[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
EXAMINING THE EXTENSION OF SAFETY NET HEALTH PROGRAMS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
JUNE 23, 2017
__________
Serial No. 115-41
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
28-525 WASHINGTON : 2018
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].
COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi DORIS O. MATSUI, California
LEONARD LANCE, New Jersey KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky JOHN P. SARBANES, Maryland
PETE OLSON, Texas JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia PETER WELCH, Vermont
ADAM KINZINGER, Illinois BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
GUS M. BILIRAKIS, Florida YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio DAVID LOEBSACK, Iowa
BILLY LONG, Missouri KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana JOSEPH P. KENNEDY, III,
BILL FLORES, Texas Massachusetts
SUSAN W. BROOKS, Indiana TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma RAUL RUIZ, California
RICHARD HUDSON, North Carolina SCOTT H. PETERS, California
CHRIS COLLINS, New York DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
TIM MURPHY, Pennsylvania DORIS O. MATSUI, California
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
----------
Page
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 6
Prepared statement........................................... 7
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 8
Witnesses
Michael Holmes, Chief Executive Officer, Cook Area Health
Services....................................................... 11
Prepared statement........................................... 13
Answers to submitted questions............................... 111
Jami Snyder, Associate Commissioner for Medicaid/SCHIP Services,
State of Texas, Health and Human Services Commission........... 17
Prepared statement........................................... 19
Answers to submitted questions............................... 126
Cindy Mann, Partner, Manatt Health............................... 24
Prepared statement........................................... 26
Submitted Material
Statement of the Children's Community Association, submitted by
Mr. Green......................................................
Statement of the North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition.................... 71
Statement of Children's Health Groups, submitted by Mr. Lujan....
Statement of the American Academy of Dermatology Association,
submitted by Mr. Burgess....................................... 74
Statement of America's Essential Hospitals, submitted by Mr.
Burgess........................................................ 76
Statement of American Academy of Family Physicians, submitted by
Mr. Burgess.................................................... 78
Statement of America's Health Insurance Plans, submitted by Mr.
Burgess........................................................ 83
Statement of the Healthcare Leadership Council, submitted by Mr.
Burgess........................................................ 88
Statement of support from Minnesota House Members, submitted by
Mr. Burgess.................................................... 90
Statement of support from 1,200 local state and national
organizations, submitted by Mr. Burgess........................ 92
EXAMINING THE EXTENSION OF SAFETY NET HEALTH PROGRAMS
----------
FRIDAY, JUNE 23, 2017
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:23 a.m., in
room 2123, Rayburn House Office Building, Hon. Michael Burgess,
M.D. (chairman of the subcommittee) presiding.
Present: Representatives Burgess, Guthrie, Barton, Upton,
Shimkus, Murphy, Lance, Griffith, Bilirakis, Mullin, Hudson,
Collins, Carter, Walden (ex officio), Green, Engel, Schakowsky,
Butterfield, Matsui, Castor, Sarbanes, Lujan, Schrader,
Kennedy, Cardenas, Eshoo, DeGette, and Pallone (ex officio).
Also Present: Representatives Costello, Dingell, and Ruiz
Staff Present: Zachary Dareshori, Staff Assistant; Jordan
Davis, Director of Policy and External Affairs; Paul Edattel,
Chief Counsel, Health; Adam Fromm, Director of Outreach and
Coalitions; Caleb Graff, Professional Staff Member, Health; Jay
Gulshen, Legislative Clerk, Health; Peter Kielty, Deputy
General Counsel; Alex Miller, Video Production Aide and Press
Assistant; Mark Ratner, Policy Coordinator; Kristen Shatynski,
Professional Staff Member, Health; Jennifer Sherman, Press
Secretary; Josh Trent, Deputy Chief Counsel, Health; Jacquelyn
Bolen, Minority Professional Staff Member; Jeff Carroll,
Minority Staff Director; Waverly Gordon, Minority Health
Counsel; Jerry Leverich, Minority Counsel; Rachel Pryor,
Minority Health Policy Advisor; Tim Robinson, Minority Chief
Counsel; Samantha Satchell, Minority Policy Analyst; Andrew
Souvall, Minority Director of Communications, Outreach and
Member Services; and C.J. Young, Minority Press Secretary.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. The Subcommittee on Health will now come to
order. The chair wishes to observe that today's hearing was
originally scheduled to occur last Wednesday morning. But on
that Wednesday morning, the Capitol Hill family and the entire
country was shocked and horrified to learn about an awful
attack that took place against our own. This past week has been
sobering and difficult for all of us in many different ways, a
number of friends, indeed. A member of this very committee is
still in the hospital. They continue to need our prayers and
best wishes as they fight to heal, to recover, and, in coming
days, join us again. Last week's awful tragedy reminds us that
what unites is more important than what divides us. We are not
first Democrats or Republicans, we are Americans. We love our
country, and we respect our colleagues. We are saddened, but we
are strong. We are troubled, but we will unite around our
common duty and our common service to our fellow countrymen
that spirit of unity.
Pause for just a brief moment of quiet reflection for
those, especially the member of the committee who is not able
to be here today. But, of course, we still have other people
who are recovering from their injuries.
The chair will recognize himself 5 minutes for an opening
statement.
In 2015, this committee passed the Medicare Access and CHIP
Reauthorization Act--you are welcome--which extended funding
for many of the Nation's safety net programs, including the
community health center funding and the State Children's Health
Insurance Program. With funding for both the community health
center fund and the SCHIP program set to expire yet again at
the end of this fiscal year, our committee has the
responsibility of taking a critical look at how these programs
operate, and setting out a long-term path to funding, and,
perhaps, reauthorization.
The Community Health Center Fund plays an important role in
supplementing the services that federally qualified health
centers are able to deliver to underserved communities by
providing care to all Americans regardless of income,
regardless of ability to pay. Additionally, the Community
Health Center Fund provides resources for the National Health
Service Corps which actually provides scholarships and loan
repayment opportunities to new doctors willing to serve in
medically underserved areas. This program has proven effective
at placing providers, providers who are young and energetic and
willing to work hard in some of the most medically unserved and
challenging areas.
The State Children's Health Insurance Program provides
healthcare coverage to over 8 million children across the
Nation through flexibility capped allotments to states. The
program has been able to successfully support children while
providing states with opportunities to tailor their respective
programs as to best meet the needs of their populations.
However, the programs are not without challenges. In regards to
the Community Health Center Fund, we are interested in seeing
how federally qualified health centers can best maximize this
investment. Succeeding in underserved areas can be difficult,
and I look forward to learning more as to how the federally
qualified health center can continue to deliver results and
where improvements might be made.
As for the State Children's Health Insurance Program, there
are multiple points for consideration. As is the case with
other Federal insurance programs, there are considerable
concerns regarding the long-term sustainability of the program.
Following the passage of the Affordable Care Act, the program's
Federal match rate rose an unprecedented 23 percent, providing
some states with as much as a 100 percent Federal match. This
increase in funding has challenged the program by both shifting
the nature of shared responsibility of the State Children's
Health Insurance Program to the Federal Government and making
states more dependent on Federal dollars.
The issue is further complicated by concerns raised by the
Congressional Budget Office on the efficacy of the enhanced
match rate. According for the Congressional Budget Office, an
elimination of the enhanced match rate would basically not
impact coverage rates for children in the country, while a
continuation of the enhanced funding would add another $7 1A\1/
2\ billion to the deficit over the next 5 years if no other
policies were undertaken to offset its cost.
So today's hearing should focus on how to best proceed with
the Affordable Care Act's increased funding for the State
Children's Health Insurance Program, the increased funding
rate, and what a continuation of this funding would mean for
taxpayers, and what it would mean for covered children.
With these challenges before us, I would like to welcome
our witnesses and thank them again for joining us today, thank
them for their forbearance as the hearing got rescheduled
twice.
On the CHIP front, we have Ms. Jami Snyder who serves as
the Associate Commissioner for Medicaid and CHIP in my home
State of Texas, and Ms. Cindy Mann who served the
administration as the administrator and director of the Center
for Medicaid and CHIP services at the Center for Medicare and
Medicare Services from 2009 to 2014. I am interested in hearing
today how each of your experiences on both sides of this
partnership has worked, and where you believe we can improve
the ability of states to meet the needs of children in the
program.
And finally, Mr. Michael Holmes serves as the CEO of Cook
Area Health Services, which I believe is in Minnesota. And as
the treasurer for the National Association of Community Health
Centers, Mr. Holmes, I look forward to your testimony today on
the role that the Community Health Center Fund has played in
supporting your work. There is much to discuss today. I look
forward to our conversation. Both the Community Health Center
Fund and the State Children's Health Insurance Program provide
State and local opportunities to improve access to care in the
United States.
I yield back the balance of my time, and recognize the
ranking member of the subcommittee, Mr. Green of Texas, 5
minutes for an opening statement, please.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
The Subcommittee will come to order.
The Chairman will recognize himself for an opening
statement.
In 2015, this Committee passed the Medicare Access and CHIP
Reauthorization Act, which extended funding for many of the
nation's safety net programs, including the Community Health
Center Fund and the State Children's Health Insurance Program
(SCHIP). With funding for both the Community Health Center Fund
and the SCHIP program set to expire yet again at the end of the
fiscal year, our Committee has the responsibility of taking a
critical look at how these programs operate and setting out a
long-term path to reauthorization.
The Community Health Center Fund plays an important role in
supplementing the services that Federally Qualified Health
Centers (FQHCs) are able to deliver to underserved communities
by providing care to all Americans, regardless of income or
ability to pay. Additionally, the Community Health Center Fund
provides resources for the National Health Service Corps, which
provides scholarships and loan repayment opportunities to new
doctors willing to serve in medically underserved areas. This
program has proven incredibly effective at placing providers,
often those who are young, energetic and willing to work hard,
in the most medically underserved areas.
The SCHIP program provides health care coverage to over 8
million children across the nation. Through flexible capped
allotments to the States, the program has been able to
successfully support children while providing States with
opportunities to tailor their respective programs as to best
meet the needs of their respective populations.
However, these programs are not without challenges. In
regards to the Community Health Center Fund, we are interested
in seeing how FQHCs can best maximize this investment.
Succeeding in underserved areas can be difficult, and so I look
forward to learning more as to how FQHCs can continue to
deliver results and where improvements to the program can be
made.
As for the State Children's Health Insurance Program, there
are multiple points for consideration. As is the case with
other federal insurance programs, there are considerable
concerns regarding the long- term sustainability of the
program. Following the passage of the Affordable Care Act, the
program's federal match rate rose an unprecedented 23%,
providing some states with as much as a 100% federal match.
This increase in funding has challenged the program by both
shifting the nature of the shared responsibility of SCHIP to
the federal government, and by making states more dependent on
federal dollars.
This issue is only further complicated by concerns raised
by the Congressional Budget Office (CBO) on the efficacy of the
enhanced match rate. According to the CBO, an elimination of
the enhanced match rate would basically not impact coverage
rates for children in the country, while a continuation of the
enhanced funding would add an additional $7.2 billion to the
deficit over the next five years if no other policies were
adopted to offset its cost. Therefore, today's hearing should
focus on how best to proceed with ACA's increased SCHIP funding
rate and what a continuation of this funding would mean for
taxpayers and for covered children.
With these challenges before us, I would like to welcome
our witnesses and thank them for joining us today as we unpack
these important issues:
On the CHIP front, we have Ms. Jami Snyder who serves as
the Associate Commissioner for Medicaid and CHIP in my home
state of Texas and Ms. Cindy Mann, who served as the
Administrator and Director of the Center for Medicaid and CHIP
Services at the Centers for Medicare and Medicaid Services
(CMS) from 2009 to 2014. I am interested in hearing today how
each of your experiences on either side of this has partnership
worked, and where you believe that we can improve the ability
of States to meet the needs of children covered under the
program.
And finally, Mr. Michael Holmes serves as the CEO of Cook
Area Health Services and as the Treasurer for the National
Association of Community Health Centers. Mr. Holmes, I look
forward to your testimony today on the role that the Community
Health Center Fund has played in supporting your work.
There is much to discuss today, and I look forward to our
conversation on these programs. Both the Community Health
Center Fund and the State Children's Health Insurance Program
provide state and local opportunities to improve access to care
in the United States.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman. And, again, we
appreciate the loss we had, the injuries you had, and
particularly to our committee member, last week. But I am glad
he is progressing very well. The Children's Health Insurance
Program, CHIP, and Federally Qualified Health Centers, FQHCs,
are critical components of our healthcare safety net. Funding
for both expires at the end of this fiscal year, and timely
reauthorization is utterly critical. That said, we cannot talk
about either without talking about Medicaid, and, literally,
the elephant in the room. The American Health Center Act, or
TrumpCare, guts Medicaid, makes structural changes that would
inevitably lead to the rationing of care after seeing the House
Republican's bill to kick off 14 million enrollees on Medicaid,
cut 834 billion from programs, the Senate plan to kick even
more kids off of Medicaid over time, and make even steeper cuts
somehow managing to be more mean than even the House bill.
In 3 years, the Senate bill will start the process of
kicking millions off their Medicaid coverage. And then as if
that wasn't enough, starting in 2025, the plan leads to even
more Medicaid cuts that every year becomes deeper cuts than the
year before. CHIP is designed to sit on top of a strong
Medicaid program, and reauthorizing it while simultaneously
destroying Medicaid is simply unacceptable.
TrumpCare jeopardizes coverage for millions of kids with
Medicaid and CHIP, and the Trump budget doubles down on cuts
that directly hurt kids. To make matters worse, the Trump
administration's budget proposals, an additional $610 billion
cuts to Medicaid, eliminates enhanced CHIP matching for states,
rolls back the requirement on states to maintain current kids'
eligibility in CHIP, and cuts support for CHIP kids over 250
percent of the Federal poverty level.
More than \1/3\ of all children in the U.S. and almost half
the kids under age 6 are covered by Medicaid or CHIP. The vast
majority of these children, more than 90 percent, are covered
by Medicaid.
I strongly support CHIP and will continue to urge my
colleagues to fully extend the program for 5 years. And I have
long championed community health centers and want to see the
health center fund extended for the same amount of time.
Without an extension of funding, the health center program will
be decimated. Given all the uncertainly my colleagues are
introducing in the health insurance programs, a clean extension
of these two pillars of the healthcare safety net is of utmost
importance. But again, extending these programs without
destroying Medicaid is unacceptable. CHIP stands on the
shoulders of a strong Medicaid program. And in fiscal year
2016, Medicaid provided more than 40 percent of the community
health center's funding. They are tied together as three legs
on a stool that helps children get healthcare they need. No
child should be left off worse because of Congress's actions.
With that, Ms. Chairman, I would like to yield 1 minute to
my colleague from Massachusetts, Joe Kennedy. And after
Congressman Kennedy, I yield the remainder of my time to
Congresswoman DeGette.
Mr. Kennedy. Thank you to the ranking member.
