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From YouTube: Fixing Health Care: What's Next
Description
This video from a session at NCSL's 2017 Legislative Summit in Boston looked at federal proposals to replace the Affordable Care Act that portend dramatic changes for states. From the most visible features such as health exchanges, insurance subsidies or credits and the Medicaid expansion, to lesser known provisions, such as payment reforms and financing sources, states face major unknowns.
A
My
name
is
dick
cow
key
from
the
NCSL
health
policy
staff
here
at
the
Denver
office,
because
his
topic
can
be
a
bit
complex.
As
you
may
see,
we
have
several
resources
available
and
some
of
those
are
printed
more
useful.
There
are
additional
materials
that
are
posted
on
the
NCSL
website
and
even
in
your
NCSL
app,
if
you
can
make
it
work,
and
that
includes
full
bios
for
the
speakers
and
other
extended
handouts.
A
A
selected
resource
includes
some
of
the
technical
material
and
more
extensive
reports,
and
it
also
includes
a
summary
chart
and
even
links
to
the
text
of
all
seminar.
It's
all
seven
major
pieces
of
legislation,
including
the
original
ACA
and
the
six
bills
that
were
under
consideration.
The
lawyers
among
you
may
know
that
this
is
a
CLE
or
continuing
legal
education
session
eligible
for
professional
credits,
so
do
sign
the
CLE
form
and
there
are
some
some
handouts
that
may
be
specific
to
legal
interests.
A
A
He
was
president
of
NCSL
in
2010-2011
has
been
on
our
Executive
Committee
for
almost
20
years
here
at
the
Massachusetts
State
House.
He
was
one
of
the
principal
architects
of
the
landmark
Massachusetts
health
care
reform
law
that
resulted
in
near
universal
health.
He
was
founding
co-chair
of
the
state's
healthcare
financing
committee
until
promoted
to
their
Senate
President
pro-tem,
and
he
currently
is
president
of
the
Massachusetts
assisted
living
Association.
Would
that
Senator
Moore.
B
Thanks
very
much
dick
and,
on
behalf
of
my
colleagues
from
Massachusetts,
welcome
again
to
Massachusetts
and
I
hope
everybody's
having
a
great
time
here
and
learning
a
lot
both
in
the
sessions
and
maybe
a
apart
from
the
sessions
and
seeing
a
little
bit
of
the
city
and
spending
some
money
to
close
the
deficit
that
we
have
in
the
state
budget
would
be
helpful.
Let
me
just
say
that
I
suspect
among
the
people
here,
a
certain
Crips
among
the
speakers
as
well.
Health
care
is
not
a
simple
issue.
B
The
people
have
views
all
over
the
map,
well
from
total
government
management
and
resources
like
a
single-payer
folks.
There
are
folks
that
believe
in
that
there
are
some
where
they
think
government
should
be
somewhat
responsible,
overseeing
consumer
protection,
perhaps
encouraging
help
for
those
who
might
not
be
able
to
afford
the
the
prices
of
both
health
care
and
of
health
insurance
and
provide
some
oversight.
They'd
have
a
more
limited
role,
simply
making
sure
that
the
basics
are
there
and
some
that
think
there
should
be
basically
no
role
that
basic
free
market
activity.
B
So
there's
a
range
and
most
thing
and
that's
fairly
oversimplifying
the
differences,
because
there's
a
lot
of
gray
areas
in
between
each
of
those
those
types.
Briefly,
what
Massachusetts
did
we
were?
We
had
a
history
of
making
adjustments
and
reforms
of
health
care,
whether
children's
health,
elderly
prescription
assistance,
things
of
that
nature
that
provided
the
basis
for
some
interest
in
designing
a
program
that
got
us
too
close
to
virtual
coverage
with
people
either
insured
or
on
insured
by
private
sector
or
combination
of
private
and
public
or
all
public.
In
the
process.
We
did
it.
B
Interestingly,
with
bipartisan
development,
with
a
Republican
governor,
Mitt
Romney,
a
heavy
heavily
majority
Democrat
in
the
legislature,
we
did
it
with
a
universal.
You
know
a
uniform
vote
in
the
Senate
with
140
members
voting
all
for
the
reforms
in
the
house,
158
of
160
voted
for
the
reforms,
including
leadership
and
in
the
Senate.
At
the
time
we
had
then
state
senator
lady,
united
state
senator
and
now
ambassador
to
New
Zealand,
Scott
Brown,
who
was
voted
for
the
reform.
B
So
it
was
something
that
we
had
worked
closely
with
a
minority
party
and
both
accepting
amendments
and
in
working
on
in
the
conference
committee,
something
that
we
probably
it
seems
that
Governor
Kasich
recently
wrote
a
piece
in
The
Globe
on
Friday.
That
suggest
that
maybe
we've
tried
the
all
democrat
or
republican
versions,
and
maybe
it
will
be
time
to
start
working
on
something.
That's
a
compromise
of
sorts
in
between.
B
So
we'll
see
what
the
current
landscape
is
from
our
panelists
several
panelists
today
as
to
what
might
be
coming
down
the
line
and
what
would
be
the
role
of
the
states?
How
involved
should
the
states
be?
Do
they
want
to
be
and
what
issues
that
are
facing
you
and
your
respective
legislatures
and
States
as
we
go
forward
so
I
look
forward
as
I
think
you
do
perhaps
to
the
discussion
from
our
keynote
speaker
and
from
all
of
our
panelists
during
the
course.
The
next
couple
of
hours,
Thanks.
C
All
right,
good
morning,
it's
like
church
all
right,
so
we're
in
the
beginning
of
day.
Three
most
of
you
have
already
been
at
a
couple
of
our
meetings,
so
we're
gonna
really
kind
of
kick
this
off
a
little
bit.
But,
as
you
know,
we've
been
in
the
middle
of
a
discussion
of
healthcare
at
the
national
level.
It
is
a
has
been
has,
maybe
maybe
not
they're
gonna
vote
they're,
not
gonna
vote
they're
gonna
repeal
they
were
not
gonna.
Repeal
they're
gonna
go
lighter
version
they're,
not
so
trying
to
prepare
for
this.
C
This
particular
session
was
a
bit
challenging
because
we
really
didn't
know
what
the
topic
was
gonna
be
until
a
couple
of
days
ago,
based
on
what's
going
on
in
Washington
DC's,
so
and,
as
you
all
know,
we're
in
an
unpredictable
time
when
it
comes
to
the
health
care
I
we're
also
knowing
that
you
guys
most
of
you
in
the
room
probably
have
spent
some
considerable
amount
of
time
talking
with
a
couple
of
experts
on
Sunday.
So
we
heard
from
two
federal
experts,
Seema
Verma
and
Calder
Lynch
from
the
Centers
of
Medicare
and
Medicaid
Services.
C
And
so
you
know
those
were
some
of
the
deep
dives
today
we're
trying
to
stay
more
on
the
higher-level
discussion.
There's
some
folks
that
didn't
have
the
deep
dive
so
we're
hoping
to
be
able
to
touch
a
variety
of
different
topics
today
and
get
some
information
out.
But
today
it's
my
privilege
to
introduce
Jane
Norton
this
morning
as
we
as
she's
a
seasoned
state
and
federal
policy
maker
she's
she's.
C
Actually
you
know
from
our
from
my
part
of
the
world
secretary
Price
she's,
actually
secretary
prices,
director
of
intergovernmental
and
external
affairs
and
she's
charged
with
being
the
direct
and
to
a
connection
with
state
government.
So
she
is
basically
our
connection
with
with
secretary
prices
office,
but
just
a
quick
overview
of
why
she's
one
of
us
she's,
an
early
Colorado
state
legislator,
she's
been
the
Colorado
Colorado,
lieutenant
governor
with
Governor
Bill
Owens
and
she's,
a
former
HHS
reasoning,
region,
8
director
and
she
covered
six
states
Utah
to
South
Dakota
North
Dakota.
D
Don't
know
if
I'm
seasoned
or
old,
but
Thank
You
senator
Peters,
for
that
and
it's
a
pleasure
to
be
with
you
senator
Moore.
Thank
you
so
much
for
this
opportunity
and
for
all
of
you
here.
Let
me
just
begin
by
saying
how
much
I
have
admired
the
work
of
NCSL
over
the
years
and
I
certainly
respect
the
work
that
you
as
state
legislators.
D
Do
you
were
on
the
front
lines
of
providing
some
of
the
solutions
for
some
of
our
most
intractable
problems
and
I
appreciate
that
that
you
do
that
states
are
the
laboratories
of
democracy
and
know
best
how
to
innovate
and
craft
solutions
to
meet
unique
needs.
So
it's
a
privilege
again
to
be
here.
Thank
you
for
the
opportunity.
During
my
time
with
you
today,
I
want
to
tell
you
a
little
bit
about
the
department
about
secretary
price
and
his
priorities
and
then
maybe
some
suggest
some
ways
that
we
can
work
together
going
forward.
D
More
importantly,
I
look
forward
to
listening
to
your
thoughts,
your
ideas,
your
challenges,
your
solutions
about
how
we
can
make
healthcare
more
affordable
and
accessible.
Well,
let
me
introduce,
or
in
some
cases
reintroduce
you
to
the
US
Department
of
Health
and
Human,
Services
or
HHS.
Our
mission
at
HHS
is
to
enhance
and
protect
the
health
and
well-being
of
all
Americans.
We've
fulfilled
this
mission
through
a
staff
of
over
79,000
employees
over
300
programs
providing
for
effective
Health
and
Human
Services
and
fostering
advances
in
medicine,
Public,
Health
and
Social
Services
this
year.
D
Our
budget
is
set
at
just
at
one
point:
one
trillion
dollars:
HHS
has
11
operating
divisions,
including
eight
agencies
in
the
US
Public,
Health
Services,
and
three
Human
Services
agencies.
These
divisions
administer
a
wide
variety
of
Health
and
Human
Services
programs
and
conduct
life-saving
research
for
the
nation
protecting
and
serving
all
Americans
in
your
electronic
materials
associated
with
this
session.
This
morning
you
have
an
overview
of
HHS
and
the
agencies
that
comprise
HHS
I'm
pleased
to
bring
greetings
from
Secretary
Tom
Price.
Dr.
D
price
is
a
third-generation
physician,
he's
the
third
physician
to
hold
the
post
as
Secretary
of
HHS,
but
maybe
more
interesting
for
this
room.
Is
that
he's
also
the
seventh
former
state
legislator
to
hold
the
post?
His
four
terms
in
the
Georgia
State
Senate
twelve
years
in
Congress
and
20
years
as
a
practicing
physician,
have
afforded
him
valuable
experiences
and
insights
to
the
work
that
we
do
to
meet
our
mission.
D
President
Trump
secretary
Price
and
the
entire
administration
are
as
determined
as
ever,
to
solve
the
health
care
challenges
we
have
in
this
nation,
because,
what's
happening
right
now
to
Americans
is
unacceptable.
Let
me
remind
you:
premiums
have
more
than
doubled
under
Obama
care,
increasing
on
average
by
nearly
$3,000,
despite
promises
that
premiums
would
decrease
by
$2,500
thousands
of
Americans
living
in
counties
across
the
country.
Right
now
may
have
no
health
care
plan
being
offered
on
their
Obama
care
exchange
for
next
year
in
over
13
counties
or
roughly
40%
of
the
counties
of
our
nation.
D
Folks
may
only
have
one
coverage
option
on
the
exchanges
next
year,
meaning
they
really
have
no
choices.
Over
the
past
two
years,
the
number
of
health
issuers
offering
plans
on
Obamacare
exchanges
has
fallen
by
half
millions
of
Americans
are
paying
billions
in
IRS
finds
just
for
the
right
to
go
without
health
insurance
in
2015,
6.5
million
Americans
paid
three
billion
dollars
just
so
they
could
go
without
Obamacare.
