there is commonality mr. smith, and you, mr. miller, that you support community first choice programs in the context of delivering access and care through more affordable rates. of home versus

community-based care versus 15% perfect health care is what we have been able to achieve in our state. the graham cassidy further costs that incentive, would that be a huge cost saver miami talking in the tens of aliens, if not even in the hundreds of billions of dollars, if we could get states to achieve a better balance on community based health care? i think it would be, and it is one of the innovations that states can do today under existing waivers. >> well, graham cassidy actually roles that back. it does incentivizes that. i think we should put the pedal to the metal and incentive is it even more. states have taken us up on it and i think this is real savings. plus, who does not want to service committee help at home? this is the right strategy. over our colleagues to say that there are no saving in changes

that we can make in medicaid, here is a win-win. people would love to stay at home and age, love to have their care delivered there is. that. and guess what, it is way cheaper than nursing home health care. if you're going to accept a population of people reaching retirement and the mandy moore services, you want to implement something like this. and thedefinitely -- mandy moore services, you want to implement something like this. >> i think we are talking about two different programs. the program was created in 2005 and then the community first trust revision which offered an enhanced match. with that enhanced match, states were required to be statewide. you could not have any waiting list whatsoever. in medicaid waivers, and we have had 30 years of its areas and home and community-based

waivers, states were allowed to have a waiting list. but not under the community first choice however. so there were a number of states, including arkansas who could not afford to go statewide even with the six percentage point enhanced match rate. that therethis is are both incentives and barriers to be able to do some of the things that are available. >> i appreciate it. >> i should say, we ensure access to community care and the bill. >> i think the issue for us and the pacific northwest is that we are just a little tired of the tail wagging the dog when it comes to this issues. we deliver better care at lower cost. we deliver better care, probably to thousand to $3000 last.

we know what innovation is and we want to run towards this. want to walk, and i get that, but these are real savings. the innovation out in this bill that is over to existing, you will let us even further behind in achieving them of these savings. that is my point, mr. chairman. i think my time has asked hired but i hope that people will hear what ms. miller has said, that these are the big things that will help to drive down costs. and you, mr. chairman. chairman: senator brown? sen. brown: let me tell you about the young man in the blue shirt behind me. this is a doctor who i met at a children's hospital. old is caden, three years and his older brother and grandmother. he looks like any three-year-old with this smile, and he has

already been through more in his three years on this earth that most of us will go through in our lives. born with failing kidneys due to a condition, but thanks to his medicaid coverage, the doctors at cincinnati children's hot to were able to make sure -- cincinnati children's hospital were able to give him dialysis treatment when he was two weeks old. two years later a kidney transplant was covered by medicaid to save his life and like hundreds of thousands of children in ohio, he realizes that the medicaid program to have reauthorized, and at writers on september 30, because of chip and medicaid, he is doing ok. now, senator cassidy, in light of your response to the question, your answer that because of the flexibility that

medicaid can take care of caden in children's hospitals, and because of the possibility given to governors can take care of of your treatment as well, and that because of flexibility, medicaid can take care of seniors in nursing homes, and that it can do all kinds of things, can you assure us today, that states who have the capacity to fully cover high-cost patients like caden will do so? >> i absolutely think so. aspect for financing for coverage that we are talking about, whether it is traditional medicaid or through the new law grants will have a capped amount of federal dollars. a finite amount. unless the state is able and willing to put up additional dollars, there was no guarantee that high cost, high need individuals will continue to receive the care that they need. >> may i correct miss mann?

michelman who are carved out of the cap, can receive as much as they need. and the payments to manage care companies, these payments are in those provisions. >> it has been fundamentally an hearing,oughout this we talked earlier about the competition in lansing, other city,in every indianapolis, how do you find opioid treatment? the competition in state capitals from all of those advocates, senior advocates, hospital advocates how does this play out? how are patients like caden protected? is my concern.at i am looking at the cbo analysis which said that in 2020, with

expansion and manage russians days would receive 10% -- expansion and non-expansion states would receive about 10% less funding. by 2026, and this impacts pennsylvania, states would receive 30% less funding, for the states have expanded than they would receive under the aca subsidies. non-expansion states would receive 30% more. so i think we're looking at huge transfers of funding from expansions dates to non-expansion a. in harrisburg -- expansion states to non-expansion state. in harrisburg, that would be a huge problem. as to thisconfused proposal, which does not seem to protect the remaining 76% of children on medicaid. another question to miss miller and ms. mann. -- many nursing home

residents and ohio rely on medicaid. i met a man who told me that his parents worked all their lives, my mother is 95, you hear this story over and over, they receive a pension of $1500 a month. medicaid keeps her alive so she is able to spend time with her children and grandchildren. , will nursing homes like the one that this man's parents rely on, will they continue to receive the funding? >> we talked about being able to reduce costs, reducing provider payments, and that is usually the first place that states will go, because they do not want to reduce eligibility of benefits. we worry about the risk to high-quality nursing homes and beviders, the it will affected by the limitation on the dollars of that states will have to spend.