Ladies and gentlemen, anybody who has welcomed a child into
this world knows that moment when you lock your eyes with your
son or daughter the first time, the promise that you make to
protect them under any circumstance. You learn quickly,
sometimes far too quickly, that no matter how hard you try,
nature will test the strength of that promise because children
are not immune to an unexpected accident or a life-altering
diagnosis. Facing that tragic reality, we as a country and as a
community invest in their care through CHIP, through Medicaid,
through a ban on lifetime caps into a strong community health
center program. It is that recognition that our children are
society's most precious resource that brings us together here
this morning. But TrumpCare threatens the fundamental guarantee
of compassion for our kids. It segregates and stigmatizes
children not just for their illness, but for the fate and
fortune of their family. And that is a vision that, for our
healthcare system on our Nation, that we should never accept.
Thank you, and I yield back.
Ms. DeGette. Thank you.
We used to all agree in this country that every child,
regardless of his or her parents' income, should have a chance
at a healthy start. That is why we have been working in a
bipartisan way to make this country get closer to that goal. I
worked on the very first CHIP bill in 1999. And because of the
bipartisan collaboration, 95 percent of Americans children have
coverage. That is an all-time high. So why would Congress pass
this TrumpCare bill which will take coverage away from over 3
million children? There would be an unprecedented $834 billion
cut in Medicare which covers more than 35 million kids. Half of
the 9 million children in CHIP are actually in Medicaid. And
so, Mr. Chairman, it is really hard for me to see how we can
have a bipartisan reauthorization of CHIP by the end of
September without a strong bedrock foundation of Medicaid.
I yield back.
Mr. Burgess. The gentleman from Texas yields back his time.
The chair thanks the gentleman. The chair recognizes the
gentleman from Oregon, Mr. Walden, 5 minutes for an opening
statement, please.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. I thank the chairman.
Today marks a really important step forward in this
committee's work to strength our healthcare safety net by
examining the extension of two very important safety net
programs. Both the Children's Health Insurance Program, CHIP,
the Community Health Center Program, have enjoyed strong
bipartisan support for many years. Under current law, Congress
needs to renew funding for these important programs, since the
current funding streams will soon expire. We recognize that
CHIP and community health centers play a significant role in
the Nation's safety net for millions of Americans, for millions
of American children, and pregnant women who are generally low-
to moderate-income, and millions of individuals who may be
medically underserved or face other barriers to care.
Individuals and families served by these programs are not
just program enrollees: They are our neighbors. They are our
friends. In my district alone, there are 12 federally-qualified
health center organizations with 63 delivery sites leveraging
more than $41 million in Federal money in order to serve over
240,000 patients. In many parts of rural eastern Oregon, a
health center can serve as the main primary care provider in
the communities that face a shortage of private practice
doctors. And in three of my counties, there are no physicians,
and there are no hospitals. The Student Loan Repayment
Incentive offered through the National Health Service Corps
also helps staff those centers and ensure patients in those
communities can see a provider in a timely manner. So I am glad
to be here and join my colleagues, hopefully on both sides of
the aisle, in moving this process forward. We are united in the
effort to protect patients and to support innovative patient-
centered solutions at state and local levels.
As a result, there are strong bipartisan recognition that
CHIP and the health center program play key roles in our
Nation's healthcare delivery system by providing health
coverage and medical care for millions of low income Americans.
Both programs have demonstrated successes in helping reduce
cost for patients and families, improve health outcomes, and
deliver cost-effective care. We view our state and local
partners in these programs as key allies in the common cause of
putting patients first. This is a shared responsibility.
In my State of Oregon, our health centers partner with
local providers, health systems, and the patient community
through coordinated care organizations that work to provide
comprehensive services focusing on prevention, chronic disease
management, and locally controlled patient-centered care.
Today, we start our funding extension discussion by hearing
from experts who have firsthand experience running CHIP
programs and health centers. We want to better understand if
these programs face barriers to innovation. We want to hear
creative strategies to deliver quality care, and we seek your
guidance on what is working and what is not.
As we move forward, this committee also faces important
considerations regarding extending funding for these programs.
There are decisions to be made regarding how much funding
should be provided, for how long, and how Congress should pay
for it so as not to burden the next generation with additional
debt.
Particularly, the committee will closely examine the
question of whether the 23 percent bump for a state's match for
CHIP is appropriate to continue as we look at funding
questions. I have concerns the 23 percent increase upends the
traditional financial Federal-state partnership.
As we embark on this effort, I know we all share the goals
reducing cost and ensuring patients served by these programs
have the peace of mind that they can continue to access timely,
high quality care. And it goes without saying that this needs
to be bipartisan. We look forward to working with our
colleagues on the other side of the aisle. And it is important
to note as well that CHIP is one of those programs that is
actually a block grant to the states that seems to perform
quite well when we rely on our state partners in this effort.
So with that, Mr. Chair, unless others on our side seek the
balance of my time, I am more than happy to yield back to get
on with the hearing.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
Today marks an important step forward in this committee's
work to strengthen our health care safety net by examining the
extension of two popular safety net programs. Both the
Children's Health Insurance Program (CHIP) and the Community
Health Center Program have enjoyed strong bipartisan support
for many years. However, under current law, Congress needs to
provide additional funding for these programs since current
funding streams will soon expire.
We recognize that CHIP and community health centers play a
significant role in our nation's safety net for millions of
Americans--children and pregnant women who are largely low-to-
moderate income, and millions of individuals who may be
medically underserved or face other barriers to care.
Individuals and families served by these programs are not
just program enrollees--they are our neighbors, and friends. In
my district alone, there are 12 federally-qualified health
center organizations, with 63 delivery sites leveraging over
$41 million in federal dollars in order to serve over 240,000
patients. In many parts of rural Eastern Oregon, a health
center can serve as the main primary care provider in the
communities that face a shortage of private practice doctors.
The student loan repayment incentives offered through the
National Health Service Corps also help staff those Centers and
ensure patients in those communities can see a doctor in a
timely manner.
So I am glad to be here and join my colleagues on both
sides of the aisle in moving this process forward. We are
united in the effort to protect patients and to support
innovative, patient-centered solutions at the state and local
levels.
As a result, there is strong bipartisan recognition that
CHIP and the Health Center Program play key roles in our
nation's health care delivery system by providing health
coverage and medical care for millions of low-income Americans.
Both programs have demonstrated successes in helping reduce
costs for patients and families, improve health outcomes, and
deliver cost-effective care.
We view our state and local partners in these programs as
key allies in the common cause of putting patients first. In
Oregon, our health centers partner with the local providers,
health systems, and the patient community through Coordinated
Care Organizations that strive to provide comprehensive
services focusing on prevention, chronic disease management,
and locally controlled, patient-centered care. So we want to
start our funding extension discussion by hearing from these
experts who have first-hand experience running a CHIP program
and a health center. We want to better understand if these
programs face barriers to innovation, we want to hear creative
strategies to deliver quality care, and we seek guidance on
what's working and what's not.
As we move forward, this committee also faces important
considerations regarding extending funding for these programs.
There are decisions to be made regarding how much funding
should be provided, for how long, and how Congress should pay
for it so as not to add to the burden of federal debt that
Americans already face.
Particularly, the committee should closely examine the
question of whether the 23 percent bump for a state's match for
CHIP is appropriate to continue as we look at a funding
question. I have concerns that the 23 percent bump upends the
traditional financial federal-state partnership.
As we embark on this effort, I know we all share the goals
of reducing costs and ensuring patients served by these
important programs have the peace of mind that they can
continue to access timely, high quality care.
Mr. Burgess. The chair thanks the gentlemen. The gentleman
yields back.
The chair would observe that there is a vote on the floor.
There is still almost 9 minutes left. So with the committee's
permission, I am going to recognize the ranking member of the
full committee, Mr. Pallone, 5 minutes for an opening
statement, after which we will recess for votes until votes
have concluded on the floor. Mr. Pallone, you are recognized
for 5 minutes, please.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
A little over a month ago, House Republicans voted to
repeal the Affordable Care Act and gut the Medicaid program in
order to give tax cuts to the rich and privileged few. The
result, 23 million people could lose health insurance, 3
million of them children. And then yesterday, Senate
Republicans finally made public their bill where they proposed
even steeper cuts to Medicaid. And now, today, Republicans will
talk about the importance of our safety net programs, the
Children's Health Insurance Program, CHIP, and the Community
Health Center Fund. I agree wholeheartedly about the importance
of extending these programs. But what our Republican colleagues
seem to ignore is that our safety net is interconnected. To
tear down Medicaid, which is supported by CHIP and community
health centers, is misguided and hypocritical. Mr. Chairman, I
believe we should judge a Nation by how it treats its children.
CHIP covers 8.9 million kids. It stands on the shoulders of a
strong Medicaid program that covers 37.1 million more children.
Every single one of those kids deserve access to a doctor and
access to good healthcare, yet every Republican on this
committee voted for a bill in committee that capped health
coverage for kids in every one of our communities. And as a
result of that vote, 3 million children would lose their health
insurance, and that is simply not right.
Today we will have a conversation about community health
centers also, that providers that serve so many of our most
vulnerable children, the Community Health Center Fund provides
70 percent of the funding for the health center program, which
accounts for 20 percent of revenue for community health
centers. According to estimates, failure to reauthorize this
funding will result in the closure of approximately 2,800
health centers, and 50,000 clinicians and other staff losing
their jobs, and most importantly, 9 million patients losing
access to care.
So I strongly believe in a swift reauthorization of this
funding for community health centers. At the same time, I will
remind my Republican colleagues again that Medicaid is the
largest single funding source for community health centers,
providing more than 40 percent of their revenue during fiscal
year 2016. We can't ignore the devastating consequences that
Republican efforts to cut Medicaid by $834 billion over the
next 10 years will have on community health centers and
millions of Americans. And this includes four in 10 children
living in poverty nationwide who currently receive care at
community health centers.
So, Mr. Chairman, GOP efforts to repeal the ACA and
jeopardize the Medicaid program will harm children
significantly. So I urge my colleagues to first immediately
reverse course and stop the dismantling of the Medicaid
program.
I yield the remainder of my time split between Ms. Castor
and Mr. Lujan. I guess we will start with Ms. Castor.
Ms. Castor. Thank you, Mr. Pallone.
We are at a remarkable place here in America after decades
of bipartisan work. The overwhelming number of American
children have health coverage, 95 percent. That is something to
celebrate. And I wanted to thank you all of the policymakers,
the doctors, the nurses, folks back in our local communities
that have worked to achieve a 95 percent coverage rate. This is
smart policy. This makes America stronger. Kids are healthier,
they do better in school, they miss fewer days of school, they
are more likely to attend college, and they earn higher wages.
But all of this progress is at risk because the GOP has
produced bills--one here in the House, one that is even worse
in the Senate that came out yesterday, that will rip coverage
away from America's kids.
All of the progress we have made is at risk. Why? Just to
give massive tax cuts to wealthy special interests? Those are
not our values. Our values are reflected in the fact that we
work together in a bipartisan way to make sure kids can see a
doctor and get the care that they need. But what the GOP bills
do is the most radical detrimental restructuring of children's
healthcare ever proposed under the 50 years of Medicaid. And it
must be rejected. And, in fact, it is wholly inconsistent for
us to be talking about CHIP reauthorization, because Medicaid
and CHIP are so closely interconnected. You cannot have a CHIP
reauthorization without a strong Medicaid initiative. So let's
jettison those plans and work together to cover the remaining 5
percent of kids that don't have healthcare coverage.
And I am happy to the yield the balance to my colleague,
Mr. Lujan.
Mr. Lujan. Medicaid is the single largest health insurer
for children. Because of Medicaid, the CHIP program, and ACA,
95 percent of all children now have health coverage at an all-
time high. Sadly, Medicaid is in the crosshairs of our
Republican colleagues. And you have heard the numbers: 37
million kids who depend on Medicaid nationwide, half a million
in New Mexico alone; the 3 million of the 23 million people who
will lose coverage are children. It is simple. A strong CHIP
program depends on a strong Medicaid program. You can't reach
out with one hand in the guise of reauthorizing CHIP while
cutting $1 trillion from Medicaid with the other. You just
can't have it both ways.
I yield back.
Mr. Burgess. The chair thanks the gentleman. Does the
gentleman from New Jersey yield back?
The gentleman from New Jersey yields back.
The chair thanks the gentleman. Chair makes a technical
observation that SCHIP is authored until the end of fiscal year
2019 as was accomplished in the Affordable Care Act. It was
only funded through fiscal year 2015. This is the second
funding bridge that has had to occur because of the fiscal
cliff that was built into the ACA.
We now stand in recess until immediately after the last
vote.
[Recess.]
Mr. Burgess. The chair would remind members pursuant to
committee rules all Member's opening statements will be made
part of the record. And we do want to thank our witnesses for
being here today taking time to testify before the subcommittee
on this important issue. Each witness will have the opportunity
to give an opening statement, followed then by questions from
members. Again, as previously mentioned our witnesses, but
today we will hear from Mr. Michael Holmes, Chief Executive
Officer, Cook Area Health Services; Ms. Jamie Snyder, Associate
Commissioner for Medicaid SCHIP Services, Health and Human
Services Commission State of Texas; and Ms. Cindy Mann, partner
in Manatt Health. We appreciate you being here today.
Mr. Holmes, you are now recognized for 5 minutes for an
opening statement, please.
STATEMENTS OF MICHAEL HOLMES, CHIEF EXECUTIVE OFFICER, COOK
AREA HEALTH SERVICES; JAMI SNYDER, ASSOCIATE COMMISSIONER FOR
MEDICAID/SCHIP SERVICES, STATE OF TEXAS, HEALTH AND HUMAN
SERVICES COMMISSION; AND CINDY MANN, PARTNER, MANATT HEALTH
STATEMENT OF MICHAEL HOLMES
Mr. Holmes. Thank you, Chairman Burgess, Ranking Member
Green, members of the subcommittee. My name is Mike Holmes. I
am the CEO of Cook Area Health Services, a Federally qualified
community health center providing medical, dental, behavioral
healthcare in nine locations to more than 12,000 patients in
rural northern Minnesota. On behalf of the more than 1,400
community health center organizations nationwide, I wanted to
thank the subcommittee for the longstanding bipartisan support
you have consistently shown for community health centers.
Since 1979, Cook Area Health Services has provided critical
healthcare access to patients and communities who would
otherwise go without. Our service area covers more than 8,300
square miles, and many of our patients travel 50 miles or more
to access care. Each one of our sites is located in a town
where the population is fewer than 600 people.
As with many rural community health centers, we are the
only game in town. Our health center story is just one part of
a much larger national story. For more than 50 years America's
community health centers, also known as FQHCs, have served as
the medical home for our Nation's underserved communities and
populations.
Today, health centers represent the Nation's largest
primary care network, providing high quality care to more than
25 million patients. Our record of success would not be
possible without the ongoing support of Congress. And I am here
today to urge you to continue that support by extending your
investments in the health center program, and specifically, the
community health centers fund, which provides enormous value to
patients, communities, the health system, and the taxpayer.