D
The
administration
remains
committed
to
improving
our
health
care
system
so
that
better
serves
the
American
people.
Our
goal
is
to
foster
a
successful
patient-centered
healthcare
system
where
Americans
have
more
choices
and
lower
costs
where
patients,
families
and
doctors
are
in
charge
of
their
medical
decisions
and
where
Washington's
interests
take
a
backseat
to
patients
needs.
The
status
quo
is
unacceptable
and
it's
not
sustainable.
D
In
addition
to
health
care
reform,
doctor
price
has
laid
out
three
clinical
priorities
for
the
department.
I
think
this
is
an
area
work.
We
can
do
much
good
bipartisan
work
together.
Our
first
clinical
priority
is
combating
the
opioid
crisis.
Today's
opioid
crisis
is
the
deadliest
drug
epidemic
in
United,
States
history
and
it's
getting
worse.
In
2015
52,000
people
died
in
overdoses
in
America,
most
of
them
to
opioids.
D
2016
is
estimated
to
be
even
worst,
most
likely
exceeding
59
thousand
deaths,
a
19
percent
jump
from
the
previous
year.
Drug
overdose
is
now
the
leading
cause
of
death
in
America
among
adults
under
50
years
of
age.
Hhs
is
at
the
forefront
of
combating
this
crisis.
In
addition
to
representing
HHS
on
president
Trump's
presidential
commission
on
the
opioid
crisis,
secretary
Price
has
laid
out
a
five-point
strategy
to
address
the
epidemic
and
I
know
the
states
can
be
great
partners
in
this
strategy.
D
Our
first
strategy
is
improving
access
to
treatment,
including
medication,
assisted
treatment
and
recovery
services
to
help
the
90%
of
Americans,
who
are
struggling
with
addiction,
but
are
not
getting
treatment.
Hhs
through
the
21st
century
cures
Act
recently
made
available
485
million
dollars
in
grants
to
the
states
for
evidence-based
prevention
and
treatment
activities.
D
We
can,
through
programs
like
the
CDC's,
data-driven
prevention
initiative
and
enhanced
state
opioid
overdose
surveillance
program
that
provide
grants
and
technical
assistance
to
state
and
local
authorities
to
help
track
developments
and
respond
in
real-time.
Our
fourth
strategy,
providing
support
for
cutting-edge
research
on
pain
and
addiction.
D
Every
day,
HHS
researchers
at
institutions
like
the
National
Institutes
on
drug
abuse
and
scientists
across
the
nation,
funded
by
HHS
grants,
are
exploring
critical
questions
about
addiction,
treatment,
new
and
safer
painkillers
and
even
addiction
vaccines
that
will
inform
our
efforts
in
years
to
come
and
our
fifth
strategy
advancing
better
practices
for
pain
management.
In
addition
to
promoting
treatment
and
recovery,
we
have
to
avoid
independence
in
the
first
place,
which
means
rethinking
the
current
revolution
and
pain
management
and
ensuring
that
everything
HHS
does
in
payments
prescribing
guidelines.
D
That
is
everything
we
do
promotes
healthy,
evidence-based,
F
methods
of
managing
pain.
We
recognize
that
executing
much
of
the
important
work
against
this
epidemic
falls
to
states
and
local
governments,
and
we
want
to
partner
with
you
and
be
supportive
with
you.
In
implementing
these
best
practices,
the
Secretary
has
been
conducting
a
listening
tour
on
the
opioid
epidemic.
So
far,
he's
visited
seven
states
to
hear
from
state
and
local
leaders,
health
care
providers
first
responders
and
family
members
involved
in
this
public
health
crisis.
D
D
Our
third
clinical
priority
is
preventing
childhood
obesity.
Almost
one
in
every
five
American
kids
is
obese.
These
kids
are
going
to
have
serious
health
problems
in
the
future.
We
have
to
do
a
better
job
of
encouraging
kids
and
families
to
eat
right
exercise
and
engage
in
physical
activities
and
again
we
need
to
partner
with
the
states
in
solutions
to
these
critical
clinical
priorities
that
were
addressing
in
addition
to
these
clinical
priorities
addressing
the
high
cost
of
prescription
drugs
as
a
priority
for
the
administration.
D
Last
week
it
was
announced
that
for
the
first
time
in
five
years,
the
average
premium
for
a
Medicare
Part
D
prescription
drug
plan
is
projected
to
decline
in
2018.
This
is
encouraging
news
for
the
nearly
43
million
seniors
who
are
enrolled
in
the
program.
Luring
drug
costs
is
a
key
principle
of
the
president's
efforts
to
address
our
challenges
in
the
health
care
system
and
HHS
is
committed
to
doing
all.
We
can
to
increase
affordability
and
accessibility
of
care.
D
Reflecting
this
commitment,
HHS
has
begun
a
broad
effort
to
make
prescription
drugs
more
affordable,
particularly
for
America's
seniors.
This
announcement
by
CMS
comes
on
the
heels
of
a
proposal
released
last
month
that
would
allow
seniors
to
share
in
the
discounted
drug
prices.
Hospitals
are
already
receiving
under
Medicare.
D
I've
talked
a
little
about
about
what
we're
doing
at
the
Department
of
Health
and
Human
Services,
but
I
do
want
to
mention
a
new
expectation
as
to
how
we
do
our
work.
The
secretary
wants
us
to
be
able
to
look
back
on
his
administration
as
setting
a
new
standard
for
productive,
fruitful
partnerships.
We
all
understand
that
the
real
intervie
innovators,
the
real
problem
solvers,
are
not
just
in
Washington
DC
they're,
all
across
our
country,
the
president
and
our
secretary
understand
and
appreciate
that
achieving
health
care
goals
depends
on
empowering
states
and
local
communities.
D
States,
as
administrators
of
the
program
are
in
the
best
position
to
assist
the
unique
needs
of
their
respective
populations
and
to
drive
reforms
that
result
in
better
health
care
outcomes.
In
terms
of
executing
those
partnerships.
Our
office,
the
office
of
intergovernmental
and
external
affairs,
is
your
front
door
to
the
office
to
the
apartment,
we're
here
to
help
you
decipher
the
department,
whether
it's
arranging
for
a
meeting
providing
technical
assistance,
helping
with
constituents
casework
or
just
answering
your
questions.
D
We
like
to
say
that
we
don't
write
the
stone
tablets,
but
we
go
up
to
the
mountain
and
get
them
and
deliver
them
to
the
folks
who
need
them.
That
was
supposed
to
be
a
joke.
I
trust
with
the
note
yeah
we're
not
quite
away
but
I
I
trust
that
a
number
of
you
have
worked
with
our
IAEA
staff
liaison
to
state
legislators
in
our
department,
Jennifer
Stowe
Jennifer.
Where
are
you?
Would
you
raise
your
hand
she's
a
great
resource
for
you
after
the
session
is
over
ie?
D
A
is
also
an
important
has
an
important
presence.
There
are
10
regional
offices
that
directly
serve
state
and
local
organization.
A
president
appointed
regional
director
leads
each
office.
Each
regional
director
ensures
the
department
maintains
close
contact
with
state
local,
territorial
and
tribal
partners
in
addressing
the
needs
and
communities
and
individuals
served
through
HHS
programs,
so
for
so,
for
those
of
you
in
New,
England
are
acting
regional
director
for
region.
1,
Paul
Jacobson
is
here
in
the
audience
Paul.
Where
are
you?
Would
you
put
your
hand
up
Paul's,
another
good
resource
for
you?
D
If
you're
in
Maine,
Vermont,
New,
Hampshire,
Connecticut,
Massachusetts
or
Rhode
Island
pause
your
man
there
so
also,
we've
we've
compiled
a
lot
of
information
on
your
electronic
materials,
the
list
of
the
ten
regional
offices.
So
let
me
just
close
by
saying
thank
you
for
all
that
you're
doing
in
your
States.
This
administration,
on
our
team
at
HHS
have
immense
respect
for
what
state
governments
can
do
to
invent
to
advance
our
mutual
mission
of
improving
and
protecting
the
life
of
our
citizens.
D
It's
great
to
see
groups
like
NCSL
bringing
people
together
to
combat
some
of
these
intractable
issues,
and
we
recognize
that
you
should
have,
because
you
have
unique
needs.
You
should
be
able
to
come
up
with
unique
solutions,
so
I
look
forward
to
being
a
part
of
your
conference
to
continuing
to
hear
and
listen
and
learn
from
you
and
thank
you
again
for
allowing
us
to
be
a
part
of
this
morning's
panel.
I'll
now
turn
it
back
over
to
Senator
Peters.
Thank
you.
Thank.
C
So
we're
gonna
start
and
do
a
couple
of
questions
here,
but
the
first
one
I
want
to
ask
is
based
on
the
the
lack
of
bipartisan
effort
in
the
discussion
of,
and
the
dialogue
are
surrounding,
the
issue
with
the
affordable
care
act
and
whatnot.
This
group
of
elected
officials
in
this
room
is
a
bipartisan.
Is
there
anything?
Is
there
something
that
we
can
help
with,
or
is
there
a
lesson
or
a
precedent
or
break
through
that
state
legislators
can
bring
working
up
from
the
state
level
to
help
you
to
do
your
job.
D
That's
a
great
question
and
I
think
the
bipartisan
approach
obviously,
is
the
most
sustainable
strongest
approach
that
we've
seen
over
the
history
of
legislative
action
and
good
good
policy
going
forward.
One
of
the
breakthroughs
that
I
think
that
in
in
terms
of
a
bipartisan
approach,
was
Alaska's
1332
waiver
and
it
took
a
bipartisan
approach.
Obviously,
in
order
to
have
enabling
legislature
legislation,
the
state
legislature
had
to
come
together
pass
a
bill
signed
by
the
by
the
governor
and
then
went
to
CMS
and
was
approved.
D
1332
s
allows
States
to
provide
state
innovation
waivers,
provide
the
states
to
have
flexibility.
Alaska's
problem
was
high
premiums
and
not
many
people
being
covered,
so
they
address
that
in
their
waiver
and
it
was
a
great
bipartisan
approach.
So,
hopefully,
we'll
see
more
of
those
kinds
of
efforts
coming
forward
from
you
in
the
States.
B
Yes,
a
congressional
action
is
needed
for
funding
for
the
chip
program
after
as
of
October
1st.
So
do
you
see
any
discussions
going
on
to
really
move
that
forward
so
that
we
can
see
that
continue
without
any
interruption
and
the
states
I
think
need
to
have
some
understanding
that
the
the
it's
going
to
be
able
to
continue
in
some
way
and
whatever
the
design
is
going
to
be
if
it's
going
to
change
and
so
that
they
can
react
and
not
leave
families
and
children
in
the
lurch.
C
C
But
what
can
we
see
or
what
does
state
legislators?
What
can
we
help
work
with
your
office
to
maybe
hold
off?
You
know,
I,
guess.
My
question
to
your
boss,
a
couple
months
ago,
was
I
think
based
on
a
pain
management
approach
on
how
insurance
companies
are
paying
for
the
fun
drugs
that
we
like
to
fight
with.
Now,
what
do
you?
What
can
we
do
to
help
push
that
or
what's
the
time
frame,
to
kind
of
change,
how
pain
management
is
paid
and
reimbursed
that.
D
Just
like
no
I,
don't
I
need
tylenol,
you
know,
so
what
the
states
can
do
really
really
is
maximize
your
prescription,
drug
monitoring
programs,
you
all
have
them.
The
states
have
them
a
provider.
Education
is
another
really
important
thing.