if i could respond. they are exempted from the calculation of the aggregate of cap. at the end of the day, the state has to meet a certain amount of savings in order to stay below the aggregate cap and nobody in the medicaid program is going to be immune from the cuts the state will have to make. chairman. implore the john kasich, my republican governor, has run for office. you abouteatedly repealing and replacing the affordable care act yet he has the intellectual integrity to his takeout understanding. i would love to bring in governor kasich, bring in the nevada governor who has spoken about this, and bring in the governor of arizona who has changed his position.

let the wind blow through the body from both sides. let's hear why state governors don't like this proposal, think it is a disaster. mccaskill: thank you mr. chairman. to fullyeeds more time evaluate this legislation. they probably do not have the latest version. they have very clearly said all-told federal spending on medicaid would be reduced by a trillion dollars over the 20's -- 2016-2017 time. they said millions would lose coverage in medicaid. they went through three reasons why. total enrollment in the market would be lower because the current law subsidies for coverage would be eliminated and

the individual mandate would be repealed. we have more than half of this bill about medicaid. every example i hear about the problem of obama care about the individual market for people who do not get subsidies. it says over and over get but it bears repeating, every example, republican senators have sighted people on the individual market without subsidies. i know that is expensive. that is why i buy insurance on the individual market and do not take any employer contribution. i've seen my premiums go up. we need to do something to stabilize that but the notion this bill is going to do that, there is nothing in this although will do that. the individual market is going to be less ability. that is in the cbo report. it is going to be chaotic in terms of the timeline you are asking states to come up with a

delivery system. there will be fewer people in the market. mandate.l not be a not only are you going to ask the state to do more with less , youall it flexibility actually said was some new shows up at the hospital without insurance the state will pay the bill. that is that going to happen. there is not going to be money for that. that hospital at the end of the ears going to call the insurance companies and say, with too much uninsured care. we are raising your premiums. so not only will premiums go up, they will go up in the employer market because uninsured care will go up under this plan. ono, there is a big loophole federalism. bill at oneyour point that the federal to adjust is allowed how much states get aced on an

adjustment factor. on page 29 of the bill, considered legitimate factors impacting health care factors in the state but i cannot find a definition for "legitimate factor." couldn't secretary price say ?arvey is a legitimate factor >> no. it is a risk adjustment commonly used in insurance that uses age. older people are more extensive. disease burden, cost of living. so if in pennsylvania there is a higher cost of living, that would be an adjustment. allowa factor that will movement. >> but it is open-ended. >> no, it is actually a very established actuarial process. >> i'm talking about the language of the bill. it leaves it open-ended.

>> it is a risk adjustment factor and it is commonly understood what it means. >> it says legitimate factors. it does not say risk. it says legitimate factors that impact health care expenditures in the state. i'd send those are the actuarial important factors. hugs i don't think your bill is specific about that. i do nott leaves -- >> think your bill is specific about that. it leaves the power with the secretary of hhs. i know mr. woodruff spoke eloquently about doing more with less. stabilizing individual market, taking care of everyone who does not buy insurance. to buyre nobody has insurance. and by the way, all of the states are going to set all of this up in less than two years. could you briefly talk about any of the witnesses about the feasibility of the timeline in this bill of terms of states

taking over the responsibility and having to file plans as quickly as they will have to file plans. isn't it possible they are going to default to traditional medicaid? to address it. the timeframe between filing an by march 30 1, 2019, i believe and it going into effect in 2020. comments were made earlier that states, there are a number states that do not meet all year round. but, and fact they have committees that meet all year round. you have committees that go out and do public hearings. all year round. i would suggest -- >> they cannot legislatively act, though. >> no. but they can -- >> i wish we could legislatively act but unfortunately we can't.