Our success is reflected in the core requirements every
health center must meet, each health center must be open to
all. We must serve our medically underserved area of our
population; we must offer comprehensive ranges of primary care
services; and each health center is governed by a consumer
majority board which works closely with health center
leadership and clinicians to develop innovative responses to
community needs.
In 2010, Congress created a dedicated source of funding to
sustain and grow the national investment in health centers,
with an initial 5-year authorization, the CHC fund directed
resources to both operational expansion and capital investment
in health centers. As a result of this investment, new health
center sites were added in more than 1,100 communities, health
centers are serving approximately 6 million additional people,
and they have expanded services like behavioral and dental
care.
At our health center this funding allowed us to add new
access points in Tower, Minnesota, and helped us expand dental
services in three other communities and to significantly expand
our care coordination services. In 2015, Congress extended the
Community Health Center Fund for 2 additional years alongside
CHIP and a number of other programs. With that extension
nearing its expiration date, we strongly urge you to renew
these investments and to do so for at least 5 years so that
health centers like mine can continue to provide reliable
access to our patients.
Without action by the end of the fiscal year, health
centers and our patients face major disruptions in care. HHS
has estimated that should Congress not act by September 30th,
it would lead to the closure of 2,800 health center sites, loss
of over 50,000 jobs, and, more importantly, a loss of access to
care for some 9 million patients.
In conjunction with my testimony today, the Minnesota
delegation has given me a letter, noting their support for
health centers and the impact on Minnesota CHCs. In my written
testimony, I have highlighted several other programs which fall
under the subcommittee's jurisdiction. Two key workforce
programs are set to expire on the same timeline as the health
centers' fund.
The National Health Service Corps, which provides
scholarships and loan repayments to clinicians willing to work
in underserved areas, is a key tool health centers use as we
recruit and retain clinical staff. Fifty-four percent of
National Health Service Corps clinicians practice in health
centers today. Additionally, the Teaching Health Centers
Graduate Medical Education program brings physician residency
training right into community-based settings like FQHCs where
providers are needed the most.
And finally, I would like to note that the Medicaid program
is extremely important to health centers and those we serve.
And every State the program works hand in hand to turn the
promise of coverage into the reality of care. Nearly half of
all health center patients are covered by Medicaid.
This is a time of rapid change in our health system. Health
centers probably help with that change, even though as we
remain committed to our basic founding principle, ensuring that
every American in need has a place to go for high quality care.
That purpose is made into reality every day for 25 million
patients because of the support of Congress. And that support
begins here in this subcommittee. I urge you to continue that
support by extending these critical programs on a timely basis,
and appreciate the opportunity to testify before you today and
thank you for making health centers an ongoing priority.
[The prepared statement of Mr. Holmes follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Mr. Holmes. The committee thanks
you for your testimony.
Ms. Snyder, you are recognized for 5 minutes for an opening
statement, please.
STATEMENT OF JAMI SNYDER
Ms. Snyder. Good morning, Chairman Burgess, Ranking Member
Green, and distinguished members of the Subcommittee on Health.
Thank you for the opportunity to provide testimony on the
Children's Health Insurance Program. My name is Jami Snyder, I
serve as the Director of the Medicaid and CHIP programs for the
State of Texas.
This morning, I would like to provide insight into how CHIP
has worked for the State of Texas in response to the
subcommittee's inquiries concerning the reauthorization
legislation. The Texas Health and Human Services Commission
implemented the state's CHIP program in 1998. The program
currently serves approximately 380,000 children. Since
implementation, the state has seen a notable reduction in the
overall rate of uninsured children below 200 percent of the
Federal poverty level, from 18 percent in 1998 to 6 percent in
2015.
CHIP statute allows states the flexibility to operate CHIP
as a Medicaid expansion program, as a separate state program,
or as a combination of the two. Texas has historically operated
CHIP as a separate program, which has afforded Texas the
freedom to design a system that aligns with the state's
philosophy of ensuring accountability in the management of
public funds, and increasing personal responsibility for
program participants.
Unlike the Medicaid program, which offers an extensive and
prescriptive medical benefit for children, CHIP regulations
offer states flexibility to tailor the CHIP benefit package to
meet the unique needs of the populations served. This allows
CHIP to function as a nimble program that is more easily able
to respond to changes in the states' fiscal outlook, emerging
Federal legislation, as well as the evolving needs of
beneficiaries.
Since the onset of the program, Texas has delivered CHIP
services through a managed care model. The state currently
contracts with 17 managed care organizations, delivering
services to CHIP members Statewide. The managed care delivery
system offers additional advantages as MCOs are incentivized
through a risk-based, capitated payment system to contain costs
while implementing innovative service delivery and provider
payment mechanisms to improve health outcomes for their
members.
Medicaid regulations make it difficult for states to
implement cost-effective, or effective cost-sharing mechanisms
for the full range of Medicaid beneficiaries. In contrast, CHIP
offers states greater flexibility to design programs in which
families retain a measure of responsibility for the cost of
their child's care.
Most families in CHIP pay an annual enrollment fee, and all
families in CHIP make copayments for office visits,
prescription medications, inpatient hospital care, and
nonemergent care provided in an emergency room setting.
CHIP is a critical part of the health care safety net in
Texas, offering a healthcare benefit to children who do not
qualify for the Medicaid program. Texas' overall experience is
that CHIP simply works. It provides reliable medical and dental
benefits to the covered population at a rate of $156 per
member, per month, which is $67 less on a per-member basis than
the cost for coverage for the state's Medicaid population.
The state's quality data also offers evidence of the
efficacy of the program, indicating a 21 percent increase in
children age 3 to 6, accessing well child visits, and a 90
percent increase in children receives recommended vaccines in
the first 2 years of life for measurement years 2011 through
2015.
A decision to not reauthorize the CHIP program would result
in a loss of over $1 billion in funding annually to the State
of Texas, and a corresponding loss of healthcare coverage for
more than 380,000 children. If funding for the program is not
extended beyond September 2017, it is estimated the state will
exhaust remaining resources by February 2018. As such, Texas
would be faced with the prospect of dismantling the CHIP
program. And as mandated by the ACA, the state would also be
expected to continue adherence to maintenance of effort
requirements at a lower Medicaid Federal matching rate for over
250,000 children now served under the state's Medicaid program.
Through its routine budgetary planning process, Texas has
assumed continued funding for the CHIP program for fiscal years
2018 and 2019 at the enhanced Federal matching rate. Should
Congress elect not to move forward in reauthorizing CHIP, the
State of Texas will no longer be able to administer this
critical program, which has a proven track record of success,
stemming from its adherence to the fundamental principles of
state administrative flexibility, personal responsibility, and
innovation aimed at enhancing outcomes for beneficiaries.
[The prepared statement of Ms. Snyder follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The chair thanks the gentlelady for her
testimony. Ms. Mann, you are recognized for 5 minutes please
for an opening statement.
STATEMENT OF CINDY MANN
Ms. Mann. Good morning, Chairman Burgess and Ranking Member
Green, and distinguished members of the subcommittee. I am
pleased to be here this morning. I am Cindy Mann, a partner at
Manatt Health, and I work on matters primarily focused on
public coverage, and particularly the Medicaid and the
Children's Health Insurance Program. And as noted, prior to
joining Manatt, I served as the Director of the Center for
Medicaid and CHIP services at CMS responsible for Federal
policy, Federal oversight of Medicaid and CHIP and supporting
statement implementation of these programs. I am going to focus
today on my testimony on the role of CHIP in providing
affordable coverage to children, the issues facing Congress on
the expiration of the funding. But I also do want to note the
strong support of the comments by Mr. Holmes in terms of the
incredibly important value and critical function of federally
qualified health centers.
With 20 years of experience with the CHIP program--it is
hard to believe it is 20 years behind us--we know what has made
this program successful, and we know what has put it in
jeopardy. CHIP works when it has robust and stable funding, and
when it has a strong Medicaid program with which to partner in
covering children.
Let's look first at the CHIP's history on financing. When
the program was first started, the funding was ample for states
that were just ramping up their program, but very quickly by
2002, some states began to see shortfalls in their funding, and
we saw a mismatch between the allotments and states' needs in
terms of coverage of children. And that was not unexpected. In
some respects, Congress didn't know how many states would pick
up the CHIP program, what the participation rates would be, but
it gives us an example of what happens when you have a mismatch
in funding.
Georgia, for example, reluctantly froze enrollment from
March to July of 2007, and only lifted a freeze after Congress
passed a supplemental budget. Florida froze enrollment, it
froze it for just 5 months, and during those 5 months, 44,000
children, CHIP children, were placed on a waiting list. When
CHIP was reauthorized in 2009, there was strong support from
the Congress to avoid those kinds of shortfalls and enrollment
freezes. CHIP has provided ample funding and revamped the
system for distributing dollars. It built in new adjusters; it
built in contingency funding; and a new system for
redistributing funds across states.
That funding formula has been maintained through the
subsequent extensions. Going forward, adequate financing for
CHIP must be assured. Beyond extending the basic program
funding, Congress also needs to consider the issues that have
been raised so far, the 23 percentage point increase in the
match rate, and the maintenance of effort provision, both of
which were in the Affordable Care Act.
As my colleague from Texas noted, the enhanced funding for
the CHIP program is very much integrated into state budgets and
helping a number of states to adopt a plan for program
improvements. But we must also recognize that that enhanced
funding goes hand in hand with the maintenance of effort
provision. Without the maintenance of effort provision,
millions of children will be at risk of losing coverage, or
paying much higher costs for that coverage.
CHIP made affordable coverage available to millions of
children, but given the marketplace changes, the uncertainties
of the futures of subsidies and cost-sharing reductions,
indeed, even the uncertainties in the Medicaid program. It is
essential to protect not just the funding for the program, but
children's eligibility for coverage. And I would suggest that
it is unlikely we would continue the MOE requirement without
also supporting state's ability to fund that requirement and
that need for stable coverage for children.
Next, let me just circle back to my point about CHIP
working, in large part, because of the foundation of Medicaid.
Medicaid, of course, is the much larger program covering about
37 million children, the two programs depend on each other,
kids go back and forth between the two programs all the time as
family circumstances change. But even more fundamentally is
that Medicaid supports CHIP by covering so many of the children
with the greatest healthcare needs: lowest income children,
children in poor health, kids in foster care, kids with
disabilities.
CHIP wasn't designed to do that heavy lifting. It doesn't
have the financing structure, it doesn't have the benefit
structure to do that. CHIP is an incredibly critical part of
that coverage continuum for children, but it can't do the job
alone.
Finally, I would say that Congress has much to be proud of,
given its long-standing support of children's coverage.
Together, Medicaid and CHIP have brought the uninsurance rate
for children below 5 percent. It was over 15 percent in 1997
when CHIP was first enacted. It is a historic low, and it is a
great achievement, but with sweeping changes to Medicaid now
under consideration, and CHIP reauthorization outstanding, much
is at stake for our Nation's children.
Thank you for your time and support.
[The prepared statement of Ms. Mann follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The chair thanks all of our witnesses for
their testimony today, and appreciate your being here and your
being flexible with us as this hearing was rescheduled a couple
of times.
I now want to go to vice chairman of the committee, Mr.
Guthrie, 5 minutes for his questions, please.
Mr. Guthrie. Thank you very much. Before I get into my
questions, I know we have had some comments from some of my
colleagues, and the others on Medicaid and the way the AHCA
dealt with Medicaid. As we know, Medicaid is a program that is
growing rapidly and could implode. So what we decided to do,
and we very carefully sat down and walked through the AHCA, was
how are we going to move forward? And the principled way of
moving forward, I know there is a block grant option in the
bill, but the principle way we decided to move forward was on
an approach to Medicaid, that in the 1990s, was bipartisan. As
a matter of fact, every sitting Member of the Senate who was in
the Senate in the 1990s on the Democratic side signed a letter
to President Clinton supporting an option of going to per
capita allotments, some being key ranking members and then
leadership on the other side.
Medicaid, over the next 10 years, under our proposal, will
grow, not cut, will grow by 20 percent, so I just want to make
sure the record reflects more than some of the rhetoric we have
heard.
First, Ms. Snyder, in addition to basic medical benefits,
Texas' CHIP program include behavioral health services; vision
exams and corrective lenses; hearing exams and hearing aids;
physical, occupational and speech therapy; and durable medical
equipment. There is also limited dental benefit. In your
testimony, you seem to contrast this with Medicaid extensive,
yet prescriptive medical benefit for children. I believe every
member of this committee wants to ensure low-income children
have adequate access to healthcare, whether in Medicaid or
CHIP. But it sounded like you might have some ideas on the way
Medicaid could better serve children. Do you have any ideas you
would like to share with us?
Ms. Snyder. Thank you, vice chairman. Absolutely, we are a
fundamental believer in Texas in both the Medicaid and CHIP
programs. I think, as is evidenced by my testimony, we enjoy
the flexibility that the CHIP program offers to states in
designing a benefit that actually is responsive to the
population that served under the CHIP program, which is a
population of children that don't qualify for Medicaid.
Certainly, we always in Texas are, and like many other states,
looking at opportunities to infuse elements of personal
responsibility into programs such as Medicaid, and clearly, we
already have done so with CHIP. But we do realize that the
populations that are served under those programs are distinctly
different, and so want to be cognizant of those differences in
terms of the populations as we consider cost-sharing
opportunities, benefit limitations, and so forth.
Mr. Guthrie. Thank you. Mr. Holmes, also, the reliance
community health centers is very important in our health safety
net. And in 2015, we extended the community health center fund
for 2 additional years. In your testimony, you call on us to do
a longer-term basis for at least 5 years. Maybe some of the
reason for that is self-evident, but would you like to describe
what is better for you in a longer extension over a 2-year
extension, the things you can do differently, or maybe more
efficiently?
Mr. Holmes. Thank you, Mr. Vice Chairman. Two years is a
short period of time for safety net providers to go into the
workforce and recruit new providers. One of the more difficult
conversations any safety net provider has when they are trying
to bring in new physicians, new dentists, is to have that
discussion about, if the lead time to recruit these providers
is 1 to 2 years, to say, we hope to have a job for you in 2
years. It really limits our ability to have realistic
conversations with new providers that we need to help serve our
patients. Two years is a short planning cycle for any small
business to try and address changes in the environment, and
certainly, in a healthcare environment that is changing
rapidly. And a longer planning cycle just would make us more
effective in how we deliver care to our patients.
Mr. Guthrie. Thank you. Also, every health center must meet
statutory-defined criteria to receive in HRSA, section 330
grant. One of the conditions that must be made in order for
health centers to receive one of these grants, and how does an
applicant demonstrate to HRSA the need for health services? And
I have a 30-second time left.
Mr. Holmes. There are 19 basic requirements to fund to be
eligible to receive health care center funding. Each one of
those areas must be defined and documented in a competitive
grant application which occurs every 3 years at the current
time.