I
know,
Massachusetts
has
done
a
great
job
with
that
prescribing
practices,
but
beyond
that,
making
sure
that
you
have
safe,
convenient
places
where
people
can
dispose
of
their
prescriptions,
that
they
don't
need
any
longer.
D
But
I
was
with
Kellyanne
Conway
when
the
secretary
went
to
Chattanooga
and
what
a
great
recovery
community
they've
really
come
together
in
some
innovative
ways
and
I
think
that's
what
you
can
do
in
your
States
as
well,
as
is
the
kind
of
listening
sessions.
The
roundtables
raising
awareness
just
talking
to
people
when
you're
doing
town
hall
meetings
talk
to
them
about
the
statistics,
I
mean
I,
don't
think
a
lot
of
people
really
realize
how
significant
of
a
crisis
this
is
and
Kellyanne
said.
D
This
is
a
crisis
that
is
a
it's
a
nonpartisan
issue
in
need
of
a
bipartisan
solution
and
I.
Think
if
there's
anything
that
we
can
come
together
around
because
it
is
it
it
affects.
All
of
us
is
that
this
can
be
a
bipartisan
thing
that
we
can
all
work
on
and
we've
got
to
work
on
it.
It's
taking
too
many
it's
taking
too
many
wives.
D
C
C
E
We
had
a
focus
group,
our
leader
earlier
today,
which
really
focused
on
the
mental
health
aspect
of
it
and
how
we
really
need
to
really
start
focusing
more
on
the
addiction
and
stopping
that
long-term
effect
of
opioids
we're
starting
to
get
a
good
sense
as
far
as
the
prescription
drug
monitoring
programs,
as
far
as
legislation
to
look
at
the
prescribers,
but
that's
kind
of
the
next
step.
Along
with
this
blossoming
problem
with
the
illicit
drugs
with
Joran
and
fentanyl.
F
Sorry
jump
the
line,
I
apologize
for
just
a
follow-up
comment:
I'm
Senator,
green
from
Hawaii
I'm,
an
ER
dr.,
Ike
inscribed.
These
pills,
though,
as
infrequently
as
I
can
just
a
couple
stats.
I
know.
Some
of
you
have
heard
these,
but
it's
important
to
remember.
We
have
four
percent
of
the
world's
population
as
Americans
and
we're
consuming
80
percent
eight
zero
percent
of
opioids
by
prescription
the
killin
people.
As
we
all
know,
we
started
the
PDMP
program
in
Hawaii.
F
We
made
it
mandatory
that
you
sign
up
but
not
use
it,
and
only
11
percent
of
our
providers
are
using
it
right
now.
So
it's
just
not
it's
helping,
but
it's
not
penetrating.
Yet
people
are
only
becoming
aware,
though
we
do
expect
to
have
success.
We
held
a
lot
of
work
groups,
but
our
citizens
are
just
not
aware
yet
that
in
Europe
you
take
tylenol
when
you've
got
pain
and
in
America
you
take
pain,
pills,
so
I
guess
my
reflection
after
working
like
many
of
you
for
many
years
on
this
is
we're.
F
G
Thank
you,
Jim
Dunnigan,
representative
from
Utah
I'm,
so
excited
about
your
background
and
Seema's
background
and
secretary
Price
background
from
the
states
and
just
say:
please
don't
forget
that
and
gents
terrific
to
work
with
she.
Really.
She
really
is.
If
the
only
approval
we
had
to
get
would
be
from
John
I
think
we'd
be
in
good
shape.
I
want
to
mention
that
Utah
submitted
an
1115
waiver
a
year
ago
and
that
the
waiver
addresses
it
provides
to
childless
adults,
full
Medicaid
coverage.
So
it's
part
of
the
coverage
gap,
but
it's
a
targeted
the
coverage
gap.
G
When
we
worked
with
CMS
last
year
and
the
prior
year,
they
said
we'll
give
you
more
flexibility.
If
you
do
it
at
your
traditional
Medicaid
match,
rather
than
the
enhanced
match.
So
the
waiver
that
we
submitted
was
that
our
current
F
map
we
want
to
cover
the
chronically
homeless
and
those
with
substance,
abuse
and
mental
health
issues
rather
than
incarcerate
them
and
put
them
into
jail.
We
want
to
divert
them
to
treatment
the
waivers
been
in
there
a
year.
We
tried
to
craft
exactly
how
CMS
directed
it.
G
So
we
could
get
quick
approval
and
I'm
just
would
like
your
help
and
your
support
to
take
a
look
at
that.
You
know.
Seema
said
that
she
wants
to
change
from
the
agency
of
no
to
the
agency
of
yes
and
more
flexibility
and
innovation.
We
are
volunteering
to
be
one
of
the
innovators.
We
will
accept
a
yes
I
want
to
be
very
clear
on
that
and
she
says
she's
talking
in
months
instead
of
years,
so
it's
been
a
year
and
in
March
we
got
the
letter
from
secretary
Price
and
SEMA
and
they
said
more
flexibility.
G
You
know,
give
us
your
idea,
so
we've
adjusted
and
updated
the
waiver
just
completed
our
new
public
comment
period.
A
week
ago
we
heard
from
HHS
CMS.
That
said,
if
you
want
to
add
those
little
tidbits
of
flexibility,
that
we
encourage
you
to
add
that's
going
to
postpone
your
approval
back
several
months
from
where
it
might
have
been.
So
we
appreciate
the
offer
flexibility
yesterday
or
Sunday.
G
H
Hi
I'm
representative
Sarah,
Copeland
Hans's
from
Vermont
and
just
to
kind
of
orient
folks
who
may
not
be
familiar
with
what
Vermont
has
been
doing
in
health
care
reform.
I
have
now
been
in
the
legislature
long
enough
to
have
been
through
two
different
attempts
to
move
Vermont
to
a
universal
health
care
system,
and
each
time
we
have
fallen
short
of
achieving
that
goal.
H
We
have
stepped
back
and
focused
on
what
we
know
needs
to
be
done
anyway,
which
is
to
improve
the
delivery
system
and
to
to
try
to
contain
the
rate
of
growth
of
healthcare,
and,
as
you
know,
if,
if
if
human
beings
are
not
are
not
to
be
left
to,
you
know
die
on
the
streets
from
preventable
illnesses.
Our
best
way
to
control
the
rate
of
growth
is
to
make
sure
that
people
are
getting
the
right
care
at
the
right
time
in
the
right
setting
so
that
they
can
stave
off.
H
You
know
a
downstream
higher
cost
incidence,
and
so
what
we
are
doing
right
now
in
Vermont
is,
is
really
just
continuing
to
work
on
our
blueprint
for
health,
which
is
the
recognition
that
the
20%
of
sickest
people
are
consuming
80%
of
that
healthcare.
If
we
can
keep
those
people
well
and
and
and
prevent
other
people
from
falling
into
that
20%
of
the
sickest
people
category,
we
can
control
healthcare
costs
for
the
entire
population
and
we
can
improve
people's
quality
of
life
and,
incidentally,
ability
to
to
provide
for
themselves
and
for
their
family.
H
So
we
are
moving
towards
an
all
payer
model
and
and
the
all
payer
model.
The
goals
of
the
all
payer
model
will
be
to
improve
the
patient
experience
and
to
to
streamline
the
delivery
of
care,
but
also
to
contain
the
rate
of
growth
of
it'll
per
capita
healthcare
spending
and,
and
that
I
think
is
going
to
be.
The
the
the
next
phase
of
focus
in
Vermont
is
to
continue
to
work
towards
towards
that
type
of
system
of
care
and
I.
Guess
the
the
question
that
was
posed.
H
You
know
when
I
was
asked
to
prepare
for
this.
Is
you
know
what
what
what
would
we
ask
of
of
our
federal
partners,
and
so
I
guess
you
know?
You
have
already
pledged,
though,
that
you
know
that
you,
your
administration,
would
like
to
give
states
that
continued
flexibility
to
innovate,
and
we
thank
you
very
much
for
that,
because
we
and
many
other
states
are
trying
to
be
incubators
of
new
ideas
on
how
to
how
to
fix
healthcare.
H
H
We
need
to
be
able
to
know
going
down
the
road
that,
as
we
are
working
so
hard
to
contain
the
rate
of
growth
of
spending
that
we're
not
going
to
end
up
pulling
the
rug
out
from
underneath
people
which
will
cause
some
of
our
most
vulnerable
populations
to
be
at
risk
of
falling
into
that
very
sick
category,
and
then
I
guess.
The
third
thing
I
would
say
that
we
would
love
from
from
the
administration,
would
be
a
really
strong
push
to
allow
for
all
publicly
funded
health
systems
to
be
able
to
negotiate
for
prescription
drugs.
H
C
I
C
J
State
representative
Dave
Heaton
and
I'd
like
to
talk
about
the
1332
waiver
request.
I
was
one
of
the
states
that
is
down
to
one
provider
Iowa
and
we're
down
to
one
provider,
and
if
we
don't
get
a
request
for
our
1332
way,
we're
honored,
we
will
lose
that
provider
and
we
will
be
there
with
no
insurance
in
our
state
for
individual
policies.
J
Our
insurance,
commissioner,
is
sent
in
the
request.
It's
been
there
and
I
think
it's
been
in
there
for
about
a
month,
maybe
a
month
and
a
half,
and
we
realized
that
this
is
a
temporary
solution.
We
understand
that,
but
we
need
the
federal
government
to
make
a
real
permanent
reforms
to
the
ACA.
If
we
are
to
save
the
health
insurance
options
for
our
farmers,
for
our
small
business,
people
like
I
used
to
be
and
those
who
are
retired
before
they
get
their
Medicare,
these
people
will
have
no
health
care.
J
So
in
terms
of
what
Iowa
needs
we
need
you
approval
of
our
32
13
32
request.
The
other
major
issue
for
us
is
Medicaid.
We
are
in
year
two
of
using
managed
care
for
our
program.
It
has
been
successful
in
breaking
the
Medicaid
cost
curve
in
Iowa,
but,
as
Washington
looks
to
reform
Medicaid,
we
need
everyone
to
remember
that
this
program
has
significantly
different
cost
drivers
in
Iowa
seniors
and
the
disabled
represent
25%
of
the
enrollment
but
consume
70
percent
of
the
funding.
J
We
must
learn
the
lesson
that
the
creator
of
10
from
the
creator
of
creation
of
TANF,
that
there
needs
to
be
a
reasonable
growth
factor
built
into
the
system
if
it
is
to
be
block
granted
or
switch
to
a
per
member
per
month
formula.
Without
that
it
would
be
very
difficult
to
maintain
the
needed
level
of
services
to
these
most
vulnerable
Americans.
B
B
The
focus
of
this
section
of
the
panel
will
be
primarily
on
the
impact
of
the
health
reform
on
the
insurance
market
and
various
aspects
of
that.
Obviously,
one
of
the
issues
that
affects
insurance
is
that
we
didn't
get
into
yet
in
the
priorities
from
the
administration,
our
cost
containment
as
well
of
health
care
itself,
because
that
bit
those
are
building
blocks
of
what
the
insurance
policies
call
for.
B
We
did
do
some
work
on
that
in
Massachusetts,
and
the
state
auditor
was
a
commission
to
do
a
study
and
has
determined
that
that
that's
cost
containment
legislation
has
made
some
progress,
but
we
still
have
a
ways
to
go
because
the
cost
continues
to
escalate
beyond
normal
inflation.
But
with
that,
let
me
start
with
I,
don't
know
who
would
like
to
start
first
as.
B
K
You
it's
a
pleasure
to
be
here
with
you
today.
Thank
you
so
much
for
the
invitation.