>> you can go out and build your plan. etc. put from consumers, put your options together so you are ready when you do come back into legislative session. many governors can call a legislature back into session. i think what makes this so very different from the aca and the long ramp up to that versus where we are today, the aca completely disrupted the distribution system, right? you moved from an individual market based on insurance agents insurances marketing plans. that blew up because it got federalized. you had to build healthcare.gov, do all of these things that interrupted the distribution system. we now have a distribution system.

we have carriers who are serving people they did not serve previously. they are going to want to hold onto to those customers. they are going to want to continue and make it the easiest distribution system possible. otherwise they lose their customers. if all of the infrastructure, technology developed, states are going to throw that out. they want to keep it. that is why you are going to go to implement -- >> i appreciate the chairman letting you go over for two minutes. i am not sure it would've witnesses tother go over for two witnesses, but i would've liked to hear from the witnesses that would talk about what a huge mountain that is to climb but we will have to wait for that. >> u.s. senator. sen. cassidy:'s to ask a question or two. that will be fine. then senator wyden and i will want this up.

said what haveer you heard. let me go through some of my notes. been a little ironic. on the other side of the aisle there has been a lot of, oh my gosh they can't pull this off. it a lot of good comments by senator carper. transforming the health care in massachusetts quite successfully and it was being praised at the same time it was being said it cannot be done. there are questions about the stability fun. 2020.ity funded 2019 and also a $2 million implementation fun. i will also point out senator nelson talked about the need for in cases of public health emergency, $5 million in this pond for public health emergencies. if more is needed it will be given but it specifically

excluded what might be needed. he also mentioned the need of the state of florida right now of getting every dollar they can. if we waive the medicaid match, florida and sup with 15 billion dollars. senator stabenow suggested we're cutting a train from medicaid. into otherrpose it areas. the money is still available for the state. senator bennett suggested this democraticer from states to republican states. virginia is represented by two republican senators. misery by senator mccaskill, ending up with 4 billion more dollars between 2020-26. is on way, they issue flexibility. senator bennett also raised, oh my gosh there are folks in your state who cannot afford their insurance. this gives your state the likability to do premium support.

afford thecannot employee contribution to be on employer-sponsored insurance, you can do premium support so they can get on there. fromeport just came out cbo that said they imagine states would imitate successful programs in one state and implement in another. an issue ofo whether or not a restriction on funding will restrict access and sen. cantwell: live learned so much from, she talks about how her state gets and senator learned soho i have much from, she talks about her state. senator cantwell's state is one of those states that is absolutely done. senator brown suggested everything i said is fundamentally unorthodox witches and ad hominem attack which is underneath the dignity of this body and i am ready to address my point whatever he thinks is

wrong but i think and ad hominem attack is beneath us. there are reports people will follow up. , theenator mccaskill standard and poor study, the standard & poor's study which says there will be dire effects, they basted on the study which scored us over 20 years and this bill is only for 10. that study assumes the next 10 years there is no money whatsoever but that is absurd. programs around here. the standard and poor, is frankly just not worthwhile. regarding the individual mandate, aside from the fact people hate it, one of the reasons they voted for donald trump is it doesn't work. it doesn't work. that is per jonathan gruber the architect of the affordable care

act. he reported research he did for the national bureau of economic research in which and i quote the individual mandate, no significant effect in 2014.e on coverage he tries to say maybe there is, but he cannot prove it. i'm going to submit this for the record, mr. chair. the individual mandate had no effect. what does have an effect is a governor getting engaged. if a governor decides to get engaged, he can't. for example by doing things like automatic enrollment. aei alsoccaskill, the has a paper about how automatic enrollment could be instituted so that those who cannot get coverage for whatever reason could be covered automatically just as we do on medicare. let me finish by saying this, there is one thing we have bipartisan agreement on.

the affordable care act is not working. is proposal we have advanced considered radical today but on the other side of the island is single-payer. there are 16 cosponsors for sen. itders:'s proposal because is a tacit acknowledgment that the affordable care act is not working at this i submit for the record, mr. jim. these yellow counties are the ones in which there is only one insurance company covering and the red ones, some of which are in missouri, are the ones in which there are no insurance companies covering. with a problem, we can either go forward with the single-payer option which the other side of the housings to favor or we can do what we've done with massachusetts, arkansas, other states, giving them the opportunity to implement and perhaps i questioned to and stay, they will deliver better care at lower cost. we actually think that will happen. thank you for indulging me. by the way, by hand large my

colleagues have been simple. you have been so respectful in a really good debate. thank you. i thank you for thinking carefully. i think you for your civility. it is a privilege to be in this body. i cannot praise you in a. thank you. i yield back. >> thank you. i think you have more than demonstrated stability yourself. you did go over but that is ok. you had these people attacking you all day. you should have a little more time as it is. we are now going to finish with senator wyden who will -- senator than has another question. youram very grateful for generosity. >> of my colleague would hold up. german i did have a five-minute closer. senator mccaskill apparently has something important to her so she can take the five minutes. >> you will take your five minutes. >> i only need one minute. >> i immediately take my four back.