Mr. Guthrie. And what you do is critical, so we really
appreciate your efforts. We appreciate it.
I yield back.
Mr. Holmes. It is critical for us to show Congress that we
do what we say we are doing, and that we are who we say we are.
And without that, we want to have a process that is transparent
for all organizations to say, this is what we do, this is who
we serve, and this is how we can care for our patients.
Mr. Guthrie. Thank you. I yield back.
Mr. Burgess. I thank the gentleman. The gentleman yields
back. The chair recognizes the gentleman Mr. Green for 5
minutes of questions please.
Mr. Green. Thank you, Mr. Chairman. I would like to ask
unanimous consent to place in the record letters from both a
number of associations encouraging a 5-year extension on
funding for the Children's Health Care Program.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Green. One thing I think is really important and I
highlight that Medicaid and CHIP are linked together, and many
of our CHIP kids receive Medicaid benefits. In fact, two-thirds
of the CHIP kids actually receive the more comprehensive
Medicaid benefit package, because states have recognized how
important coverage is for children. That is why I am disturbed
by what the House has done passing TrumpCare, and what the
Senate looks like they are poised to do next week.
The conversation about children's coverage is something
that this committee should have before passing legislation,
capping, and blocking, granting coverage for 37 million
children. This morning, I read that 3 million children will
lose coverage under the House bill, and Senate cuts to Medicaid
are even deeper over time. Even one child losing coverage in
our country is unacceptable. We can do better for our children.
Ms. Mann, can you start off with some of the important
contexts we should have as we consider the reauthorization in
CHIP, which I want to be clear, I strongly support and believe
Congress must immediately do. What do people mean when they say
CHIP stands on the shoulders of Medicaid? And can you discuss
the history of CHIP and how it worked with Medicaid programs to
bring us to the highest rate of coverage for children in our
history?
Ms. Mann. Thank you. I would be glad to address that
question. CHIP was established to extend coverage to children
who otherwise weren't going to be eligible for Medicaid, and
states could cover those children, either in Medicaid or in
separate CHIP programs. So the idea that CHIP sits on top of
Medicaid is, in fact, exactly how it is designed by Congress,
and how it is operated in the program. And why CHIP needs that
support is that Medicaid really does, as I noted, much of the
heavy lifting. Both in terms of numbers, Medicaid covers about
37 million children, CHIP covers over 8 million children.
Medicaid covers the children who are often in the poorest
health, foster care kids, kids with disabilities. Any child,
when they get a disability, when they get a chronic illness,
they often have to turn to Medicaid, even if they are eligible
for the CHIP program. It is not necessarily designed to be that
robust a benefit package. They work hand in hand.
And at the same time, what CHIP has done is really helped
modernize the Medicaid program over the years. When CHIP was
started, it really got a lot of energy around children's
coverage, and people started to look at not just how to design
the new CHIP program, but what should we do to improve the
Medicaid program? So simplified applications made it easier for
families to enroll. That had a lot to do with the success and
the uninsured rate that we have seen. So the two really are
side by side and complement each other, and are needed for the
continuum of coverage for children.
Mr. Green. Following up on my colleague from Kentucky, do
you have anything to say about the flexibility of Medicaid
between different states with different Medicaid programs?
Ms. Mann. There is a great deal of flexibility in Medicaid.
In fact, often you hear from Members of Congress and others, oh
my God, it is such a complex program, in part, because there
are 56 jurisdictions that administer it, and there is quite a
bit of distinction and differences among them because of the
flexibility accorded to states in the program.
States have a lot of flexibility to design their delivery
system as a managed care, is it fee for service? Accountable
care organizations? They design their payment system; they
design their care management system. The area where Medicaid is
clear, however, is on the benefit protection for children. It
is actually 50 years, almost to the day, where Congress adopted
the early periodic screening and diagnostic treatment program
to make sure that all kids in Medicaid get screened for vision,
hearing, developmental delays, other problems. And if they have
a medical problem, the benefit requirement in Medicaid is that
they get treated.
Mr. Green. I am almost out of time. Texas receives a 1115
waiver that, I think, bipartisan, we supported. There is
flexibility in states. Although, before I was elected to
Congress, served 20 years in the state legislature, and I
watched how we were funding Medicaid back then. And my concern
is that the flexibility--we also vote this Federal money, in
Texas, our match is two-thirds Fed, one-third state, of course,
Louisiana gets a little better than that. Someday maybe we will
get to that level. But we also need to have guidelines for what
we know that funding will go through.
Ms. Mann. Absolutely.
Mr. Green. So I want flexibility, but I also make sure it
is spent on the healthcare for poor people, including children.
Ms. Mann. Absolutely.
Mr. Green. Thank you, Mr. Chairman.
Mr. Burgess. The gentleman yields back.
The chair thanks the gentleman. The chair recognizes the
chairman of the full committee, Mr. Walden. The gentleman from
Oregon, for 5 minutes, please.
Mr. Walden. I thank the chairman. And I want to thank our
witnesses for your testimony. We appreciate what you do in our
states, and communities, and what those you represent here
today do.
Mr. Holmes, in your testimony, you say that many of your
patients travel over 50 miles off and over secondary roads to
access care in your health center, and that oftentimes, you are
the only provider in the communities you serve. In addition to
isolation and distance, what other challenges exist that we
should know about in care and delivery that are unique to rural
areas? And I would just preface that by saying my district
would extend from the Atlantic Ocean to Ohio. And so it is
bigger than nearly every state east of the Mississippi River.
So I am used to pretty remote, rural, extreme remote, whatever
the furthest-out remote nomenclature is, we got it in my
district. But can you speak to some of those issues and the
reimbursement issues?
Mr. Holmes. Delivery of care in a service area that is
almost the size of New Jersey is challenging. It is challenging
because we are in small communities. Two of our health center
sites are attached to critical access hospitals. And the
critical access hospitals are small. They are 14 beds, and 16
beds, they have attached long-term care units. We have to be
able to recruit providers to see these patients. We are in a
frontier area, and it is long distances between sites. If we
are not there, no one else is there. The next level of care for
our system, or our health delivery system, is 40 to 50 miles
away to an entry point.
When we look at rural areas, it is where we have our
agriculture; it is where we have our forest products; it is
where we have our mining; and we can't relocate those jobs to
urban areas. We have to deliver care to the people that are
working in those industries, and it presents challenges of
distance, and time, and access. Payment reimbursement
methodologies that come to FQHCs help on a per-visit basis to
subsidize or offset some of the infrastructure costs. I could
be much more economically efficient if I had all of my patients
and all my providers in a single site, but I can't, because I
can't have patients traveling 60, 70, 80 miles in.
Mr. Walden. Let me ask, I am thinking about the clinic I
have in Fossil, Oregon, it is 92.2 miles to The Dalles, Oregon,
where Mid-Columbia Medical Center is. That would be most likely
the nearest hospital, so more than 90 miles away. This is one
of three counties where we have physician assistants, but
beyond that, no other access and no hospital in this three-
county region.
Talk to me about telemedicine and what role it can play and
what you encounter. I understand the recruitment issue, and
some of that goes back to the states because they want to do
their board certification. So I have had various health centers
and providers say, we can wait 6 months to a year to get
through the process from the State of Oregon to get approval to
get somebody here, and meanwhile, they go somewhere else,
perhaps. We are not as bad as some, not as good as others. Can
you talk about telemedicine?
And then, I had an amendment before it became law and then
it expired on sort of bonus payment for home healthcare,
because it is more expensive to go out and back 90 miles each
way to take care of somebody in a remote area. Perhaps you
could address those things?
Mr. Holmes. We have a common electronic medical record
platform across all of our sites. We have some clinics that are
mid-level provider sites only. They are staffed by nurse
practitioners or physician's assistants. If they have issues or
questions about care of a patient, they can route that chart to
one of our physicians in one of our other sites for assistance
in care delivery.
We have some telemedicine capabilities. We have telemental
health services with the University of Minnesota, Duluth, where
we can have patient's access, some psychiatric and psychology
care. And we do have some telederm setups. But part of the
problem we have with telemedicine is that in the rural areas,
there is not a significant infrastructure for high speed
internet.
Mr. Walden. Right.
Mr. Holmes. So we can't do home monitoring, because in many
places, there is not even a cell service, cell phone signal.
And so we end up having patients coming into our sites, which
is the closest access point they can. And we will work with the
patient there, whether it is with direct hands-on care, or
through some telemedicine.
Mr. Walden. That is helpful. We also have jurisdiction over
spectrum and broadband buildout. It is a big bipartisan effort
on our committee to get access. We just had a hearing this
week, as a matter of fact, on getting access to unserved areas
first with the Federal support, and then underserved after
that, and how we mapped that and really figure out where those
areas are. So thank you all for the work you do and for your
testimony today.
I yield back.
Mr. Burgess. The gentleman yields back the chair. The chair
recognizes the gentleman from New Jersey, the ranking member of
the full committee, Mr. Pallone, 5 minutes for questions,
please.
Mr. Pallone. Thank you, Mr. Chairman.
I believe deeply in the CHIP program. I want to see a full
5-year extension of current CHIP policy. However, I also
believe deeply in the Medicaid program. And I know that a lot
of our success with the CHIP program is due, in part, because
it bills so seamlessly on top of the Medicaid program in its
current form. And as virtually every stakeholder agrees, the
TrumpCare bill passed by the House would decimate coverage for
23 million people, 3 million of them children. What is worse is
that the Senate's own TrumpCare bill doubles down against kids.
And it is a fact that these proposals are bad for kids.
So with that in mind, Ms. Mann, I wanted to ask you some
questions. First, why is the current full 5-year extension of
the CHIP program with the maintenance of effort in the so-
called 23 percent bump in payments for states so critical now
more than ever?
Ms. Mann. Thank you. MACPAC, the pediatricians, and NGA
have all recommended a 5-year extension. MACPAC with 23
percentage points and the maintenance of effort, and I think
for good reason. And I think it goes back to the points that
Mr. Holmes made about health center funding. These 2-year
cycles are just not sufficient for states to be able to really
do the kind of planning and improvements that make sense for
kids. And I also think the other side of that is to look at
what is going on broadly in the healthcare marketplace right
now. If CHIP were to end more abruptly, then children will be
at risk of not having coverage, or if they find coverage, they
will have significantly higher out-of-pocket costs.
This is really a time of great uncertainty in our
healthcare marketplace, small ``m'', and it is really a time,
given the bipartisan support for children's coverage, to give
CHIP 5 years to be stable and to do the job it needs to do for
children.
Mr. Pallone. Well, I obviously agree with you and the
importance of an immediate and full extension, but I also share
the same belief about reauthorizing the community health center
fund. I think we need to do it immediately. But again, when you
talk about the health center program, a lot of success due, in
part to the Medicaid program, which provides more than 40
percent of community health center revenue each year. And
unfortunately, all that success, I think, is jeopardized with
TrumpCare. And yet my colleagues argue that a cap on the
Medicaid program is not a cut at all. In fact, the
administration was up here testifying on the budget of the Ways
and Means chair arguing that TrumpCare was not a cut to
Medicaid at all. So I would like to hear from someone who knows
a lot about Medicaid and CHIP, many have likened the capping of
the Medicaid program to be just like managed care, which, in
Medicaid, is quite widespread. Is the cap in Medicaid like
managed care?
Ms. Mann. Well, I will jump in and answer that. And I am
sure Ms. Snyder also has a view on that. It is very unlike
managed care. States use managed care largely for CHIP programs
and for their Medicaid programs. They set rates, they set rates
at a regular period of time. They adjust rates based on the
acuity and the needs of the population that are served. They
take into account policy changes, healthcare cost changes, and
they are constantly reexamining their rates.
In the cap in the bill, it is set based on spending from
years back, moved forward, adjusted by a national trend rate
that is not related to the actual needs and cost of serving
people in that state. And it doesn't adjust based on acuity of
the needs; it doesn't adjust based on the healthcare costs in
that community.
Mr. Pallone. So what is going to happen to benefits and
provider revenue with a capped or block granted Medicaid
program?
Ms. Mann. Well, states have three major levers to do
significant reductions of spending in the Medicaid program:
enrollment, provider payment rates, and benefits. I think
likely, with the kinds of changes that are proposed, all three
will be relied on by states. But if you think about going to
provider rates, which is maybe the first place states will
turn, we worry a lot about access for kids. Access is in good
shape for kids right now in our Medicaid program, but if we
thin out the payment rates for providers, if we lower our
payment rates for managed care organizations, we are going to
have access issue and problems of serving children, as well as
seeing some children who are on optional kinds of programs,
kids with brain injuries and other types of HCBS services, Home
and Community Based Services may be losing their coverage and
services all together.
Mr. Pallone. Are there any winners for this policy,
regardless of what states are carved out? And is it going to
matter?
Ms. Mann. Well, no states are carved out, and I think it is
just a fact of math that when there is a Federal and state
partnership to share all costs and the Federal Government is
saying, I am pulling out of that partnership, and I am setting
my limits at a certain amount, and the state is responsible for
everything above that, every state becomes a loser in that
formula.
Mr. Pallone. All right. Thank you. Thank you, Mr. Chairman.
Mr. Guthrie [presiding]. Thank you. The gentleman from New
Jersey yields back. The gentleman from New Jersey is
recognized.
Mr. Lance. Thank you, and good morning to the distinguished
panel.
Is it the view of the panel that the current formula for
Medicaid, which is open ended, as I understand it, should
continue as it exists permanently without any analysis of a
potential modification? I ask the question legitimately and I
was one of 20 Republicans not to vote for the healthcare plan
on the floor of the House of Representatives. Ms. Mann, I will
start with you.
Ms. Mann. I think the shared commitment, the shared
partnership around underlining financing of the program is
critical and needs to be retained. I think there are always
areas of improvement. There has been years of complaints about
how the FMAP itself, how that share is actually the formula for
that. That could be looked at, though it is a quagmire of
political complications when one does.
Mr. Lance. I think that is the understatement of the day.
As I understand it, the costs have increased relatively
significantly in the last decade. Is that accurate?
Ms. Mann. The costs per enrollee, actually, in the Medicaid
program, have grown much more slowly than either commercial
insurance or Medicare. Medicaid costs have grown, but that is
because it is covering many more people.
Mr. Lance. Others on the panel who would like to address
the issue?
Ms. Snyder. I would be happy to respond to the question.
Very similar to Ms. Mann, I think we can all agree that
there is always opportunity for improvement when we look at the
funding formula for Medicaid as it currently stands. As a
state, I can tell you Texas is looking very closely at the
implications of the ACA, as well as the proposal that has been
advanced by the Senate, specifically for the implications for
the State of Texas and how the proposed funding formulas would
play out for the program, versus the funding formula that we
are now working with.
Mr. Lance. Yes.
Mr. Holmes. From a rural standpoint and a small safety net
provider standpoint, I think it is important to recognize that
not all Medicaid patients are evenly distributed across all
payer types and across all providers. In the rural areas, there
is a higher level of Medicaid population and where nursing home
care paid by Medicaid may be 64 percent nationally. In the
nursing homes that I am familiar with, their Medicaid
population is 90 percent. And so there is a disproportionate
percentage in some of our communities that rely on Medicaid.