As
we
all
know,
as
Senator
Peters
was
just
remarking,
it's
been
quite
a
rollercoaster
these
last
couple
of
months
waiting
to
see
whether
Congress
would
change
and
replace
the
Affordable
Care
Act
particularly
focused
on
changes
to
the
individual
market
in
the
marketplaces
and
for
now
with
Congress
out
of
the
DC
back
at
home.
Things
are
really
at
a
pause
at
a
really
critical
time.
K
As
you
know,
insurers
are
in
the
process
of
finalizing
their
rates
along
in
talking
with
the
states,
as
well
as
deciding
whether
or
not
they're
going
to
participate
in
the
marketplaces.
So
I'm
going
to
focus
very
briefly
on
a
couple
of
the
key
issues
that
face
the
trumpet
Minister
as
in
the
short
term,
the
Affordable
Care
Act
is
continuing,
as
is
their
of
course,
very
important
reforms
that
Congress
should
be
considering
as
well
as
states,
but
I
want
to
mention
these
three
things.
K
First
is
marketing
and
outreach,
and
it's
not
something
that
what's
been
a
big
part
of
the
congressional
debate.
But,
as
we
all
know,
one
of
the
key
issues
in
the
individual
market
is
attracting
young
and
healthy
risk
to
have
a
balanced
risk
pool,
and
there
are
requirements
in
the
Affordable
Care
Act,
for
responsibilities
of
HHS
to
enroll
individuals
to
make
sure
that
they
can
get
their
determinations.
K
The
second
issue
dimension
is:
are
the
mandates
the
individual
and
the
employer,
mandates
experts
disagree
and
how
important
they
think
the
mandates
are
for
ensuring
a
healthy
risk
pool.
But
at
least
some
insurers
think
that
it's
important
and
and
included
as
part
of
their
thought
process
about
how
they
set
premiums.
And
then
the
third
issue,
which
is
by
far
the
most
critical
and
most
important,
especially
in
the
near
term,
are
the
cost-sharing
reductions
as
part
of
the
Affordable
Care
Act.
When
people
purchase
insurance.
K
Some
individuals,
based
on
their
income,
get
assistance
through
tax
credits
which
helps
pays
for
their
premiums
and
cost-sharing
reductions,
pay
for
help
pay
for
out-of-pocket
costs.
So
when
you
go
to
see
the
doctor
when
you
get
your
treatments
etc
and
those
are
available
to
people
between
a
hundred
and
two
hundred
and
fifty
percent
of
the
poverty
level,
those
individuals
are
entitled
under
the
law
to
those
two,
those
reductions
and
so
the
uncertainty
about
whether
those
payments
are
going
to
be
made
has
caused
a
lot
of
insurers.
K
To
cite
that
as
a
reason
why
they
may
not
participate
in
the
market
as
well
as
or
thinking
about
increasing
their
premiums
estimate
between
10
to
20
percent
based
on
whether
or
not
the
cost-sharing
reductions
are
paid.
So
these
are
three
very
important
short-term
issues.
Again,
there
are
things
that
we
should
talk
well
sure,
we'll
talk
about
the
course
of
the
panel
that
Congress
should
can
consider
and
things
that
states
of
cross
the
states
the
marketplaces
are
in
different
states
and
things.
As
we've
mentioned,
different
states
are
considering
to
stabilize
their
markets.
L
L
G
L
I'm
I'm
gonna
focus
on
some
of
the
same
issues,
but
from
a
slightly
different
perspective.
The
Affordable
Care
Act
established
important
new
norm
of
social
policy,
which
is
this
idea
that
everyone
should
be
able
to
my
insurance,
regardless
of
their
health
status.
That
isn't
the
way
the
individual
market
used
to
work.
L
The
the
the
individual
insurance
market
was
in
fact
perfectly
stable
and
in
a
way
that
I
think
most
people
would
find
unsatisfactory
prior
to
the
ACA
insurers
had
businesses
that
actually
could
make
money,
but
that
was
because
they
could
also
exclude
people
with
serious
conditions
they
could
charge
higher
premiums
for
people
are
going
to
spend
particularly
more
money
and
so
on.
What
the
ACA
did
was
basically
say:
okay,
we
want
a
different
social
norm.
L
If
you're
gonna
have
a
different
social
norm,
you
also
have
to
take
into
account
what
the
what
that
does
to
the
to
the
market,
to
the
business
of
health,
insurance
and
I.
Think
that's
one
of
the
failures
of
the
Affordable
Care
Act,
so
in
a
sense,
switching
the
rules
without
taking
into
full
consideration
how,
in
our
insurance,
actually
works,
destabilized
the
market,
the
ACA
destabilize
the
market.
L
Well,
that's
not
exactly
true,
but
it
is
true
that
people
with
subsidies
received
subsidies
that
went
up
dollar
for
dollar
with
a
premium
as
long
as
they
stayed
with
the
second
lowest
cost
silver
plan,
but
somebody
did
pay
more
and
that's
the
taxpayer
and
that
gets
to
the
real
problem
with
the
US
health
system,
the
incredible
and
efficiency
waste
and
overspending
that
we
have
in
our
health
system.
So
the
Affordable
Care
Act
focused
on
spreading,
including
more
people
in
insurance
coverage,
but
not
really
seriously
address
the
cost.
Part
of
it.
L
Republicans
have
bit
enough,
I
would
say
more
than
anybody
can
chew,
because
essentially
they
raised
their
hands
and
said:
ok,
we'll
solve
the
cost
problem
too,
and
and
as
everyone
here
knows,
the
cost
problem
is
not
solved
easily,
not
easy
and
generally
not
solved
by
by
Washington
legislation.
It's
it's
resolved
in
ways
that
require
working
on
a
daily
basis
at
the
local
level,
states
can
contribute
to
that.
L
They
can
contribute
to
stabilizing
their
insurance
markets,
but
they
can
also
contribute
to
helping
the
the
costs
were
slowed
down
by
having
less
restrictive
requirements
for
who
can
provide
services.
For
example,
lots
of
other
things
that
states
could
do,
but
with
that,
let
me
turn
it
over
to
Kim
good.
M
Morning,
everyone
I
have
spent
the
my
entire
career
in
the
insurance
business.
I
was
a
small
business
owner
in
Oklahoma.
I
ran
a
multi
lines,
insurance
agency
there
and
my
discipline
discipline
was
employee
benefits,
so
I
worked
with
small
and
large
businesses.
I'm,
selecting
health
insurance
products.
I
did
that
for
about
25
years
before
I
had
the
opportunity
to
serve
as
Oklahoma
State
Insurance
Commissioner,
which
is
an
elected
office
and
served
in
that
capacity
for
six
years
before
joining
BlueCross
BlueShield.
M
So
I
like
to
tell
people
that,
in
those
capacities,
I
have
bought,
Blue
Cross
sold,
Blue
Cross,
regulated
Blue,
Cross
and
now
work
for
Blue,
Cross
and
I
can
tell
you
that
at
every
one
of
those
different
perspectives,
things
are
very
different.
This
is
an
extremely
complex
environment,
healthcare
itself
and
health
insurance
is
no
exception.
It's
very,
very
complicated
I
can
tell
you
one
of
the
prevailing
things
that
I
have
learned
in
all
my
years
of
experience
is
as
a
business.
The
insurance
industry
can
pretty
much
respond
to
whatever
the
rules
are.
M
They
can
run
their
business
based
on
whatever
the
rules
are.
They
just
need
to
know
two
things:
what
are
the
rules
and
that
everybody
plays
by
the
same
rules
right?
Those
are
the
two
fundamental
issues
that
we
care
about
as
a
business,
our
business.
Don't
kid
yourself,
the
CEOs
think
they
run
the
business
actuaries
run
the
business
right
and
actuaries
by
their
very
nature
are
conservative
people.
They
are
there
to
determine
risk.
M
They
are
there
to
ensure
the
solvency
of
our
industry
as
an
insurance,
commissioner,
that
was
my
principal
responsibility
to
ensure
that
companies
remain
solvent,
so
they
could
fulfill
the
promises
that
they
were
making
to
their
policy
makers
and
that's
the
actuaries
job.
They
look
at
a
lot
of
different
factors
to
make
those
decisions
right.
They
look.
M
Historically,
it
claims
they
look
at
the
benefits
that
they
are
going
to
better,
that
they're,
providing
they're
looking
at
medical
trends,
but
they're,
also
taking
into
consideration
existing
federal
and
state
laws
and
regulations,
and
when
all
of
those
things
are
in
flux
or
any
one
of
those
significant
things
are
in
flux.
They
take
the
most
conservative
route.
They
are
going
to
price
for
the
worst
case
scenario
and
that's
what
you're
seeing
today
the
second
part
about
that
in
terms
of
level
playing
field.
That's
when
competition
is
at
its
best.
M
That's
what
regular
is
about-
it's
not
to
micromanage
a
company
but
to
create
the
guardrails
so
that
a
market
can
function
effectively
where
everybody
does
play
by
the
same
rules,
and
we
can
have
a
true
sense
of
competition
when
regulation
or
laws
pick
winners
and
losers.
That's
not
competition
right,
that's
winners
and
losers,
so
we
have
to
get
back
to
an
environment
where
the
market
is
effective,
because
companies
are
allowed
to
compete
fairly
and
understand
the
rules
and
the
rules
will
apply
to
everyone.
I.
M
Well,
just
a
couple
of
things
that
come
to
my
mind
and
I
heard
Chiquita
mention
something
about
marketing.
We
know
that
the
administration
is
reduced
or
cut
back.
The
promotion
of
health
insurance
I'm
just
going
to
tell
you
that
the
best
opportunity
we
have
to
lower
costs
overall
is
to
get
more
young
people
in
the
pool.
M
I
know
that
probably
sounds
like
a
broken
record
to
a
lot
of
you,
but
until
we
got
you
know,
the
whole
principle
of
insurance
is
spreading
the
risk
the
young
people
pay
for
the
old
people,
we're
all
gonna
get
old,
someday
the
closer
I
get
to
it.
The
more
I
hope
there's
more
young
people
in
that
pool,
so
it's
a
benefit
to
all
of
us
and
a
benefit
to
cost
overall,
if
we
ensure
that
young
people
are
in
there,
but
let's
face
it.
M
If
I'm
a
26
year
old,
27
year
old
kid,
that's
I've,
just
gotten
off
my
my
parents,
health
insurance
plan.
My
most
important
thing
is
whether
I
can
say
that's
pay
my
cell
phone
bill.
It
isn't
about
buying
insurance,
so
we're
going
to
have
to
figure
out
a
way
to
entice
these
young
kids
to
buy
insurance
and
understand
it's
their
responsibility
to
do
so.
That
is
not
a
new
problem
right.
It's
a
long-standing
challenge!
M
We've
not
met
it
head
on
yet
so
what
you
could
do
anything
you
can
do
to
help
promote
young
people
buying
coverage
is
going
to
help
everyone
overall
I.
You
know
I,
really
appreciate
the
comments
about
1332
waivers
I,
heard
Jane
comment
on
on
Alaska.
Today.
We've
been
very
involved
in
that
situation,
but
let's
face
it,
you
know
they
redirected
all
their
premium
tax
to
get
that
waiver
and
I
would
suspect
for
most
of
you.
That
would
be
a
heavy
lift
right
premium.
M
Tax
generally
is
the
second
or
third
largest
contributor
to
your
state
general
funds,
and
it's
gonna
be
really
hard
to
put
that
money
aside
for
that
purpose
or
any
part,
Idaho
is
an
example
that
I
think
is
great.
I,
don't
know
if
anybody's
from
Idaho
in
here,
but
Insurance
Commissioner,
Dean
Cameron,
who
was
a
former
legislator
great
guy.
M
If
there
are
ways
in
which
they
can,
they
can
provide
and
help
you
create
creative
solutions.