laughter] >> he gave up his five minutes. >> i want to thank you for meeting.his chairman including allowing me to ask questions. mr. chairman, like mike alexander would like to submit for the record some letters from colorado about this bill. >> they will be placed in the record. >> thank you. i would also like to submit by the record a study by the kaiser family foundation about the percentage of births financed by medicaid. >> without objection. >> thank you. it is interesting, senator, to , alabama 58%,3% arkansas 67%. so, think there's a lot we have to learn from each other because somebody is going to have to pay .or these births finally, mr. chairman, for the last seven years the republican party has made repealing of the affordable care act their

defining issue. over 60 accounts in the house of representatives to repeal. it has helped over 600,000 coloradans obtain access to health insurance. president trump said he could do better and promised a much more generous version then the senator from louisiana was talking about. his promise on the mandate. much more generous vision of repeal and replace on the campaign trail. promisingn to repeatedly no custom medicare and medicaid, he said everyone has got to be covered. "i'm going to talk -- cover everybody. everybody will be taking care of i don't care of it cost me both. they will be to get better than you are today." when asked about repeal and replace he said, i'm going to do it simultaneously. it will be fine. we are not going to have a two-year time or two daytime with nothing. it will be repealed and replaced and we will know. it will be great health care coverage for less money. better, much better, less money. not a bad combination.

this is the commitment he ran on in the promise he made to the american people. this is not remotely on her that. mr. chairman, what you to know i stand ready to work with you and anybody else to meet the outcomes the president suggested when he was running for office. >> thank you. sen. mccaskill:, i understand you would like to make a stamina. i just. i have one question you may not have the answer. sen. cassidy: my would like to losehow much misery will -- senator, i would like to know how much we will lose. i did not see any analysis of how you would offset that. if your staff could provide what the provider tax would be in the negative, i know that the shifting of money helps the states that did not expand medicaid but i would like to know what would be left after the provider taxes. senator mccaskill, if you

would sit in it that i would appreciate it. submitted to the entire emitting. senator wyden, you can make your statement. senator wyden: here's where we are with respect to the spell. senator collins came out against this bill a little bit ago. this fight reporting is over. my message to the american people is that it is going to be critical to keep fighting this deeply-flawed bill. especially until saturday, which is when the next procedural window closes. two other concerns. when i asked senator cassidy weathers specifically the fifth version of the bill was it, it seemed to me there was a little bit of fudging and that is another reason to keep fighting. there has been an important development not referenced. i wanted to know specifically whether there would be ironclad attractions for people with respect to those who have a pre-existing condition.

mr. woodruff from the cancer society who knows a little bit no,t this subject said there would not be ironclad protections because states could wave them. that is confirmed, colleagues. reportr word in the cbo tonight. two last points, mr. chairman. first, really look forward to killing this flawed bill and then going back to the kind of positive work that you and i want to do that has really been our tradition starting with the children's health insurance program and not have this kind of a abomination of a process ever again. mr. chairman, which is close by saying i ask unanimous consent that a letter from democratic members of the many requesting we reconvene as soon as tomorrow to can -- continue this google discussion been made part of the record and i look for to work with you. as i think everybody is that enough time on this right now so we will not do that but i do appreciate your comments and appreciate working with you.

it is a pleasure for me and you are a very, very fine man with a very, very balanced approach towards these things. >> to web >> while there is enough funding to insured chip services will continue to the end of the month we certainly recognize time is of the essence and we must act quickly to extend funding for chip. there has been strong support for this and that is why writing member wyden and i have a bill out there to extend the program funding or five years. it is not going to end. we need to be careful about it. we need are committed to working with colleagues in the senate and house to act in swift order and develop a smart fiscal solution that will ensure no lapse and care for our nation's most vulnerable children. as the author of the chip bill and i think everybody knows that, i was able to talk my friend senator kennedy and in the divide toover

join me on the bill and it was one of his proudest achievements. as the author of that bill, that bill has done enough a lot of good and i want to make sure nobody falls in up. up -- fouls it up. thist to personally thank group of witnesses today. it has been a real hard thing to sit there all this time and answer the questions you have. you have all been just stellar as far as i'm concerned and i think very highly of you. some of you i agree more with that and others of course, but that is always the case. all i hope we can reach a point someday in our lives around here were the answer to everything is notmore money that we do have. and, the answer to everything is

not more federal government we do not need. and, the answer around here is that we can work together to try to solve these problems without bankrupting the country. are alreadyee, we enrolled difficulty because of the health situation in this country. the affordable health care is anything but affordable and everybody knows it. everybody, at least one size, don't want to admit it. but it is true and we are going to be in real trouble if we do not turn this thing around. and i want to especially thank our witnesses for being here. i want to thank everyone for participation in attendance today. i would especially like to think our witnesses for providing expertise today. you've all been just really good as far as i'm concerned. for any of my colleagues who have written questions for the record, i asked that you submit businesslose of wednesday, september 27. with that, you will be happy to

hear, you folks who have sat there so patiently all day, the hearing is adjourned. ]gavel pound [indiscernible conversation]

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