And so any time we have a change in that system, I worry about
unintended consequences and how the rural providers, and rural
safety net providers, and all safety net providers adapt to
those changes.
Mr. Lance. Regarding rural America, is this particularly
important as it relates to those in nursing homes, as opposed
to children and other populations served by Medicaid?
Mr. Holmes. In the rural areas, we still have a significant
nursing home population, a long-term care population, but we
have a disabled population, and we have a population of moms
and kids.
Mr. Lance. Well, that is true across the country,
obviously. Is there a disproportionate percentage in rural
America in one of the cohorts you have just mentioned?
Mr. Holmes. I believe that there is a disproportionate
share in the rural areas for long-term care, because we have an
aging in rural parts of the country. A lot of the younger
people have moved out of the rural areas to urban areas where
the jobs are. And so we have a graying of the population in
these rural communities. Along with that graying of the
population, I think there is a greater reliance on some of the
programs to help provide care.
Mr. Lance. Thank you. I think that this is an issue that
deserves a great deal of attention, and I am not one who wants
to make this a partisan issue. I think that it is a very
difficult issue, and we have to examine it, in my judgment,
based upon the facts that we want to cover as many Americans as
possible. We also have a responsibility to the tax-paying
public with a rising Federal debt. And I hope that we can
examine these very difficult issues in a bipartisan capacity
moving forward, because I do not think that this is an issue
that should be politicized.
I yield back 17 seconds.
Mr. Guthrie. The gentleman yields back his 17 seconds. The
lady, Ms. Matsui from California, is recognized.
Ms. Matsui. Thank you very much, Mr. Chairman.
CHIP and the Community Health Centers' Fund are critically
important programs for serving children and families in our
communities. And I do look forward to working with my
colleagues to continue their funding in the future, and
hopefully far into the future. However, we all know we can't
have a conversation about safety net that CHIP and community
health centers provide without including Medicaid as their
foundation, because Medicaid is the foundation of our Nation's
safety nets.
Forty-one percent of children in California are on Medicaid
and CHIP. That is about two in every five kids. I say 41
percent on Medicaid and CHIP because you can't separate the
two. CHIP eligible children in California, in fact, receive
services through the Medi-Cal program. The CHIP and community
health centers programs and the children and families they
serve, will be devastated by the Medicaid cuts proposed by the
TrumpCare bill.
Ms. Mann, I am going to ask you this, because the way it
looks now, if the TrumpCare bill goes through, billions of
dollars will be cut from Medicaid. Would states be able to
continue to cover the same number of people? Would they be able
to cover the same type of services? Where might they cut? And
are there examples of difficult choices states have had to make
when budgets were squeezed?
Ms. Mann. Sure. The Medicaid program, I think, certainly as
CBO has projected, the reductions in Medicaid funding $834
billion over 10 years would result in about 14 million people
in the Medicaid program losing coverage. That will grow over
time due to the impact of the caps, and how the caps get
tighter and tighter over time just because of the way the math
works. So, we will see necessarily, I think, lots of impacts to
the program, both on that coverage number, but also in terms of
whether we see limitations on the kinds of benefits to people
are able to access. states will have to look, for the first
time, I think, really closely at so-called outlier cost people:
elderly people, children who are in special waiver programs,
for example, whose expenditures are so much higher than the cap
would be. Every time they enroll somebody in that situation,
the state will lose a lot of money under the way the caps are
designed.
We also see big concerns about access, whether lower
payments to providers, lower payments to health plans will
narrow networks, children won't be able to get access to
specialty care, and the kind of services that they need in a
timely way.
Ms. Matsui. So it seems to me you will be rationing care
here. It seems to me they would have to make very difficult
decisions as to what population will get the care that they
need.
Ms. Mann. What you will have even more than you have now,
there are always issues at the state level about funding the
Medicaid program. It is a big expenditure. States do not just
spend their money without a lot of examination. But under a
capped environment, you will have both cuts and a limit. And
that will increase the competition between populations and
between providers inside the state.
Ms. Matsui. OK. Thank you.
I would ask you also about in California, children receive
full EPSDT, which is Early and Periodic Screening, Diagnostic
and Treatment services through Medi-Cal. Can you talk about the
impact of access to these services on children and families?
And can you talk about the differences in the benefits and
resulting health outcomes?
Ms. Mann. EPSDT was really designed initially because of
concern about low-birth weight babies, about children growing
up, even children going into the Armed Forces, and as young
adults and not being in healthy shape. It is really a very
sensible benefit package that says there should be screening,
diagnostic testing. And then it simply says that when a child
needs treatment, as recommended by their doctor, they get the
treatment that they need. That is an incredibly important
service that is available to children, and, I think, the kind
of standard we all want for our children. With reductions in
spending, that might be a hollow promise; you might have the
promise even for EPSDT if it is still there, but can a child
find a provider, can a child get to a dentist, can that child
get to the specialist that they might need for a particular
kind of circumstance.
Ms. Matsui. I see I am out of time and I would like to
submit my questions for the record.
Thank you. I yield back.
Mr. Guthrie. The gentlelady yields back. The gentleman from
Virginia, Mr. Griffin, is recognized for 5 minutes.
Mr. Griffith. Thank you, Mr. Chairman. I appreciate it very
much.
Mr. Holmes, you have been talking about some of the rural
issues, and I appreciate that, because my district is larger
than the State of New Jersey. And you indicated that the
territory that you cover is about the size of New Jersey, or a
little bit less than that. And one of the things that has been
rattling around in my head is that--the telemedicine issue that
you touched on earlier is that we ought to be able to figure
out a way to save money longterm, maybe not initially but
longterm, by using telemedicine and not only save some money
but increase the effectiveness of the care in the rural areas
or at least make it more accessible. For example, I have a bill
in that deals with making sure that folks, by telemedicine,
talking to the appropriate neurologist, et cetera, can get a
quicker response on getting the tPA, in the case of a stroke.
Because, obviously, if you are in a rural area, sometimes you
can't get to the hospital where the right doctor has to look at
you currently to give that medication. But we can speed it up.
You mentioned that you all are providing some services for
mental health. I think that is extremely important, because if
we can catch that, just like with the stroke, instead of having
somebody in long-term care, which we have talked about and how
expensive that is, tPA can stop a lot of that. Likewise, with
mental health, if we catch it early in a regular clinic and we
are doing that a little bit in my district now. What we found
is that people are much more likely to go to the clinic, the
community center, if they can just step into the other room and
get the mental health, even if it is by telemedicine, because
we don't have the ability to have population to have
psychologists or psychiatrists in every one of those
communities. But there is still a certain stigma. Maybe that is
not the way it is supposed to be, but there is, particularly in
rural areas, to getting mental health services. If they can
just step into another room in the clinic, nobody knows whether
they are getting their foot looked at for toe fungus or whether
they are getting a mental health evaluation.
So just some comments on that, and do you believe that
there might actually be some savings there longterm,
particularly in rural settings, because we prevent folks from
having more serious maladies.
Mr. Holmes. I believe there are opportunities for cost
savings by integrating behavior health into primary care, along
with medical services. We have a couple of rooms set up in some
of our clinics that have the telemedicine capabilities, the
hookups for behavioral healthcare. Those patients are scheduled
routinely. There is no indication that it is a specialty
behavioral health visit for that patient when they are in the
waiting room.
And some of the other things we do is that we do have some
behavioral health specialists that come in from some of the
local mental health agencies to our clinics. And they have
office space and exam room space embedded right into other
space. So we try and care for the patients in the best way that
we can within the local situation, within the local facilities.
There still are reimbursement challenges with telemedicine.
The originating facility is not usually a part of the
reimbursement methodology. So you have to build the
infrastructure without having payment for that infrastructure.
You have to maintain it. You have to have enough bandwidth to
have interactive television in those interactive conversations.
Mr. Griffith. All right. Let me springboard off of that.
And I believe I have got my names right. Sometimes I get them
wrong. But the Stark Act, currently, if I understand correctly,
prevents us from using some of our facilities in conjunction
with a hospital that might be willing to pay for some of that
infrastructure, because at one time, they were worried about
collusion and raising the bills. Today, I have got underserved
areas. I could use some space in a nursing home, long-term care
facility, and put in some telehealth stuff, even if it was in
conjunction with the hospital, because, in all fairness, I only
got one hospital that's really in competition if you are
talking about somebody having a heart attack. But my folks have
to travel about 45 minutes to get there.
So do you think we need to also look at maybe relaxing some
of that, particularly when we can get into underserved areas?
Mr. Holmes. Antitrust issues are certainly an issue for
medical delivery, especially now when we are seeing the
development of large systems of care and yet we have small
providers that are trying to deliver services in a cost-
effective way. Small areas don't have the depth of resources to
have competitive services. We have to find the best way to
deliver that care to our populations. But we have to be, at
this point, careful of antitrust issues. And it is always
something that is in the back of our minds.
Mr. Griffith. So what you are saying is we have to try to
figure out the balance. We would prefer to have competition,
but where there is no competition, maybe we need to take a look
at giving some flexibility on the antitrust issues to make sure
that we are getting services there.
Mr. Holmes. Yes, sir, I agree.
Mr. Griffith. All right. I yield back, Mr. Chairman. Thank
you.
Mr. Burgess. Thank you. The gentleman's time has expired.
And now recognize Mr. Lujan from New Mexico.
Mr. Lujan. Thank you.
Mr. Burgess. Five minutes.
Mr. Lujan. Thank you, Mr. Chairman.
Ms. Mann, I keep hearing on the news that TrumpCare doesn't
cut Medicaid, yet the CBO said that is just not true. And I am
looking at these quotes from different stakeholders. The
American Academy of Pediatrics says, ``The U.S. and its
healthcare legislation fails to meet children's needs.'' There
is too much at stake for those of us who care for children to
be silent. Pediatricians will continue to speak out for what
children need until we see legislation that reflects it. The
Children's Hospital Association are unified in calling on the
Senate to reject the bill. They say, at its core, the bill is a
major step backwards for children and their health. And the
American Academy of Family Physicians say that this legislation
would have a profoundly negative impact on Americans.
So, Ms. Mann, can you set the record straight? Is TrumpCare
a cut for children, families, and for everyone in the Medicaid
program?
Ms. Mann. Yes.
Mr. Lujan. That is a pretty straightforward answer. Just so
that I am clear, you respond to that question with a resounding
yes.
Ms. Mann. With a resounding yes. There is $834 billion
taken out of the program. There is 14 million people, by CBO
standards, losing coverage. There is countless other changes
that states will have to make if those cuts are imposed. And
children will suffer both from the caps, from their parents
losing coverage, from the loss of the expansion. There is
enormous ramifications to the Medicaid program. Negative
ramifications.
Mr. Lujan. I appreciate that clarification, Ms. Mann. When
I asked that question during our 27-hour markup in this
committee, I was responded to several times that Medicaid was
not cut. I appreciate the clarification of the reduction, the
cut of $834 billion from the Medicaid program.
Ms. Mann, as we have heard today, the Children's Health
Insurance Program is an important provider of health insurance
coverage for nearly 9 million American children. However, the
Medicaid program is a primary source of coverage for low-income
children covering four times as many kids as CHIP. In New
Mexico, for example, there is over 414,000 kids that rely on
Medicaid and 15,000 kids that rely on CHIP.
Can you please describe the role that Medicaid plays in
children's coverage?
Ms. Mann. Sure. And that ratio that you have in New Mexico
is pretty much what the national average looks like. It is,
first of all, a much larger program, as you noted from your New
Mexico figures. Medicaid just covers so many more children. And
it covers infants. It covers newborns. It covers kids at school
age. It covers adolescents. It covers 100 percent of a state's
foster care kids, for example. Any child who has been
determined disabled under the Social Security definitions, they
go into the Medicaid program. They don't go into the CHIP
program. Covers early intervention services for very young
children. Covers school-based healthcare services. It is a
program with lots of different functions and lots of different
ways in which it serves the child population.
Mr. Lujan. And I think you addressed the next question I
had, which was what would the concern be associated if the
Senate passed their bill or the House-passed Republican repeal
bill, otherwise called as TrumpCare, would pass and how it
would affect CHIP. I think you eloquently described that.
Our Nation's leading children's health providers advocates,
including the American Academy of Pediatrics, Children's
Defense Fund, Family Voices, First Focus, March of Dimes have
all spoken out against the Republican repeal bill. And in a
March 22 statement, they wrote: In addition to the bill's
initial proposal to fund Medicaid through per capita caps, the
Republican bill would allow states to choose a block grant
model, which would eviscerate existing protections afforded to
children and pregnant women in the Medicaid program.
Comprehensive EPSDT benefits would no longer be required for
children, allowing states to ration limited dollars by
drastically cutting back pediatric services.
And, Mr. Chairman, I would like to ask for unanimous
consent to submit their statement for the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Lujan. And just as I close, Mr. Chairman, I appreciate
the conversation about the concerns, Mr. Holmes, with the
impact in rural communities. I represent a district that takes
about 8 1A\1/2\ hours to drive across. This is critically
important. When we talk about the concerns to these rural
healthcare facilities, the conversations that were taking place
about the importance of mental and behavioral health programs
in these small clinics, if these bills become law that would
eliminate the Affordable Care Act, we would see those programs
get eliminated, if not disappear.
And when it comes to getting broadband access across
America, I certainly agree. I have said it once, I will say it
again: If there is a debate taking place with TSA about being
able to have a phone conversation on an airplane once you board
in Los Angeles, California, and you can stay on that phone till
you get to New York, then we should be able to have broadband
coverage all across rural America in every part of our
beautiful country. We once electrified rural America. Now let's
make sure that we connect rural America with affordable, fast
Internet. Everyone should have it. We can get it done. And I am
glad to hear it being talked about today.
Thank you, Mr. Chairman.
Mr. Burgess. The chair thanks the gentleman.
The chair can see a downside to you being on the telephone
between Albuquerque and New York. But nevertheless, your
comments are appreciated.
The chair recognizes the gentleman from Georgia, Mr.
Carter, 5 minutes for questions, please.
Mr. Carter. Thank you, Mr. Chairman. And thank all of you
for being here. This is a very important program, certainly
very important in my state. In the State of Georgia, SCHIP is
the PeachCare program. We are very proud of it. It has been a
very good program that has benefited many, many recipients.
I want to ask you, I will start with you, Ms. Snyder, and
then, Mr. Holmes, I will also want you to address this, but I
know that, in my district alone, we have got six federally
funded health centers, and they serve over 55,000 patients.
Very, very important. One of the things that we require, the
Federal statute requires, is that states reimburse these
federally qualified health centers and rural health centers
using prospective payment system. And there have been groups
who said this could be done better. And let me quote real
quick. The National Association of Medicaid Directors has said:
This distinct reimbursement system limits Medicaid's ability to
use the full range of value-based purchasing strategies in this
care delivery setting, including models that incorporate
financial risk. It also prevents many states from
comprehensively transforming the healthcare system across all
providers. The directors have said states need to be allowed to
align value-based purchasing approaches.