That's
that's
another
thing.
Third
I
would
just
say,
first
and
foremost,
do
no
harm.
Remember
what
I
said
about
label
playing
field.
Consider
the
potential
impact
and
consequences
of
the
decisions
and
actions
that
you
take,
that
might
inadvertently
create
adverse
selection.
So
do
listen
to
your
insurance
companies.
I
know.
Insurance
companies
are
all
our
favorite
people
to
hate,
but
the
fact
of
the
matter
is
in
each
one
of
your
state:
their
tax
payers.
M
There
sit
there
their
good
corporate
citizens
and,
at
the
end
of
the
day,
we
just
want
to
make
sure
people
get
the
coverage
and
the
care
that
they
need.
There's
experts
within
those
organizations
that
can
help
you
craft
policy.
That
can
go
a
long
way
to
advancing
your
interest
in
protecting
your
constituents.
L
Okay,
so
other
other
things
that
stays
I've
done.
As
you
know,
ohayo
went
from
20
counties
that
had
either
none
or
one
I
think
was
non
insurer's
in
the
exchange
market
down
two
down
two
down
to
one
County
that
is
still
without
mature,
and
you
know
there
are
ways
there
ways
that
states
can
can
do
this.
L
Commercial
proposition.
What
it
basically
means,
however,
is
that
the
people
who
are
already
buying
insurance
already
had
lots
of
options
they're
going
to
be
paying
a
little
bit
more,
but
that
is
that
is
the
essence
of
insurance.
That's
one
of
the
things
people
don't
seem
to
understand.
It
has
something
to
do
with
sharing
the
cost.
When
we
say
risk
people
don't
seem
to
understand
that
it's
sharing
the
cost
and
so
and
so
that's
a
mechanism
that
works
pretty
well.
L
K
I'll,
just
really
echo
again,
I
think
what
Kim
said
being
incredibly
important
marketing
and
also
they
were
insurance,
alaska's
waiver,
obviously
a
model
that
that
HHS
is
incredibly
supportive
of
and
has
the
added
bonus
of,
adding
state
federal
dollars
to
state
dollars
a
very
effective
way.
The
the
Affordable
Care
Act
had
insurance
program
that
was
helpful
for
reducing
premiums
and
it
may
be
an
option
for
other
states.
I
would
just
add
that
again,
it
really
varies
across
the
country.
K
As
you
all
know,
different
states
are
in
different
positions
about
what's
going
on
with
their
market,
and
so
knowing
what's
going
on
with
your
local
market
is,
is
key,
but
for
some
states
Medicaid
may
be
leveraging
Medicaid
in
one
way
or
another
may
be
a
viable
option.
Joe
mentioned
tying
and
some
of
the
drawbacks.
It
may
be
more
appropriate
for
a
state
where
there
is
an
incredibly
robust,
Medicaid
managed
care
so
not
necessarily
effective
in
a
state
where
managed
care
isn't
as
prevalent.
K
B
Got
an
opportunity
for
some
legislators
or
legislative
staff,
most
of
whom
a
lot
of
whom
were
gathered
up
front
here,
but
if
you're
one
of
the
shy
ones
sitting
further
back,
please
raise
your
hand
and
we'll
try
to
get
a
microphone
to
you.
Why
don't
we
start
with
this
gentleman?
The
first
table
here.
N
Thank
you,
I'm
Mark
Levine
I'm,
a
member
of
the
Virginia
House
of
Delegates,
a
Kim
I
found
what
you
had
to
say.
Very
persuasive
and
I
have
a
question
about
certain
Trump
administration
priorities
and
how
they
affect
rising
premiums.
So,
specifically,
you
mentioned
not
advertising
the
exchanges
that
you
felt
that
made
fewer
young
people
in
and
that
raised
premiums,
and
the
second
thing
I
want
to
know
is
enforcing
the
penalty
apparently
they're
trying
to
enforce
it
less.
N
Does
that
raise
premiums
and
encourage
people
dessert
the
market
and
the
third
and
I
think
the
most
important
which
we
haven't
discussed,
which
surprises
me,
is
the
failure
to
obey
the
law
under
the
Affordable
Care
Act
that
insurance
companies
are
going
to
be
compensated
for
their
you
for
the
subsidies
that
they
pay.
Now
they
paid
it
on
a
month-by-month
basis,
but
the
law
says
it
has
to
be
paid,
and
the
trevor
ministration
is
wavering
over
whether
or
not
they're
going
to
pay
it
or
not.
N
Does
that
uncertainty
increase
premiums
and
cause
more
people
to
to
leave
the
market,
and,
in
essence,
if,
given
that
Congress
has
failed
to
do
anything
if
the
administration
were
to
support
the
Affordable
Care
Act
as
it
currently
exists,
rather
than
trying
to
some
people
are
going
to
like
this
word,
but
sabotage
it
or
make
it
implode.
Would
that
indeed
lower
the
cost
of
insurance
and
cause
more
people
to
stay
in
the
market?.
M
Lots
of
questions,
so
let
me
just
say
first
I,
think
there's
there's
always
a
legitimate
debate
that
should
occur
about
the
role
of
government
and
something
as
personal
as
our
health
care
right.
I
think
that
is
a
totally
legitimate
debate.
So,
but
that's
not
my
that's
not
what
I'm
here
to
do
today.
So
what
I'd
like
to
just
give
you
some
factual
information
in
response
to
that
the
the
issue
with
young
people
and
marketing?
M
M
If
you
go
down
and
let
borrow
money
at
a
bank
to
buy
a
house,
your
bank
is
going
to
require
that
you
have
homeowners
and
insurance
if
you
are
not
on
Medicare
today,
but
your
parents
are
they're
mandated
to
contribute
to
Medicare.
All
of
those
reasons
are,
for
social
purposes,
right
it's
to
create
a
funding
mechanism.
If
you
don't
pay
health
insurance,
you're
going
to
get
sick,
someday,
I
promise
you
we,
none
of
us
are
free
from
that.
M
You're
gonna
walk
into
an
emergency
room
and
if
you
cannot
pay
the
bill
who's
paying
for
it,
the
taxpayers
paying
for
it
or
I
am
paying
it
for
it
through
higher
premiums.
Is
that
fair
I?
Don't
think
that's
fair
right,
so
we
all
have
to
acknowledge.
We
have
a
personal
responsibility
to
pay
for
the
care
we
receive
now.
M
The
debate
becomes,
how
do
we
do
that
right
and
I'm
again,
I'm
not
here,
to
debate
those
issues,
but
I
really
encourage
you
estate
leadership's
to
take
to
the
legislators
to
take
the
lead
on
this.
We
recognize
that
this
is
not
a
political
conversation.
This
is
a
social
responsibility
and
personal
responsibility
conversation
and
we
need
to
figure
it
out.
O
My
question
is
that
there
was
a
taken
away
of
what
was
called
a
risk
corridor
to
help
insurance
companies
during
the
early
phases
of
the
Affordable
Care
Act
to
stabilize,
because,
as
we
went
to
guaranteed
health
insurance,
the
insurance
companies
could
not
necessarily,
oh
this,
is
least
on
the
individual
side
manage
all
of
the
claims
that
they
were
getting.
This
is
what
the
term
adverse
selection
is
and
as
much
as
I,
like
my
friend
from
Blue
Cross,
we
have
in
Florida,
49
out
of
67
counties
only
have
Blue
Cross
and
certainly
having
more
competition.
O
It
is
what
we're
trying
to
do
using
the
marketplace
as
it
is
so.
My
question
is
I
mean,
of
course
you
can
answer
for
me,
but
you
know
creating
a
stability
fund
that
states
can
use
to
reduce
premiums.
Do
you
have
a
comment
on
that?
Changing
the
definition
of
full-time
hours
to
40
that
there's,
certainly
clear
guidelines
on
the
1332
waivers
and
I
mean
I've
got
a
few
things
here,
but
you
know
also
maybe
getting
rid
of
the
Cadillac
tax
and
also
will
be
a
full
repeal
on
the
health
insurance
tax.
K
I'll
start
I
think
that
what
what
we
are
seeing,
some
of
some
of
the
key
issues
that
you
talked
about
are
things
that
really
are
going
to
require
congressional
action,
and
one
of
the
first
points
talking
about
a
stability
fund,
making
that
available
to
States
was
something
that
was
part
of
the
repeal
or
in
place
discussion,
and
if
we
see
in
September
a
move
and
a
push
to
bipartisan
conversations
to
stabilize
the
market,
I
think
those
ideas
will
be
a
key
part.
They
certainly
are.
K
They
were
part
of
the
original
Affordable
Care
Act,
built
on
the
Part
D
model,
very
effective
reinsurance
risk
corridors.
I.
Think
of
these
is
similar.
They
are
not
the
same
and
they
have
different
effects.
People
are
more
attractive,
I
think
to
reinsurance,
because
it
it's
more
likely
to
effect
premiums,
but
these
are
all
ways
to
help
increase
and
stabilize
the
market
and
need
to
be
very
seriously
considered
and
are
probably
very
necessary
moving
forward.
There
are
a
number
of
ideas
that
I
think
are
critical
and
hopefully,
Congress
will
be
amenable
to
supporting
some
of
these.
B
L
So,
anyway,
we're
talking
about
a
shell
game
here,
because
although
people
like
to
say
that
what
we
need
is
young,
healthy
people
to
enroll
what
we're
really
saying
and
Kim
more
or
less
said
this
is
that
we
really
want
everybody
to
pay.
I
mean
the
the
ideal
situation
for
an
insurance
company
is
to
have
people
pay
and
not
new
services
right.
So
so
we're
really
really
talking
about
a
financial
game.
You
don't
I'm,
not
arguing
that
you
that
you
don't
need
compulsion.
It's
having
been
a
young
male
myself.
I
wouldn't
have
bought
insurance.
L
It
wasn't
my
cell
phone
I,
probably
at
my
bar
bill-
was
probably
more
important
to
me,
but
but
the
idea
of
social
responsibility
really
starts
at
the
home.
It
doesn't
start
with
the
federal
government,
it
sure
doesn't
start
with
the
state
government.
Really
people
have
to
get
over
this
idea
at
that.
We
still
have
that
unless
you
do
something
you're
uninsured,
we
have
to
get
the
idea
that
unless
you
do
something
you
are
insured
so
there
are.
There
are
conservative
ideas
that
involve
something
called
automatic
enrollment
there.
There
are
lots
of
ideas
like
that.
L
One
aspect
of
the
3
R's,
though,
that
you
want
to
be
careful
about
a
number
of
the
more
profitable
plans
in
the
first
few
years
of
the
ACA
I
ended
up
losing
money
because
they
had
a
shift
tremendous
amounts
of
money,
basically
all
of
their
profits
to
the
companies
that
didn't
do
well.
They
tended
to
be
the
companies
that
were
the
big
name
companies
so
say
you
want
to
be
careful
about
how
you
set
this
up.
That
was
one
of
the
problems
with
the
ACA
originally
a
lot
of
these
things,
sunsetted.
M
Are
just
briefly
on
the
the
3
R's
just
so
you
know
where
the
risk
adjustment
programs
that
the
ACA
adopted
during
primarily
to
ease
the
transition
recognizing
that
we
were
going
to
a
mark
from
a
market
where
people
where
insurance
companies
could
deny
coverage
right.
They
could
underwrite
and
decide
they're
going
to
cover
somebody
they
could
limit
and
we're
talking
only
the
individual
market
here
right
to
a
guarantee
issue,
no
pre-existing
condition.
So
what
what
was
recognized
is
that
transition
was
going
to
be
really
costly
and
people
were
gonna
go
to
the
market.
M
They
were
gonna
pick
a
pant
plan.
Remember
those
actuaries!
There
was
no
way
they
could
really
determine
how
many
people
they
were
going
to
get
and
what
the
risk
was.
That's
what
risk
adjustment
was
intended
to
do
and
it
shared
money
from
insurance
company
to
insurance
company.
The
risk
quarter
program
was
insurance
company
to
insurance
company
with
a
backstop
of
the
federal
government.
M
Recognizing
what
Joe
said
that
you
know
it
could
be
the
first
year
there's
going
to
be
more
people
losing
money
than
then
making
money,
and
that
means
that
there
wasn't
going
to
be
enough
money
in
that
in
that
pool
the
reinsurance
program
to
take
to
take
into
consideration
that
there
gonna
be
people
that
have
not
been
able
to
get
coverage.
We're
not
eligible
for
other
plans
that
we're
gonna
go
into
the
market
and
probably
had
really
high
pent
up
claims.
People
with
cancer
I
mean
I,
know.
M
Within
our
system
we
had
a
number
of
people
awaiting
transplants
that
you
know
come
January.
They
were
covered
right,
so
large
claims,
that's
what
that
was
supposed
to
mitigate
and
then
finally
risk
adjustment.
Those
two
programs
went
away
right,
then
risk
adjustment
stayed
there,
and
that
means
we
don't
know
what
risk
we're.
Gonna
get
we're
pricing
our
products.
It's
going
out
on
the
exchange,
all
the
prices
come
out.
M
At
the
same
time,
people
pick
their
coverage,
we
don't
know
if
we're
gonna
get
all
the
sick
people
or
the
wealth
people
or
what
and
so
that
risk
adjustment
gives
money
back
and
forth
to
insurance
companies.
So
all
of
those
things
none
of
them
were
bailouts
right.
None
of
that
it
was
all
howdy.
How
do
we
share
the
costs
around
the
entire
system?
M
Recognizing
there
are
different
players
in
there
and
the
in
the
programs
for
a
variety
of
different
reason,
whether
it's
kynect
congressional
action
or
inaction
or
whatever,
as
joe
said
in
some
cases,
it's
just
like.
Okay,
in
hindsight,
we
might
have
tweaked
this
or
done
something
differently
may
have
created
some
challenges
for
the
industry.
Today
we.
C
So,
just
like,
in
NCSL
fashion,
we're
gonna
switch
topics
and
switch
switch
speakers
really
quickly
to
accommodate
our
legislators.
Adhd.
We
have
to
switch
topics
every
30
minutes
or
we
we
have
a
tendency
to
lose
attendance,
so
we're
in
order
to
keep
the
room
full
we're
gonna
switch
topics,
one
more
time.
C
P
P
I've
spent
about
40
plus
years
now
for
40
plus
years
insurance
law
and
I
would
say
that
I've
come
to
think
of
the
individual
market.
As
a
true
hothouse
flower
I
mean
something
that
needs
a
lot
of
tending,
as
you
could
tell
from
the
previous
panel
to
make
work.
Medicaid
is
a
very
interesting
program.
It
is
what
I
would
think
of
as
a
hardy
perennial.
It
is
a
program
that
is
built
to
embrace
risk.
What
I
mean
by
that
is
not
its
size,
scope,
complexity,
but
it's
a
program
that
is
designed
to
embrace
risk.
P
It
is
truly
a
public
health
program.
It
functions
like
insurance,
but
it
is
a
workhorse
of
the
first
order
for
every
state.
There
is,
of
course,
no
single
Medicaid
program,
but
a
cluster
of
51
state,
Medicaid
programs,
and
then
many
territorial
programs
and
even
within
a
state.
Of
course,
the
Medicaid
program
is
different
from
between
urban
and
rural
areas,
from
County
to
County
program
can
look
very
different.
It
is
carrying
such
a
burden
today,
I'm
sure
you're,
all
familiar
with
the
statistics.
It's
50
percent
of
all
births.
P
It's
40
percent,
along
with
chip
of
all
children.
It's
the
way
we
support
neonatal
intensive
care
units.
It's
the
way.
We
support
our
children's
hospitals,
it's
the
entire
long-term
care
system
of
the
United
States.
At
this
point.
From
a
practical
perspective,
it
is
the
way
in
which
we
have
made
it
possible
for
disabled
children
and
adults
to
live
in
the
community,
and
it's
huge
it's
about
75
million
people
if
I
had
to
identify
what
I
think
are
the
big
issues
facing
States
today.
P
They
would
be
as
follows
that
the
first
one
has
to
do
with.
In
fact,
one
of
the
observations
made
by
one
of
the
representatives
during
the
questions
for
secretary
Norton,
and
that
is
that
this
is
a
program
that,
despite
its
size,
runs
very
close
to
the
bone.
It
is
a
program
whose
size
is
predominantly
explained
by
its
enrollment
and,
of
course,
Medicaid
enrollment
is,
if
you
stop
and
think
about
it,
it's
simply
a
reflection
of
so
many
things
in
our
society.
It's
a
reflection
of
childhood
poverty.
It's
a
reflection
of
adult
poverty.
P
It's
a
reflection
of
an
aging
society.
It's
a
reflection
of
the
remarkable
strides
we
have
made
in
enabling
people
with
very,
very
serious
health
conditions
to
live
in
communities
and
to
live
a
long
and
productive
life.
That's
why
Medicaid
is
big.
So
the
question
is:
how
do
you
manage
such
a
big
program?
A
second
big
function
of
Medicaid,
which
I
think
is
something
that
was
poorly
understood
and
has
really
come
to
the
forefront
in
the
affordable
care
act
is
it's.
It
is
a
shock
absorber
for
the
private
insurance
system.
P
Our
payers
of
claims.
They
do
that,
of
course,
just
like
any
insurer
would,
but
they
are
really
the
linchpin
in
creating
delivery
systems
that
work
for
low-income
and
medically
vulnerable
populations.
There
is
no
insurer
that
I'm
aware
of
whose
responsibility
for
tackling
payment
and
delivery
reform
even
comes
close
to
Medicaid.
I
am
I
started.
My
first
managed
care
studies
of
Medicaid
programs
back
about
30
some
odd
years
ago.
P
I'm
just
completing
one
now
for
the
Commonwealth,
Fund
and
I
am
continually
blown
away
by
the
degree
to
which
Medicaid
agencies
really
are
just
core
to
delivery
of
care
itself
and
I.
Think
and
we'll
get
into
this
during
the
Q&A-
that
the
biggest
challenge
for
states
now
is
finding
a
very
practical
work
partner
in
the
federal
government.
I,
don't
care
who
who's
in
charge
a
federal
policy?
But
the
issue
is
finding
a
partner.
That's
willing
to
make
help
states
make
the
kinds
of
pragmatic
decisions
they
they
need
to
make
to
achieve
delivery
of
care.
Q
Thank
you
very
much.
Good
morning,
everybody
I'm
Barbara
Anthony
I'm,
a
healthcare
policy
consultant
with
the
Pioneer
Institute.
Some
of
you
who
said
to
me
what's
pioneer
pioneers
a
boston-based
think-tank
that
promotes
market-based
solutions
to
public
policy
issues,
whether
it's
transportation,
education,
health
care
or
whatever
the
issue
might
be,
and
before
joining
pioneer
I
was
the
Undersecretary
of
consumer
affairs
and
Business
Regulation
for
the
Patrick
administration
here
in
Massachusetts
a
great
deal
to
do
with
insurance,
particularly
health
insurance.
So
it's
a
pleasure
to
be
here.
Q
Thank
you
and
CSL
for
inviting
me
maybe
give
my
charge
as
I
understand.
It
now
is
to
give
you
all
some
information
about
what
Massachusetts
is
doing
in
the
Medicaid
sphere
to
try
to
reduce
cost,
what
we're
what
has
been
done
what's
ongoing
and
what
is
proposed
and
I'm
also
going
to
talk
a
bit
about
the
commercial
market.
You've
heard
senator
Moore
and
I
know
you.
Some
of
you
heard
David
salts
the
executive
director
of
the
health
policy.
Commission
who's
here
talked
about
the
health
policy
Commission
in
the
state
benchmarks.
Q
I
hope
I
want
to
get
to
that
as
well.
So
I
am
my
rule.
Today
is
I'm
a
messenger
all
right,
so
I'm
just
I'm
delivering
messages
when
I
do
express
an
opinion.
It
will
be.
My
own
I
will
stand
with
by
it.
So,
first
of
all,
let
me
begin
by
saying
that
Massachusetts
is
a
state
as
a
Commonwealth,
regardless
of
who
sits
in
the
corner
office,
is
a
state
of
it
that
is
committed
to
new
universal
health
coverage
and
health
access
for
all
of
its
citizens.
Q
So
what
have
we
done
to
get
to
that
place
back
in
2006?
As
most
of
you
know,
Massachusetts
passed
its
own
version
of
health
reform,
which
is
popularly
known
as
Romney
care,
and
that
then
served
as
a
blueprint
to
the
Affordable
Care
Act.
We
then
participated
in
2010
and
the
Medicaid
expansion
that
was
afforded
under
the
Affordable
Care
Act.
Now,
since
2007
Massachusetts,
like
many
states,
has
seen
a
dramatic
increase
in
enrollment
in
its
Medicaid
population.
Here
we
call
Medicaid.
Q
Medicaid
is
the
primary
insurer
for
about
one
in
four
people
in
our
population,
and
it
consumes
about
forty
percent
of
the
state
budget
at
about
fifteen
point
six
billion
dollars.
So
what
is
the
state
trying
to
do
about
this
about
trying
to
contain
the
cost
of
Medicaid,
which
some
folks
believe
is
reaching
unsustainable
proportions?
Let
me
say
the
onset
that
public
officials
here
from
what
I've
heard
and
I
haven't
heard
anything
to
the
contrary.
No
one
is
talking
about
walking
back
our
commitment
to
near
universal
coverage.
Q
So
you
can
see
that
there's
a
great
challenge
here:
how
to
contain
these
costs,
but
to
continue
to
provide
the
kind
of
coverage
that
we
believe
our
citizens
are
entitled
to.
First
of
all,
governor
Baker
who's
been
in
office
now,
I
think
for
about
two
and
a
half
years
made
a
priority
of
addressing
program
integrity.
Everybody
talks
about
doing
that,
but
I
think
this
administration
has
done
a
pretty
good
job
of
ensuring
that
only
those
who
are
eligible
are
enrolled
in
Medicaid.
It's
time-consuming
suspensive
to
do
that.
It
is
it's
fair.
Q
Q
Under
this
model,
18
accountable
care
organizations
will
cover
about
900
thousand
of
the
almost
two
million
people
in
MassHealth
this.
The
this
this
is
this
program
is
made
possible
by
a
50
billion
with
a
B
dollar
waiver
that
the
state
signed
with
the
federal
government
a
few
years
ago.
The
goal
is
to
incentivize
providers
to
keep
patients
healthy,
so
they'll
need
fewer
services
and
also
cut
costs.
Q
Now,
most
recently,
the
state
legislature-
and
there
are
some
members
of
our
state
legislature
here-
senator
chair,
always
great
to
see
you
and
other
staff
of
the
Health
Committee
I-
see
have
passed
to
revenue
producing
assessments
on
the
business
community.
If
you
have
six
or
more
employees
and
those
revenue
assessments
right
now
are
targeted
to
bring
in
about
two
hundred
million
dollars
to
our
state
budget.
This
helps
to
reduce
the
the
MassHealth
expenditures.
Q
So
there's
a
new
assessment
on
employers
with
six
or
more
employees
whose
employees
do
that
both
of
the
assessments
that
the
state
legislature
passed
have
a
sunset
two
years
and
then
they're
gone
right.