How do you feel about that? Ms. Snyder, what do you think?
Ms. Snyder. Congressman Carter, I am happy to answer
question to the degree that I can.
What I can tell you is that the State in Texas is well
aware of the requirement around a prospective payment system
and very committed to working with all of our managed care and
provider partners in the advancement of value-based purchasing
initiatives. Unfortunately, I cannot answer specific questions
in regard to FQHC reimbursement at this time, because the state
is in the midst of active litigation on the matter.
Mr. Carter. Oh, do tell about that.
Ms. Snyder. I wish I could, but I can't.
Mr. Carter. OK. We will give you a pass.
Mr. Holmes?
Mr. Holmes. Over the years, payment methodologies have
changed across all provider types, whether it has been a cost-
based payment, whether it is a discounted fee-for-service
payment, or whether it is prospective payment system payment.
FQHCs are currently reimbursed under an FQHC prospective
payment methodology for both Medicare and Medicaid.
A couple of years ago, Medicare updated their payment
methodology. And I think it is important to note that Medicare,
in that payment methodology update, retained the payment-per-
visit methodology where a bundled set of services is reimbursed
under that methodology.
We are looking at a change to value-based purchasing for
all provider types. I think the question that comes in with
value-based purchasing is how do you determine value? We have
seen, in Minnesota, for instance, we have clinical outcome
disclosures for outcomes of care for all medical groups. And
the medical groups will range from Mayo Clinic down to the
smallest safety net provider. And there are different ratings
for optimum care and for diabetic care or optimum
cardiovascular care.
But what concerns me about value-based payments is whether
or not that value truly reflects the skill and the care of the
provider or if it reflects the patient population that provider
served. If I was going to a value-based system, I would wonder
whether or not the best value is perceived in the suburban
areas where there are high levels of income, there are high
levels of poverty--or low levels of poverty and high education.
I think we have to be careful that value does not reflect our
patient populations but more accurately reflects the care that
is delivered by the provider.
Mr. Carter. OK. All right. Very quickly. I have just a few
seconds left. But I want to ask you, Mr. Holmes, if you have
experienced the 340B program? Do you all use that at all and
what has been the impact on your systems there?
Mr. Holmes. We use the 340B program. We have some savings
under 340B. In turn, we use those savings to pay for some of
our care coordinators and some of our patient assisters where
we can align our patients into the pharmaceutical manufacturers
patient assistance programs, because free is better than
discounted.
Mr. Carter. OK. Ms. Snyder, you all use 340B?
Ms. Snyder. We do.
Mr. Carter. And the impact?
Ms. Snyder. I think it is a very valuable tool, in terms of
influencing reimbursement in regard to pharmaceuticals.
Mr. Carter. OK. And what do you use the savings for? Can
you identify it specifically?
Ms. Snyder. Yes. I would be unable to identify it
specifically. But certainly, I think we are always looking at
opportunities to maximize savings that we are seeing in our
system through various means, including----
Mr. Carter. OK. Well, we are looking at that closely on
this committee----
Ms. Snyder. OK.
Mr. Carter [continuing]. And on the O&I Committee. So be
prepared on that. OK?
Ms. Snyder. Absolutely.
Mr. Carter. All right. Thank you.
Mr. Chairman, I yield back.
Mr. Burgess. The gentleman's time has expired. The chair
thanks the gentleman.
The chair recognizes the gentlelady from Florida, Ms.
Castor, 5 minutes for questions, please.
Ms. Castor. Thank you very much, Mr. Chairman. And thank
you to our witnesses and the role that you all have played with
your organizations and hitting this historic mark of 95 percent
of America's kids with health coverage now. And it certainly
isn't the time to go backwards. We need your expertise in how
we maintain that level. And anyone who cares about making sure
kids are on a pathway to success in life really need to focus
on this devastating TrumpCare bill and the most radical change
to health services for kids under Medicaid in the 50-year
history.
At the same time, we do need to reauthorize the Children's
Health Insurance Program. And there are a few portions of it
that I think are vital to maintaining that 95 percent an
upwards coverage rate. One of them is the enhanced 23 percent
bump. I have heard some people say that the 23 percent bump in
the match did nothing to improve children's coverage. Well, I
can tell you, coming from the State of Florida, and this
happened in many other states last year, we were able to
eliminate the 5-year Medicaid CHIP waiting period for children
by using that bump up. It has been a major win for children and
families.
In Florida, approximately 17,000 children were now able to
come onto the rolls. I know in Arizona they were able to lift
their enrollment freeze in CHIP, in KidCare, allowing 30,000
kids to receive healthcare coverage.
Ms. Mann, how important is it, as part of the
reauthorization, to maintain the 23 percent match, or bump up?
Ms. Mann. I think, as you note, it really has triggered in
a number of states. And the National Academy of State Health
Policy did a report talking to CHIP directors about the impact.
But also, as Ms. Snyder said, it really is integrated into
state budgets. And a new Kaiser survey of state budgets done by
Health Management shows that 26 states are experiencing budget
cuts. So I think if we pull those dollars out from the CHIP
program, we will definitely see repercussions. And as I noted
before, I think it is very much tied to the maintenance of
effort----
Ms. Castor. Exactly. That was my next question, because I
have heard folks say that that maintenance of effort that has
been in place for 7 or so years and then was extended, in a
bipartisan way, in the MACRA, some folks say that has limited
state flexibility and innovation, and it should be allowed to
expire. But, boy, that maintenance of effort has been vital to
the continuity of care.
So is that as it is important? Do the 23 percent go hand-
in-hand?
Ms. Mann. They go hand-in-hand. You could have a
maintenance of effort requirement continuing to protect
children's coverage and pull the money out from states, but I
think there would be a lot of unhappy states with that
arrangement. They really do go hand in hand. And I think even
more now than 2 years ago, in terms of the stability of
coverage is just critically important for children.
Ms. Castor. So if we didn't do that as part of the
reauthorization, do you think we would see the return of
waiting lists and lost coverage for kids?
Ms. Mann. I think we would. We definitely would see a
pullback.
Ms. Castor. One of my great fears, and I know it has been
intimated that, way back in the 1990s, Bill Clinton and the
Democrats fooled around with block grants. And I can tell you,
right now, this is very dangerous to the ability of our kids to
be successful in life when you move this direction. And I am
particularly frightened for my home State of Florida, because
Florida spends about $1,880 per child Medicaid enrollee. It is
the lowest rate in the country, Ms. Mann. If we went to
Medicaid caps, it appears that that would lock in Florida's low
spending rate. But we are a high growth state, and our needs
change over time.
What would happen to our state's ability to take care of
kids and the elderly and people with disabilities?
Ms. Mann. I think Florida is a good example of many states'
experience where they would be what is referred to as a
relatively low spending state. They would be locked into those
dollars, modified only by a small trend rate over time. And if
they chose to add benefits, if they chose to put different care
management in to help kids with asthma, kids with diabetes,
they would either have to do that at state dollars or by
cutting something else in the program.
Ms. Castor. Like education or----
Ms. Mann. As you know, in Florida there is not a lot of
give----
Ms. Castor. I mean, where would we go? Would it be folks in
nursing homes? They are very expensive. Or would it be special
needs kids or children's hospitals?
Ms. Mann. Absolutely. And nationwide, we spend about a
third of our dollars on long-term services and supports for the
elderly, for people with disabilities. Populations will be
vying for those limited dollars just to be able to keep steady,
never mind lose ground.
Ms. Castor. Thank you for helping to explain what is at
stake. Thank you very much.
I yield back.
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady yields back.
The chair recognizes the gentleman from Oregon, Dr.
Schrader, 5 minutes for questions, please.
Mr. Schrader. Thank you very much, Mr. Chairman. I
appreciate it.
Mr. Holmes, I would love to get into a discussion with you
on value based. You may have some good points if it was still a
silo-based delivery system in modern medicine. But I point out,
in the ACA, there were some risk adjustments to take some of
that issue away. And in Oregon, most of our physicians, nurse
practitioners in Medicaid/CHIP arena now use coordinated care
organizations. We get bundled payments so that it is not just
the doctor being responsible for the outcome. But you had a
social worker, a dentist, mental health provider. And, frankly,
they take it upon themselves to make sure they have ultimate
success. But I won't belabor that point. That is another
discussion.
What percentage of your community health centers' budget
comes from Medicaid?
Mr. Holmes. Nationally, it is just under 50 percent.
Mr. Schrader. OK. So that is a pretty big number. The plans
we have heard from our Republican colleagues would pretty much
devastate the funding for community health centers, because it
would be tough to make up that 50 percent.
What would happen to your expansion if the Republican plans
went into effective and you were cut significantly, and
particularly if you have any rural areas?
Mr. Holmes. Certainly, if we have an immediate reduction,
it places us in a difficult position. We have 10 different
medical and dental delivery sites in nine different
communities. There is no way for us to be able to sustain all
of those sites with a significant reduction in resources. That
means we are faced with which sites do we close, which staff do
we lay off, how do we reconfigure our providers. And it all
affects access to care for our patients.
Mr. Schrader. All right. Thank you.
Ms. Mann, I guess I will preface my comment. I am like a
lot of my Republican colleagues, I have got huge swaths of
rural Oregon in my district. And so I am a little surprised,
because 25 percent--well, no, actually, half of the kids in
rural Oregon get their healthcare through Medicaid. It is so
critical to the success and health of these communities. It is
a key portion. The rural hospitals are a key component and
portion of our economic growth in employment in these
communities.
So I am very concerned about how these reductions in
Medicaid reimbursement, certainly over the long haul, will
affect them. Can you talk a little bit more about what might
happen in rural areas if the Medicaid expansions roll back like
we are talking about?
Ms. Mann. I think one of the things we have been talking
about so far in this hearing about ways to modernize our system
of delivering care, ways to integrate behavioral health and
physical health, ways to bring in telehealth, changing care
practices, expanding our electronic health records, those all
require investments. And so the first thing that will go will
be any of those investments. And states will be scrambling to
bring their spending down below the caps that are set by the
Federal Government if the bill passes just because any dollar
spent over that cap will be wholly state dollars, and any
Federal dollars brought down over the cap will be clawed back
the next year and really harm the state.
So we will not see investments for sure, but we will likely
see reductions in funding for community providers and other
specialty providers that allow that fragile fabric of access in
rural areas to be able to work.
Mr. Schrader. All right. Thank you.
Ms. Snyder, you talk about the reduction in uninsured rate
for kids, I think 16 to 6 in Texas and stuff. What will happen
to that uninsured rate in Texas if some of the Republican
healthcare plans go through as currently envisioned? Will it go
up or down?
Ms. Snyder. So what I can tell you is the CHIP program,
clearly, in Texas precedes the advent of the ACA, the AHCA, or
the Senate proposal that was advanced yesterday. The CHIP
program in Texas is highly successful. As I mentioned, it has
resulted in a reduction in the percentage of----
Mr. Schrader. What about the Medicaid piece? If the
Medicaid reimbursement for Texas is cut as proposed, is your
children's uninsured rate going to go up or down?
Ms. Snyder. So we are, right now, looking at the
implications of the legislation that has been proposed on the
House side, as well as the proposal that was advanced
yesterday, to determine how that is going to impact the state.
What I will tell you, as a state----
Mr. Schrader. You are not sure quite yet?
Ms. Snyder. We are still looking into that, yes.
Mr. Schrader. All right. Well, I appreciate that, and that
is a good answer, given where you all are coming from. And I
feel sorry for a lot of your providers. I know rural hospitals
in your state, in many states, that did not do the expansion
are facing some pretty tough times.
I think there is some middle ground here, to be quite
honest with you. I too am in favor of making sure that Medicaid
is put on a budget, but a budget that is realistic and doesn't
result in tons of uninsured children, children that we should
not be balancing the budget of this country on. I worry about
that. But I look forward to work with my Republican colleagues
to fix this system overall.
And I yield back.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentlelady from California, Ms.
Eshoo, 5 minutes for questions, please.
Ms. Eshoo. Thank you, Mr. Chairman. And thank you to the
witnesses.
I just want to start out by speaking about what is racing
through me throughout this hearing, and that is that I have
lived my life for my children. And I think everyone here has as
well. We are talking about something that couldn't be more
sacred: our children, my children, your children, the children
of our Nation.
And I really am overwhelmingly sad by what is happening. I
can't believe that this is taking place in our country. There
is some sort of conflation that is going on here today. It is
important for us, obviously, to reauthorize the CHIP program
and the other, and with all of everything that should be a part
of it. But to have the evisceration of Medicaid as the top
issue, top line headline of today that is going on in the
Congress, what are we doing?
Children need patriots in the Congress. I don't know what
has happened to the Republican party. I don't recognize it.
Republicans that are in my district don't support any of this.
And a strong CHIP program depends on a strong Medicaid program.
So there is like a pretend thing going on here. CHIP this, CHIP
that. CHIP, CHIP, CHIP. What about the chipping away at or the
destruction of Medicaid? Does anyone here think that we are
going to be able to care for, provide what our children need in
our country if we rip away $834 billion out of Medicaid for tax
cuts that were taking care of them?
There are myths that are swimming around. The myth that 23
percent bump in the ACA did nothing to improve children's
coverage. Since the enactment of the enhanced 23 percent bump
and the matching payments for CHIP, the states have used those
additional dollars to improve the care and expand coverage for
kids in our country. There is a myth that CHIP is the primary
insurer of low-income children in the United States. Medicaid
is the primary insurer of low-income children in the United
States.
So, yes, CHIP is important, but let's not let all these
myths creep in around it. This is a shameful thing that is
taking place in our country. It really is a shameful thing, and
it is hurtful. What is going to happen to children that are
disabled? Anyone examined their conscience on that?
So I would like to go to Ms. Mann and ask you to expand on
the issue of disabled children. It is one thing for children to
get the basic care that we all provided for our children. I
think these families that have disabled children are among the
most courageous people in our country in what they need to deal
with. They get up earlier in the morning because they have a
lot of things to do for that child. It costs more money, more
doctors, more complications in their lives, more complexities.
And they try to balance their affections too, because the other
little ones may end up feeling that this one other child is
getting more attention from the parents. This is what takes
place in people's lives every single day across our country.
And we are sitting here in some insulated, air-conditioned,
green-painted room as if this one thing that we are going to
reauthorize, and we should, is just going to take care of
everything, and that anyone that is involved in it and votes
for it has absolution. They don't, in my view.
So, Ms. Mann, would you just say a few words about disabled
children and these programs that are knitted together.