I,
remember:
I
lived
in
Manhattan
after
9/11
Mike
Bloomberg
raised
property
taxes
for
three
years
in
New
York.
His
popularity
level
went
down
to
27
percent
overnight,
but
in
three
years
New
York
was
back
on
its
feet.
It
was
a
sunset
provision,
property
tax
increase
was
gone
and
the
economy
was
moving
forward.
Q
So
I
think
these
sunset
provisions
there's
something
to
say
to
them.
They
have
a
way
of
sort
of
kicking
things
forward.
Now,
governor
Baker
also
made
some
proposals
that
did
not
pass
the
legislature,
so
these
are
proposals
that
the
legislation
is
going
to
consider.
First
of
all,
shifting
a
total
of
about
320,000,
non-disabled
adults
from
MassHealth
into
commercial
plans
or
to
another
MassHealth
product.
There
are
no
premiums
involved,
but
there
will
be
co-pays
and
deductibles
and
some
changes
in
coverage.
All
of
this
is
designed
to
maximize
federal,
sovereign
subsidies.
A
federal
waiver
is
is
required.
Q
Another
thing
that
has
been
proposed
is
that
we
prevent
non-disabled
workers
from
accessing,
affordable
employer
sponsored
coverage
from
enrolling
in
in
MassHealth.
That
needs
a
waiver
as
well.
There
are
a
couple
of
other
proposals
that
I
think
are
just
worth
mentioning:
they
they
don't
deal
with
med
cade.
They
deal
with
market
reform
and
cost
containment,
particularly
on
the
commercial
side.
Q
A
moratorium
on
state
mandates
beefing
up
our
state's
price
transparency
laws,
expanding
the
scope
of
practice
for
medical
professionals
such
as
nurses,
practitioners,
podiatrists
and
establishing
a
new
class,
a
professional
dental,
therapist,
Thank
You
senator
Chandler.
One
word
about
you
heard
me
mentioned
the
health
policy
Commission
in
Chapter,
two,
two,
four
and
twenty
twelve
Massachusetts
passed
a
law
that
set
a
love
that
said
that
health
care
expenditures
in
the
state
total
expenditures,
public,
private
commercial
everything
cannot
grow
faster
than
the
state's
economy.
Q
That's
called
the
benchmark
and
it
established
the
health
policy
Commission
to
monitor
and
to
enforce
that
benchmark.
It
also
required
price
transparency
by
carriers
and
by
providers
and
a
lot
of
monitoring
by
the
health
policy
Commission
of
merges
and
affiliation.
So
I'm
happy
to
answer
questions.
Sorry
I
took
a
little
bit
longer
than
I
had
intention.
Thank
you.
Thank
you
very
much.
C
Well,
I
have
one
question
for
both
of
you
and,
and
it
basically
talks
high
level
now
elephant
in
the
room
question
here,
but
based
on
some
of
the
information
that
we
heard
from
our
good
friend
Jane,
how
do
you,
how
do
you
think
states
can
help
CMS
modify
or
modernize
the
Medicaid
program?
What
our
give
us,
maybe
one
quick
example
of
something
creative
that
states
can
do
to
help
CMS
modernize
the
Medicaid
program.
P
So
this,
of
course,
is
the
five
hundred
sixty
four
billion
dollar
question.
I
actually,
I
have
to
say
that
I
fundamentally
disagree
with
the
premise
that
Medicaid
is
not
a
modernized
program.
Medicaid
has
been
remarkable,
absolutely
remarkable
sort
of
reshaping
itself
over
fifty
years
as
the
needs
of
rose
I
mean
whether
it's
the
opioid
crisis,
we're
talking
about
or
special
ed
services
or
Zika,
or
you
name
it
I
mean
it's.
It's
Medicaid
everybody
turns
to
now
within
Medicaid.
There
are
some
huge
challenges
that
I
would
put
at
the
top
of
my
list.
P
P
One
has
to
do
with
making
alterations
that
bring
the
program
into
line
with
other
payers,
the
other
having
to
do
with
prescription,
drug
pricing
and
I
think
the
great
challenge
that
states
are
all
confronting,
and
it's
the
toughest
for
my
years
on
the
Medicaid
and
CHIP
payment,
Commission
I
would
say
this
was
the
toughest
thing
we
dealt
with
was
what
to
do
about
long
term
services
and
supports.
That
is
being
able
to
develop,
manage
long
term
service
and
support
systems.
F
Q
You
know,
as
I
said
earlier,
Massachusetts
we've
been
committed
to
near
universal
coverage
since
2006,
but
before
that
we
had
all
kinds
of
market
reforms.
No,
you
know
guaranteed-issue
no
pre-existing
conditions,
Community
Rating,
so
it's
been
a
gradual
slope
upward
for
us
in
terms
of
fulfilling
this
commitment,
but
in
terms
of
states
and
and
and
Medicaid
needs
amman.
I
think
flexibility
is
incredibly
important
here
in
Massachusetts.
We
have
definitely
through
Medicaid
waivers
taken
advantage
of
our
creativity
and
ways
in
which
to
use
Medicaid
dollars
to
stretch
them
further
and
to
maximize
federal
subsidies.
Q
I
think
the
real
challenge
here
is
that
as
a
nation,
you
know
we
have
states
that
may
have
one
set
of
goals
and
policies,
and
we
may
have
a
federal
government
with
not
necessarily
the
same
goals
and
policies
in
mountain
in
line
and
in
mind
and
there's
a
misalignment
there.
And
so
when
we
talk
about
flexibility,
we
also
quite
honestly
need
that
we
need
to
continue
the
federal
dollars
that
we
have
been
depending
upon
that
frame
and
that
Pro
help
us
provide
health
care
services
to
our
populations.
I
mean
the
bottom
line.
Is
this
there's?
Q
No
free
lunch
in
healthcare,
it
costs
money
and
if
people
aren't
don't
have
access
to
health
care,
the
thing
that
happens
is
that
they
end
up
in
somebody's
emergency
room.
We
used
to
have
that
in
Massachusetts
and
we
used
to
have
a
great
big
pool
of
money
that
was
paid
out
to
hospitals
who
had
to
care
for
people
who
are
in
emergency
rooms.
We
don't
do
that
so
much
anymore.
We
don't
want
to
go
back
in
that
direction.
So
there's
no.
Q
As
you
know,
in
that
movie,
there's
no
way
out
it's
an
old
movie
with
Kevin
Costner,
I
love
it
because
I
used
to
live
in
Dee's
in
the
river
house,
which
is
in
the
movie.
If
you,
if
you've
watched
it,
it
flies
over
in
Northern
Virginia,
it's
a
great
movie,
but
there's
no
way
out.
There's
no
free
lunch
here.
You
know
the
problem
right
now,
maybe
a
misalignment
in
terms
of
goals
and
priorities,
but
flexibility
is
key.
Thank.
C
C
B
Woodman
C
is
with
the
American
Cancer
Society
and
will
speak
not
only
from
the
standpoint
of
the
those
with
cancer
but
other
major
health
issues,
serious
health
issues
as
well
being
see,
it's
got
a
pretty
good
scope
of
what
what
the
other
high-risk
high-cost
treatments
are
and
how
they
get
impacted
by
some
of
the
discussions
with
health
reform
that
are
going
on
so
I
think
we'll
start
with
mr.
Creedy.
Thank.
R
You
I
appreciate
having
you
all
here
in
Boston,
I'm
new
to
Commonwealth
Care
Alliance
I
have
been
here
about
two
months.
So
if
I
have
to
use
some
notes
to
talk
about
the
game
plan,
we
have
there
I
apologize
in
advance,
I
also
apologize
for
being
the
last
two
people
who
are
between
you
and
your
lunch.
So
we
will
be
as
fast
as
we
can.
We
were
talking
about
going
last
on
a
panel
like
this.
R
Work
at
Commonwealth,
Care,
Alliance
I
realized
that
that
those
two
programs,
Medicare
Medicaid,
really
do
have
a
role
to
function
together.
You
know:
there's
nine
million
Americans
approximately,
who
are
dually
eligible
for
both
Medicare
and
Medicaid,
so
they
are
the
most
vulnerable
citizens
of
our
country,
20%
of
those
folks,
so
about
two
million
people
make
up
67
percent
of
the
total
cost
of
Medicare.
R
So
if
you
want
to
talk
about
innovative
solutions
to
solve
health
care
in
America,
I'd
focus
on
those
two
million
people
first,
because
they're
the
ones
who
are
spending
the
most
money
and
that's
what
Commonwealth
Care
Alliance
here
Massachusetts
does.
We
are
not-for-profit
health
plan,
but
we're
more
than
a
health
plan.
We
are
really
three
companies
and
one
we're
a
risk-taking,
managed
care
plan
based
here
in
Massachusetts
right
here
in
Boston
on
winter
Street.
We.
F
L
R
We
also
participate
in
a
program
here
in
Massachusetts
called
senior
care
options,
which
is
a
program
that
pre-existed
the
Affordable
Care
Act's
creation
of
limb
back
up
a
cycle,
one
care
was
created
as
a
dual
MMP
program:
Medicare
Medicaid
plan
out
of
the
ACA.
It
was
a
part
of
that
it
allows
states
to
combine
both
Medicare
and
Medicaid
into
one
program.
One
care
in
Massachusetts
focuses
on
people
under
65,
so
in
order
to
be
eligible
for
Medicare
under
the
age
of
65,
you
have
to
be
disabled
and
that's
who
we
care
for
here
Massachusetts.
R
Fifty
percent
of
the
people
in
one
care
for
CCA
have
four
or
more
chronic
conditions.
Seventy-Five
percent
have
a
behavioral
health
diagnosis
about
twenty
percent
are
addicted.
We
talk
about
the
opioid
crisis,
I
heard
it
over
and
over
this
morning.
That
is
that's
who
one
care
cares
for
and
that's
your
CCA.
We
will
send
case
managers
and
not
only
case
managers
but
care
providers
to
those
folks
to
bring
care
to
where
they
are.
R
It's
really
been
a
remarkable
run
for
CCA
here
in
Massachusetts
and
was
started
by
a
physician
here
who
was
caring
for
folks
who
were
severely
disabled.
It's
real
I
heard
secretary
Norton
I
gave
you
a
promotion.
Director.
Norton
talked
about
a
solution
to
a
unique
need.
Well,
CCA
is
the
solution
here
in
Massachusetts
and
the
programs
that
we
participate.
R
It
is
really
a
way
for
the
federal
government,
the
state,
government
and
providers
of
care
and
payers
of
care
and
then
finally,
the
patience
of
care
to
really
meet
the
three
goals.
That
I
think
all
of
us
are
most
important
and
I
mean
with
those
three
goals.
First,
is
to
provide
access
to
care
to
those
who
don't
necessarily
know
how
to
or
where
to
access
health
care.
I've
been
in
health
care
policy.
R
For
for
a
long
time-
and
you
know
it's
I
still
get
confused
when
you
get
a
an
explanation
of
benefits
in
the
mail-
and
it
says
this
is
not
a
bill
like
well.
If
this
is
not
a
bill,
then
what
is
it?
It
could
be.
Something
else
imagine
if
you
are
a
single
mom
or
a
disabled
person
in
who
just
found
housing
and
now
you're
getting
bills
from
from
somewhere.
That
says,
it's
not
a
bill,
but
it
says
that
you
owe
money.
R
So
that's
what
these
programs
do
is
provide
access
to
a
system
that
is
very
complicated,
very
complicated
indeed.
The
second
is
to
provide
quality
care
of
those
folks.
You
can
provide
as
much
care
as
you
want,
but
if
it's
not
working
and
if
it's
not
providing
access
to
quality
care,
then
it's
really
not
a
system
that
you
want
to
invest
in
and
then.
R
Finally,
the
third
goal
of
that
is
to
provide
savings
and
do
it
in
a
cost-efficient
manner,
so
marrying
those
two
programs,
these
two
huge
federal
and
state
programs
together,
is
my
innovative
solution
to
fixing
health
care.
They
we're
here
to
help
you
fix
health
care,
and
so
I
I
was
encouraged
by
director
Norton's
comments
about
working
with
stakeholders,
because
there
are
solutions
out
there
to
providing
access
to
quality
care
for
folks
we're
not
talking
in
Massachusetts,
especially
here
the
one
care
program,
we're
not
talking
about
Medicaid
eligible
people
who
are
able-bodied
adults.
R
These
are
severely
disabled,
mentally
ill
folks
who
need
access
to
health
care
who
costs
the
most,
and
so
this
is
an
innovative
solution.
Cci
welcome
you
to
to
Massachusetts
and
and
and
I,
encourage
that
the
conversation
in
your
states,
as
you
go
back,
can
think
about
some
of
the
things
that
we've
done
up
here.
S
Hi,
my
name
is
Dave
Woodmansee
I'm
with
the
American
Cancer
Society
Cancer,
Action
Network.
It
says
that
I'm,
a
state
director
there
I
was
in
the
90s
that
there
are
the
state
director
in
Hartford
Connecticut
our
lobbyist.
There
I
wish
I
was
as
young
as
I
was
in
the
90s,
but
I
am
now
with
our
Washington
DC
office
and
I
get
to
work
with
our
staff
and
volunteers
in
all
50
states.
S
S
That
means
you
know,
people
don't
have
an
insurance
option
in
the
marketplace
and
the
exchanges
that
is
very,
very
much
worrisome
for
from
our
perspective,
of
course,
pre-existing
conditions
are
huge
for
cancer
patients
and
others
with
serious
diseases,
so
the
exclusion
of
pre-existing
could
people
pre
X
is
not
good
for
cancer
patients
or
cancer
survivors,
to
say
the
least,
Medicaid
expansion.
You
know
one
of
the
one
it's
been
mentioned
over
and
over
how
to
reduce
costs.
One
way
to
reduce
costs
with
cancer
is
to
get
people
into
the
system,
get
them
screened.
S
Get
cancer
detected
early
when
it's
by
far
the
cheapest
to
cheat
to
treat
and
that's
all
cancers
and
that's
all
all
serious
diseases,
not
just
cancer.
That's
the
case,
for
we
also
with
traditional
Medicaid
I'll,
just
mention
one
fact
that
a
lot
of
people
aren't
aware
of,
but
in
this
country,
131
percent,
almost
one-third
of
all
children
with
cancer
are
in
the
Medicaid
program.
One-Third
of
all
kids
with
cancer
in
this
country
are
enrolled
and
Medicaid,
so
we
obviously
you
know.
Traditional
Medicaid
is
very
important
from
a
cancer
perspective,
and
you
know
we
are.
S
We
are
certainly
we're,
certainly
advocating
for
for
the
continuation
of
that
program
without
budget
without
budget
hits
that
are
a
possibility.
The
way
things
are
looking
right
now,
I'm
also
gonna
bring
up
something
else
that
may
not
be
people
may
not
love
hearing,
but
opioids
are
very
important
to
cancer
patients
and
I.
Just
plead
with
the
legislators
in
this
room.
I've
talked
to
some
of
you
at
our
booth,
and
you
seem
to
really
understand
the
importance
of
the
balance
of
policies.
S
We
understand
in
every
state
in
this
country,
there's
a
problem
with
opioids
and
that
needs
to
be
addressed,
but
all
we
ask
for
is
a
balance
of
those
policies
so
that
cancer
patients,
who
legitimately
need
these
meds
to
get
through
their
day
and
night,
with
some
decent
level
of
quality
of
life
that
they
can
still
access
them.
So
you
know
we
we've
been
advocating
for
prescription
drug
monitoring
programs
for
years
and
we
also
have
been
advocating
interoperability
states.
Border
states
need
to
be
able
to
talk
to
each
other.
S
That
is
not
necessary,
not
necessary
at
all,
but
there
are
millions
of
cancer
patients
and
cancer
survivors
who
are
not
in
active
treatment
who
need
opioids
to
get
through
their
day
a
day
or
night,
as
I
mentioned
so
I
employee,
to
continue
that
and
then
one
last
thing
I'll
mention
is
something
called
palliative
care.
Nobody
has
mentioned
that,
but
palliative
care
saves
money
period.
It's
been
proven
over
and
over
again
study
after
study,
palliative
care
saves
money
and
I
applaud
the
seven
states.
S
We
have
mono
legislation
that
we've
been
peddling
for
four
years,
we're
now
up
to
20
states
that
have
passed
it.
Seven
states
passed
it
this
year.
This
is
truly
a
bipartisan
issue.
The
states
have
passed
it
Nevada
Nebraska
Montana,
Arkansas
Tennessee
Minnesota,
so
it's
truly
a
bipartisan
issue
and
it
saves
money
again.
If
we're
looking
for
cost
savings,
it's
not
gonna
solve
all
the
problems,
but
it
certainly
it
certainly
does.
You
know,
add
to
the
savings
so
I
think
with
that
I
will
kick
it
back
to
Senator
Moore,
and
hopefully
we
have
some
questions.
S
B
Let's
start
with
see,
if
anyone
has
some
questions
not
only
or
two
speakers
up
here,
but
Barbara
Anthony's
hung
in
there,
she
can
answer
any
question
and
Chiquita
Brooks
Lesure
still
with
us.
So
if
you
have
questions
that
kind
of
you've
just
awakened
and
want
to
go
back
and
ask
that
question
of
that
speaker,
we
have
a
couple
of
folks
who
can
do
that.
The
simple
when
the
way
in
the
back
get
a
microphone
to
her
in
the
that
kind
of
a
reddish
orange.
S
There
are
various
reasons
you
know.
Sometimes
expense
is
one
of
the
reasons,
but
there
are
a
variety
of
reasons.
It's
just
that's
just
a
statistic
that
you
know
has
been.
That
has
been
shown
to
be
truth,
and
so
we
just
want
people
to
understand
that
Medicaid
from
a
kid
there's
certain
reasons
why
we
have
interest
in
the
Medicaid
program
from
a
cancer
perspective.
That
is
certainly
one
of
them.
You
know
pediatric
cancer
and
the
fact
that
31%
of
children
with
pediatric
cancer
in
this
country
are
enrolled
in
the
Medicaid
program.
T
J
R
I
said
representative:
there
are
two
programs
here
in
Massachusetts
that
cover
duals
one
primarily
or
one
exclusively
for
duals,
who
are
over
65,
which
is
a
program
that
has
existed
in
Massachusetts
for
quite
some
time
called
senior
care
options.
They
are
covered
either
in
the
fee-for-service
Medicare
program
at
their
choice
or
part
of
this
managed
care
program.
There
are
six
plans.
R
R
It
that's
a
really
good
question.
I
one
care
has
been
around
since
20
mi
stake,
I
heard
it's
been
around
since
2015
I,
don't
know
if
we
know
what
happens
to
the
folks
who
turned
65,
who
were
part
of
one
care
yet
because
we
haven't
had
enough
history
yet
to
know
what
will
happen
to
that
program
that
it's
part
of
the
ACA
z'
office
of
duals,
that's
part
of
HHS
and
CMS,
so
those
programs
will
expire
actually
in
2020.
T
Good
morning
my
name
is
Ralph
Palladino
I'm
from
New
York
City
I'm,
a
member
of
a
sweet
dc37
I
worked
at
Bellevue
Hospital
and
I'm,
a
patient
at
Bellevue
Hospital
as
well
since
1979.
The
thing
about
insurance
is
insurance
to
me
is
not
really.
Access
access
is
really
having
the
facilities,
the
primary
care,
doctors,
the
nurses
and
the
staffing
that
you
need
to
be
able
to
treat
and
take
care
of
patients,
and
they
need
to
be
in
communities
where
patients
live
to
me.
That
is
access.
We
talk
to
so
much
about
insurance
and
cost.
T
That's
fine,
but
the
thing
is
what
about
the
issue
of
access
in
that
respect?
I
have
to
wait
four
and
five
months
to
get
a
primary
care
appointment
for
a
routine
annual
visit,
four
or
five
months
specialty
clinics.
Sometimes
I
have
to
wait
two
or
three,
and
even
four
months
and
some
of
them,
which
is
not
right.
Getting
access
in
the
phones
and
just
try
to
get
through
to
make
appointments.
Bed.
T
Okay,
the
public
health
system
in
New
York
treats
the
patients
like
what
was
brought
up
before
thick,
miss
Holland,
said
about
Medicaid
and
its
relationship
to
private
insurance.
We
treat
the
patients
that
the
private
hospitals
are
not
treating
in
will
not
treat.
So
what
about
the
issue
of
public
health?
What
about
the
issue
of
expansion,
expanding
access
in
terms
of
doctors
places
to
go,
and
things
like
that?
T
B
B
Q
A
shot
at
a
lot
of
great
questions:
I'll,
just
I'm,
just
gonna-
try
to
address
the
access
issue
and
wait
times
and
things
of
that
nature,
which
I
think
you
know
vary
by
state
to
state
in
Boston.
There's
an
incredible
wait
times
to
see
a
new
physician,
even
though
I
think
we
may
have
more
doctors
per
head
than
than
lawyers
per
head,
which
is
just
an
amazing
thing
to
have
in
one
state
but
but
to
thing
it.
Q
One
of
the
things
that
we
can
do
is
what
I
mentioned
earlier
is
that
there
is
legislation
pending
here
in
the
state.
Now
that
would
expand
the
role
of
what
I'll
call
medical
paraprofessionals,
such
as
nurse
practitioners,
expanding
their
levels
of
responsibility
and
in
their
areas
of
expertise,
expanding
the
roles
of
creating
a
new
dental
dental
care,
incredibly
important,
not
cover
insurance
and
dental
care,
is
a
terrible
situation.
As
we
all
know,
stablishing
a
new
type
of
dental
professional
called
a
dental
therapist
somewhere.
Q
You
know
between
hygienist
and
a
hygienist
and
a
dentist
who
can
perform
more
things
than
a
hygienist
get
podiatrist.
Optometrists
I
mean
you
name
it.
We
are
every
time
we
try
to
expand.
We
of
course,
have
to
deal
with
entrenched
interests
and
I
don't
mean
that
in
a
derogatory
way,
but
the
usual.
You
know
medical
care
society
groups
everyone's
trying
to
protect
their
own
turf.
The
result
is
that
we
we
really
do
deny
access
to
a
lot
of
people.
Q
U
S
There
are
various
programs
and
that
that
some
of
the
manufacturers
have,
but
you
know
there
is
certainly
an
issue
as
these
drugs
get
better
and
better
and
more
targeted
and
and
and
they're
more
successful.
Treating
diseases
than
the
former
class
of
drugs
are
they're,
inherently
more
expensive,
and
you
know
we
say
that
if
people
can't
afford
their
drugs,
you
know
it's
not
doing.
The
patient
is
not
doing
the
patient
any
good
if
they
can't
afford
their
drugs.
So
you
know
we
certainly
advocate
for
people.
S
You
know
for
programs
that
allow
people
to
be
able
to
get
these
drugs,
but
it's
not
a
perfect
world,
and
sometimes
you
know
people
have
people
struggle
to
get
the
drugs
that
they
need
and
I
mean
it's
a
it's.
It's
a
national
problem.
It's
just
it's
a
problem
in
every
state
and
you
know
there
are
folks
out
there
with
some
creative
solutions
that
have
been
talked
about
in
various
states.