Ms. Mann. Yes. Certainly. Thank you for your comments. So
Medicaid has many different eligibility pathways, and there are
many different definitions of what is a disabled child. There
is a category in the Medicaid program that if you have been
determined disabled by the Social Security Administration of
the state, then you automatically get Medicaid. In that
circumstance, there are about 1.9 million children around the
country who fit in that category. And based on that medical
necessity standard that we talked about before, they get the
care that they need, and they get the kind of care that really
is not otherwise available in the commercial market. And some
of them get special waiver service. They will get respite care
for that caregiver who, as you say, is going 20 hours a day in
terms of taking care of their child. They will get a wheelchair
refitted as they age and as they grow. So it is a very
important program.
And then there are other kids within the other categories
of the Medicaid program. They may be foster care kids, they may
be just low-income kids. They might not have a disability that
meets that level of disability, that gets them into the
category of disabled, but they are kids with very significant
healthcare needs. And they too have their needs met very
strongly by the Medicaid program, which is, I think, why you
see those statements from organizations like Family Voices,
Parents of Kids with Special Healthcare Needs.
Ms. Eshoo. Thank you so much.
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady's time has expired.
The chair recognizes the gentleman from Texas, vice
chairman of the full committee, Mr. Barton, 5 minutes for
questions, please.
Mr. Barton. Thank you, Mr. Chairman. I apologize. I, after
votes, took a group of Members and staffers out to the hospital
to see Matt Mika, one of the individuals that was shot in the
incident last week at the congressional Republican baseball
practice. So I am a little bit late getting back.
I think it is obvious----
Ms. DeGette. How is he doing? Give us a report.
Mr. Barton. He is up and----
Mr. Burgess. Do not violate HIPAA, come on. This is a
Federal--yes.
Mr. Barton. He is doing very well, Diane. I can't go into
details, apparently. But he is excited, and hopefully he is
going to be out of the hospital within a week.
Mr. Green. Did the chairman invoke HIPAA?
Mr. Barton. Yes, I am not a doctor. I can just tell you
what I saw. OK? I saw a breathing, happy young man who is
wearing the cap of his employer, which I am not going to
publicize. But they sell a lot of chicken and they are
headquartered near Arkansas.
Now, to the purpose of this hearing, Mr. Chairman, we want
to talk about CHIP reauthorization and community health
centers. And I think the last CHIP reauthorization I was one of
the chief cosponsors of. So we are obviously for CHIP and the
community health centers. My family foundation has bought a
building in my hometown and donated it to the Hope Clinic,
which is a community health center for Ellis County, and the
Nel Barton annex is providing services for low-income citizens
in Ennis, Texas, and is doing very, very well. And so we are
strong supporters of the community health centers and SCHIP.
I have two questions that I have been asked to ask our
distinguished panel. This one is for Ms. Snyder and Mr. Holmes.
This committee earlier this year passed a bill to charge
millionaires, people who have won the lottery, a little bit
more if, in fact, they have come into some extra money. To put
it in perspective, this policy change would mean millionaire
Medicaid beneficiaries would only pay approximately $70 more
each month. That would save apparently several billion dollars.
Would you two support making millionaires on Medicare to
pay their fair share to help pay to extend the SCHIP and the
health center funds? That was supposed to have been asked by
Mr. Walden, but he is not here to ask it.
Ms. Snyder.
Ms. Snyder. Congressman Barton, I am happy to answer the
question. As I have mentioned in my testimony earlier and in
some of my responses over the course of the hearing, in Texas,
we are very much in support of personal responsibility and
infusing a level of personal responsibility into the programs
that we administer. Certainly, this, I think, is a good example
of an opportunity to infuse that personal responsibility into
one of our programs in a way that is commensurate. Ultimately,
we hope, with the earnings, that each of those individuals is
lucky enough to be a beneficiary of lottery winnings is able to
draw down as income.
So we would support a measure such as that and would
support that it ultimately reflect the earnings in a way that
holds individuals accountable.
Mr. Barton. Mr. Holmes.
Mr. Holmes. Certainly, the expenditures of the Federal
Government are important to its people. It is also important to
where those expenditures are directed. We have common things
that we need to do as far as defense, but we also need to look
at the care of our most vulnerable populations. And in order to
do that, we need money. That money is coming from the
taxpayers. And we have to make sure that it is a fair system
and that it is a system that has good return.
I will say, from a health center perspective, we are
concerned about the return on investment that the taxpayer is
making in health centers and that we use those dollars wisely
to lessen the burden on the taxpayer, and that we show a return
for those dollars in the savings and the Medicaid programs and
the Medicare programs and throughout all of our patient
population.
Mr. Barton. My time has expired, Mr. Chairman. I will
submit the other question for the record.
I do want to say that we are working on a bipartisan basis.
We have a bill called the ACE Kids Act. And we had it in the
last Congress with over 200 cosponsors. Ms. Castor, who just
left, Mr. Green, I think everybody in the room right now who is
a Member was a cosponsor in the last Congress and hopefully
will be in this Congress. We are going to reintroduce that very
quickly.
But it is a bill for these special needs children that have
complex medical conditions to create a medical home so that
their care can be coordinated with Medicaid across state lines.
And it is a voluntary optional program for the states to
participate in. But if they choose to participate, it
apparently is a piece of legislation that will make the care
much better and also save money for the taxpayers. And we hope
to reintroduce that bill in the very, very near future. And we
have a commitment to have a hearing on it. And hopefully, we
are going to have a commitment to move that bill.
With that, I yield back.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentlelady from Colorado, Ms.
DeGette, 5 minutes for questions, please.
Ms. DeGette. Thank you very much, Mr. Chairman.
We have been talking a lot today about--at least on this
side of the aisle--our concerns about what this TrumpCare bill
would do to Medicaid and how it would interface with the CHIP
program, because CHIP is something that we have all agreed is
important for the children of this country, but it really does
ride on the foundation of Medicaid. I want to talk a little bit
about that.
The $840 billion cut to Medicaid and converse of the
program into a per-capita cut, under TrumpCare, it would then
be combined with President Trump's budget, which cuts CHIP
funding by $3.4 billion by eliminating this so-called 23-point
bump. So Medicaid covers 37 million children, and nearly 9
million additional are covered under CHIP. I am trying to
figure out what would happen if both the TrumpCare cuts to
Medicaid and the budget cuts to CHIP went through.
Ms. Mann, can you discuss, from your knowledge, how these
proposed Medicaid cuts and the CHIP proposal under the Trump
budget would affect children in the states?
Ms. Mann. Certainly. Thank you for your question. The House
provision around setting caps for the program would
fundamentally change the commitment that the Federal Government
makes to the children, to people with disabilities, to parents,
to pregnant women, to people, elderly, who are served by that
Medicaid program. And they would force states to have to
significantly reduce their spending in order to stay within the
caps, unless they were going to spend only their state-only
dollars.
And so the kinds of things that states would end up doing,
no doubt reluctantly, would be things that would reduce access
to care, things that would potentially look at some of these
specialized programs for kids with brain injury and special
healthcare needs, pull out funding around children's school-
based services and early intervention care. A number of
different ramifications we think that that would have.
In addition, it would pull out the funding for the
expansion population. And this often talks about the so-called
childless adults in the expansion population--I say so-called,
because I would be a childless adult. My children are grown. I
am not a childless adult. But many of those individuals covered
under the expansion are parents.
Ms. DeGette. Right.
Ms. Mann. And children do better when their parents are
healthy. So between those cuts and the budget cuts, I think we
would see a really devastating change for children's coverage.
Ms. DeGette. Let me follow up and ask you, do you think of
the children who would lose their insurance or lose some of
those specialized benefits under the cuts, could they be
covered by CHIP?
Ms. Mann. CHIP is not designed, both in its financing and
in its benefit structure, to pick up those children.
Ms. DeGette. To pick up those kids. That is right.
Ms. Mann. And if you are pulling the 23 percentage points
away from CHIP, we are going to see a ratcheting down of CHIP.
Ms. DeGette. But CHIP is really designed to be in addition
to Medicaid.
Ms. Mann. That is right.
Ms. DeGette. It is not as a substitute.
Ms. Mann. It needs the foundation of Medicaid in order to
operate well.
Ms. DeGette. Now, the administration has said they might
allow states to lower the bar on Medicaid benefits, cost
sharing, and other attributes. And I think you alluded to this,
but if those programmatic changes go into effect, then how is
that going to impact kids in light of the proposed cuts?
Ms. Mann. Well, there are many ways in which whether it is
increased cost sharing and premiums for children and families
at very low incomes, we talked about lottery winners, but most
of the children on Medicaid have incomes below the poverty
line. For a family of three, that is about $1,700 a month to
support three people every month for rent, food, utilities, all
that they need. So those kinds of responsibilities may be hard
for families to bear.
In addition, if there are reductions in the benefits. If
there are waivers to EPSDT and kids can't get dental services
or kids can't get transportation. We have talked about some of
the problems that children face in rural areas. They need help
getting transportation to medical care. So those are all of the
kinds of ways besides just absolutely cutting a group of
children who are high-needs children off the program that
states may have to turn to under caps and further budget cuts.
Ms. DeGette. And states have their own set of budget issues
too. In my state, we have a constitutional prohibition against
raising taxes without a vote. So it is not like states have
huge pools of money they are going to pour into this.
Thank you so much, and I yield back.
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady yields back.
The chair recognizes the gentleman from Illinois, Mr.
Shimkus, 5 minutes for your questions, please.
Mr. Shimkus. Thank you, Mr. Chairman. I'm sorry I wasn't
here. I was with Coach Barton as we went up to the hospital. So
I haven't been able to follow all the activities that have been
going on in the hearing.
And I think it is safe to say, bipartisanwise, that we
support the Medicaid program and we support CHIP. So the real
debate, from what I am gathering, is, you know, tied into
whatever the Senate is doing, whatever we did. So let me just
ask a question. Does anyone at the panel know our national
debt?
Mr. Holmes, do you know how much our national debt is?
Mr. Holmes. I believe that it is close to $20 trillion.
Mr. Shimkus. Ms. Snyder?
Ms. Snyder. That is my understanding as well.
Mr. Shimkus. Ms. Mann?
Ms. Mann. Nineteen point six, I think. And a little over 13
is public.
Mr. Shimkus. And what is debt? When we say that, what is
that? Is it safe to say it is our promises to pay future
services either--because we know what drives our national debt.
It is the mandatory spending programs. People don't like to say
this, but it is just true. It is Medicare, Medicaid, Social
Security, and our interest payments.
I will point everybody up to the pie chart, which has
been--I use this a gazillion times. So that is 2015 spending.
And when we find on our budget, we are fighting that blue area,
which is the discretionary. And we are going to be going
through that. Does anyone reject that pie chart as being an
accurate depiction of our Federal spending?
No. OK. I am seeing everybody believing that what we put up
there is accurate.
So in the red, we have automatic spending and Social
Security, Medicare, Medicaid, which means we are not engaged in
determining those costs. They are automatic, other mandatory
interest payment. And the blue is what we call discretionary
spending.
So go to the next chart. So this is what has happened in
our Nation since 1965. As you see that the mandatory spending
continues to grow, squeezing out the discretionary budget,
which are things like defense, education, HHS, Department of
Energy, roads, bridges, infrastructure, and the like. And so if
left unchecked, in 2026, we continue to start having big
problems. And that is why we discuss it.
We don't discuss the debate on mandatory spending out of a
desire to be mean, vindictive. We actually discuss this to save
our country. Admiral Mullen said in testimony before the Armed
Services Committee, our debt is our national threat. The threat
to our country relies in that depiction there.
So what we did in our healthcare bill--and I am not sure
what my colleagues on the other side ended up saying, but the
fact is we have Medicaid spending and we have a percentage of
growth, per capita growth. So as much as they want to say it is
a cut, over the years, it has increased Medicaid spending at a
slower rate than what would happen if you left it automatic.
That is the reality of the state.
So if someone is something you are cutting Medicaid, in
real dollars, they are not telling the truth. It is an
inaccurate depiction of what we have done. And my guess is that
is what has been going on today in the hearing. Where we are
trying to get control of the threat to our Nation, which is our
national debt, and we are trying to provide to our providers a
stable funding stream that grows and let them, through the
Medicaid program in the state, manage how best to provide for
their citizens in the states. Empowering governors, who are
actually closer, so it just impels me to raise that.
And my time is almost over. But I would just end on this.
This is from a report, and I can provide it to the minority. I
am not asking for it to be submitted into the record. But
current projections bear no resemblance to a picture in which
people historically dependent on Medicaid would lose their
benefits. To the contrary, CMS estimates that Medicaid
enrollment would stay roughly constant at current levels under
the AHCA, while still be being substantially higher than
projected before the Affordable Care Act was passed. Indeed,
CMS finds that many states would still cover some of the ACA
expansion population, even if lawmakers do away with the AC's
inflated Federal matching payment rate. This would mean
expanded coverage relative to pre-AC levels, while also being
equitable for the ACA.
And my time has expired, and I yield back.
Mr. Burgess. The chair thanks the gentleman. The
gentleman's time has expired. The gentleman yields back.
The chair recognizes the gentleman from California, Mr.
Cardenas, 5 minutes for questions, please.
Mr. Cardenas. Thank you, Mr. Chairman. I appreciate the
opportunity to hear from the witnesses and also the opinions of
our colleagues.
Unfortunately, my colleague, Mr. Shimkus, his time was
expired, but I would like at least one of the witnesses to take
an opportunity to respond to the narrative that we just heard
for the last 5-plus minutes.
Ms. Mann, would you like to maybe enlighten us a little bit
about the juxtaposition between the argument that was just made
on expenditures versus healthcare?
Ms. Mann. Sure. I will take a stab at that. Thank you.
Let me say a couple of things. One is that the Medicaid
reductions in spending in the bill largely are not being used
to reduce the deficit. They are largely being used to finance
new tax cuts in the bill. So the connection there is not as
strong as it might otherwise seem.
But I think the bigger issue in terms of the healthcare
debate is there is no dispute, I think, among anyone,
healthcare policy experts, hospital administrators, consumers,
state Medicaid agencies, that we need to do what we can to
bring down healthcare costs. And that has been, I think, what
people have been engaged in, particularly in the last 4 or 5
years, the integration of behavioral health, the physical
health, the care management, the telehealth. Those are all
mechanisms to deliver better care and to do that in a way that
lowers cost.
And what won't work is if you simply take one part of the
healthcare system, the largest source of coverage for the
lowest income people, and just say, on that program, we are
going to put a cap, because that doesn't change the cost. That
doesn't change the healthcare needs. It is a tougher job to do
that.
Mr. Cardenas. In the long run, what you just described, if
you just take away dollars and reduce benefits of being able to
see a doctor or getting healthcare, in the long run, doesn't
that set us on a trajectory to increase cost and reduce the
health level of Americans?
Ms. Mann. I think that is absolutely right. When people
don't get care at the right time at the right place, they go to
emergency rooms, they have more inpatient admissions.
Mr. Cardenas. That is preventative care, which, ``A stitch
in time saves nine.'' I love that. When I was a kid, I hated
hearing that, but now that I am adult, gosh, makes a lot of
sense, especially as a policymaker.
Ms. Snyder, taking a swath of money, like $1 trillion away
from our American healthcare system, and then--I don't know if
you agree with me, but having less people having direct access
to care, doesn't that create--in the long run, we put ourselves
on charting the course of, oops, now per person long term we
are probably spending more for healthcare and maybe not even
having better care, just more emergency care, more last-minute
care.
Ms. Snyder. So what I would say is I think the CHIP program
actually provides us with a great opportunity to look at a
program that does infuse some of those critical concepts into
the program framework that can help to drive down costs. Those
include state administrative flexibility, the inclusion of
personal responsibility----
Mr. Cardenas. Yes, but with all due respect, state
flexibility is something that is thrown around a lot. But if
you have more flexibility and a heck of a lot less money or
resources to provide care for your state constituents, your
people who live in your state, can that contribute to, oops, we
are now setting ourself on a course where less care in time
early on, less preventative care means that, oops, we are now
snowballing for different reasons and having more expenditure
need on care in the long run?
Ms. Snyder. So I think that is a great question, and I
think----
Mr. Cardenas. Well, what is the answer? Is that an accurate
narrative or I am just not seeing it right?
Ms. Snyder. What I would say is it is incumbent upon
states, and it is going to be more crucial than ever that
states----
Mr. Cardenas. I used to be a state legislator. I used to be
the budget chairman. So I know what it is like to make those
tough decisions, saying we have all the things that we love to
do but just not enough money to do it. And then when the Feds
go around saying we are going to block grant you, and all of a
sudden we went from taking off a 0 of how much money the Feds
give us, then we say, oh, my gosh, that didn't reduce the need
to provide for our constituents. All it meant is we have less
money to do it with.
Ms. Snyder. And I believe that is the case. And so what it
is going to really call on us to do is to critically evaluate
the data that we have on hand and ensuring that we are making
informed and smart decisions----
Mr. Cardenas. Sure. But with all due respect, if I were a
single mother with two children and people are telling me,
reevaluate your family situation, and I have no healthcare
coverage for my children, that analysis ain't going to do my
diddly when my son gets really sick and gets a fever, and I
don't have a clinic to go to, and I don't have coverage, and I
am not part of CHIP anymore because I am on a waiting list, or
I don't have Medicaid anymore because I am on a waiting list
for my state.
And then all of a sudden, guess what I am going to do as
that single mom? I am going to end up in the emergency room.
And, gosh, darn it, I think it is going to cost the state more.
It is going to cost that hospital more. It is going to tax
them. It is not going to help my challenge.
For Heaven's sakes, if my child has a fever because he has
a more serious condition, and if I would have taken him to a
doctor 2 years ago, they would have found it early, and all of
a sudden now my child has fourth stage something else. Oh,
believe me, we are going in the wrong direction.
And I appreciate your generosity, Mr. Chairman, for
allowing some of us to go over our time on both sides of the
aisle. Thank you. I am out of time.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from New York, Mr.
Engel, 5 minutes for questions, please.
Mr. Engel. Thank you very much, Mr. Chairman.
I want to make a statement and then I have a couple of
questions for Ms. Mann.
Let me say at the outset that I strongly support CHIP, the
Children's Health Insurance Program, and our Nation's community
health centers. I was very proud to support the Medicare Access
and CHIP Reauthorization Act back in 2015, and it most recently
extended those two vital programs.
I would like to point out, though, that those
reauthorizations passed the House in March of 2015 and was
signed into law by mid-April, and yet here we are at the end of
June without a plan to fund programs set to expire in
September. It is certainly not right.
And in reality, our timeline is even tighter than that.
Months before their funds are depleted, some states must start
the process of shutting their CHIP programs down. And that
means that if Congress doesn't act fast, it is entirely
possible that children will see their coverage disrupted, and I
think Mr. Cardenas pointed that out.
So why hasn't Congress acted yet? Why didn't we vote to
extend funding for CHIP and community health centers in March
as we did in 2015? And the answer is that TrumpCare monopolized
the House's time and prevented us from doing all these
important things.
And that is not the only thing that TrumpCare has
endangered. TrumpCare will cut and cap care for the 37.1
million children on Medicaid. And on top of that, TrumpCare's
radical restructuring of Medicaid has dangerous implications
for the CHIP program. A strong CHIP program depends on a strong
Medicaid program. They work in concert to afford children
comprehensive coverage.
How? First of all, more than half of children with CHIP are
actually enrolled in expanding Medicaid coverage that is
financed by CHIP. These programs also work together to meet the
needs of different populations of kids since Medicaid covers
benefits that other insurers do not.
CHIP reauthorization is vitally important for America's
kids. I don't dispute it. My Democratic colleagues don't
dispute it. But in a discussion on this topic--a discussion on
this topic can occur in a vacuum. If TrumpCare becomes law and
Republicans therefore succeed decimating Medicaid, there is no
way to go around it. Children will be much worse off.
I want to talk about President Trump's budget, which
unfortunately exacerbates the problems that TrumpCare creates
for kids. While we should enact a full, long-term extension of
CHIP, this budget proposes harmful changes to the program.
What does it do? It will abolish the enhanced Federal
funding match that states get now. It will overturn the
requirement that states maintain children's current eligibility
levels, turning back the clock on historic coverage
improvements, and cut off support for CHIP kids above 250
percent of the Federal poverty level.
I want to talk more about this last point, because right
now, 24 states have income eligibility for Medicaid and CHIP
and are greater than 250 percent of the Federal poverty level.
This includes my State of New York. We are a high cost-of-
living state. So what you buy in New York, you buy a lot less
for the same money than you do in other states. It is
ridiculous to penalize states like mine. The administration
wants to cut off Federal dollars, give nearly half of all
states the flexibility to cover children above 250 percent of
the Federal poverty level.
We hear a lot about states' rights, and yet we want to take
away the flexibility that states have, the programs that states
deem are important for them. We want to tell them, the Federal
Government, what they can and cannot do. So much for states'
rights.
If this cut takes effect, I have to imagine that states
will have no choice but to restrict eligibility for the CHIP
program, thus cutting off care for children who have CHIP
coverage today. So it is bad enough that we won't be helping
children who need this coverage; it will be throwing children
off who have it today.
So let me ask you, Ms. Mann, since this provision would
affect my district, where one-third of children are covered by
Medicaid or CHIP, I am extremely concerned about its potential
effects. Can you tell us what we can expect to happen if
Federal support for CHIP kids above 250 percent of the Federal
poverty level is cut off?
Ms. Mann. Thank you for the question. You are absolutely
right. We have about 24 states that cover children at some
income levels above 250 percent of the poverty line.
Most of the children actually in the program, 97 percent,
have incomes below 250 percent of the poverty line. But those
states that have increased their eligibility levels have made a
determination, have exercised their safe flexibility because of
cost in that state, because of market conditions in the state,
for various reasons of concern for the kids in their states
have decided that having CHIP as an option for those children
is really important.
And I should say, New York, like every other state that
covers children at higher income levels, requires the families
to pay a portion for their care, so there is premiums and the
premiums slide in accordance with the income.
If in a state like New York with high healthcare costs and
high premiums for other kinds of coverage have to end their
coverage, go down to 250 percent of poverty, those children
will be scrambling for other kinds of care. They will pay
higher cost. Their benefits won't be as pediatric focused as
they are in the New York CHIP program. And many of them,
because of what is called the family glitch, won't be able to
qualify for subsidies in the marketplace.
Mr. Engel. Well, I had a couple of more questions, but you
have really answered them about how this in turn would effect
coverage levels----
Mr. Burgess. That is good, because your time has expired.
So the gentleman yields back, and the chair thanks the
gentleman for his participation.
I want to recognize myself for questions. The chair would
point out that the chair did delay his questions until the end
to allow all other members to ask their questions and then
accommodate their travel plans, if they had them. I may not use
the entire 5 minutes, because this has been a very robust and
insightful discussion.
We do have a task ahead of us, which is the funding for the
State Children's Health Insurance Program, which concludes on
September 30 of this year, the end of the fiscal year. That, of
course, was a fiscal cliff that was set in motion under the
Affordable Care Act, when the Affordable Care Act passed and
was signed into law in 2010, as CHIP was reauthorized to the
end of fiscal year 2019, funded only until the end of fiscal
year 2015. Your chairman, as part of the SGR Repeal, managed to
get 2 years of funding until fiscal year 2017, and that is the
task that is ahead of us at this time.
So, Ms. Snyder, I need to ask you what is just a very
practical and Texas-focused question, but since the majority of
the dais members now are from Texas, it will be appropriate.
You said in your testimony, what you provided us in your
testimony, that Texas has just concluded its legislative
session. Is that correct?
Ms. Snyder. Exactly.
Mr. Burgess. And Texas, the legislative session is every 2
years. So your budget is now set until the next legislative
session in 2019. Is that correct?
Ms. Snyder. That is correct.
Mr. Burgess. And there were some assumptions made by the
finance committees that are there in the Texas House and Texas
Senate, the budget committees in the House and Senate, there
were some assumptions made that the funding for State
Children's Health Insurance Program would, in fact, continue
until 2019. Is that correct?
Ms. Snyder. Yes, with the 23 percent additional bump in----
Mr. Burgess. So changes that we make now come after the
fact for what your state Senators and state representatives
assume to be what was going to be available for them to include
in their budget, and any changes we make now would have a
significant effect on the state budget that has already been
passed and I believe signed into law. Is that correct?
Ms. Snyder. Exactly, an $800 million impact over the
biennium.
Mr. Burgess. So I understand the importance of getting this
done. And let me just also say that under current law, under
the Affordable Care Act, under current law, something happens
to disproportionate share funding in Texas. Doesn't it?
Ms. Snyder. Yes.
Mr. Burgess. What is that that happens to disproportionate
share funding? They have funds that go to hospitals that see a
disproportionate share of Medicaid, low income, and uninsured.
What happens to those funds in Texas?
Ms. Snyder. Can I ask you to clarify the question?
Mr. Burgess. What happens under current law, under the
Affordable Care Act, so-called DSH funds, the disproportionate
share funds, those additional funds paid to hospitals, paid to
institutions to see a disproportionate share of Medicaid low-
income and uninsured, what happens to those funds at the end of
this fiscal year?
Ms. Snyder. And I am sorry, I don't know the answer to the
question.
Mr. Burgess. Well, I know the answer.
Ms. Snyder. And I apologize.
Mr. Shimkus. I know the answer too.
Mr. Burgess. And I will be glad to share it with the
committee. Those funds, under current law, under the Affordable
Care Act--of course, everyone is going to be lying down the
allegiant fields of ObamaCare. There is going to be no need to
provide additional funding to those hospitals because everybody
has got this wonderful health insurance that was provided under
the ACA.
But under current law, Texas is going to lose those funds
in October of this year, and that was an effort--we did try to
correct that in the bill that passed through this committee in
a 28-hour markup and passed on the floor of the House the first
part of May. And I know my state counterparts were very
interested that we take care of that discrepancy, and I think
that we have.
Let me just ask you, because I have run a little bit long
with that, we all want our dollars to be spent appropriately.
And Medicaid has a history. Sometimes dollars aren't always
spent appropriately. But over and above the dollars being spent
appropriately, if a patient is eligible for Medicaid, but they
also have a commercial insurance, another third party that is
supposed to be liable for their medical care, sometimes the
path of least resistance is just to bill the Medicaid system,
and that seems to be a quicker way of collecting the money.
But one of the things that we have been working on is to
enhance the ability to collect the third-party liability, if
there is coverage that is actually owed by another payer, a
commercial insurer. So what has your experience been in
managing potential overpayments within the state related to
third-party liability?
Ms. Snyder. So we are very committed in the State of Texas
to ensuring, when there is another payer source, that we are
capitalizing on that payer source and that Medicaid remains the
payer of last resort.
We have efforts underway, both within the Medicaid program
and in conjunction with our inspector general, to ensure that
we are systemically drawing on the funding that is available
from those other payer sources. It is one of our priority
projects every year, understanding that that Medicaid impact is
the payer last resort.
Mr. Burgess. Very good. Well, we will have legislation
coming on that, and I appreciate your input on that.
Mr. Holmes, let me just ask you. I certainly appreciate
what you do and what other people involved in community health
centers and federally qualified health centers provide. When a
patient sees a physician or a nurse practitioner at a federally
qualified health center who is covered by Medicaid, is the rate
reimbursed by Medicaid the same as it would be by a physician
practicing in private practice in the same town?
Mr. Holmes. It is not, in most cases. Health centers are
paid under a PPS system, and it is a bundled set of services
for the Medicaid patient. And it is based on payment
methodology that was passed through Congress many years ago.
And that is different than a discounted fee for service payment
arrangement that currently exists with a number of other
Medicaid providers.
Mr. Burgess. And that would be the provider out in private
practice?
Mr. Holmes. That is correct, unless those providers are in
a capitation system or in some type of ACO.
Mr. Burgess. Be careful. We have heard that ``capitation''
is a bad word this morning.
Mr. Holmes. It is a method of payment where you are paid on
a per-member per-month basis. And for that per-member per-month
basis, you are delivering the scope of care within that
agreement.
Mr. Burgess. And another aspect of the difference between a
doctor in private practice and a doctor working in a federally
qualified health center is the liability question. Is that not
correct?
Mr. Holmes. That is correct.
Mr. Burgess. So a doctor in private practice has to carry
medical liability insurance, which, as you know, in some areas,
can be quite expensive. But in a federally qualified health
center that cost is ameliorated by participation in the Federal
Tort Claims Act. Is that correct?
Mr. Holmes. That is correct. And it was under Congress'
direction to include health center physicians and providers in
FTCA, because they felt it was a method to save healthcare
dollars.
Mr. Burgess. And I don't disagree with that. In fact,
probably when Gene Green was in the State House in the early
1990s, our state legislature provided doctors who did a certain
percentage of Medicaid in their practice the first $100,000 in
liability coverage. That didn't last, and I don't know why. It
was probably too expensive as a state program.
But if we want to encourage the number of providers to see
patients who are covered by Medicaid, that seemed to me to be a
very forward-leaning aspect of what they did back in the early
1990s. So I want to thank my colleague from Texas. I am sure he
was the main driver of that liability assistance when it
occurred.
Well, I want to thank all of our witnesses. Seeing no other
members wishing to ask questions, I do want to thank the
witnesses for being here.
We received outside feedback from a number of organizations
on these bills, so I would like to submit statements from the
following for the record: the American Academy of Dermatology
Association; America's Essential Hospitals; American Academy of
Family Physicians; AHIP; the Healthcare Leadership Council; our
House colleagues from Minnesota; a CHIP letter from 1,200 local
state and national organizations. So without objection, so
ordered.
[The information appears at the conclusion of the hearing.]
Mr. Green. Mr. Chairman, I won't ask for the 4 minutes
extra you have on your 5 minutes, but----
Mr. Burgess. No, sir, I accrued all of the extra minutes I
gave on your side and utilized them for our side, because I
knew my questions would be most important.
Mr. Green. Well, I appreciate your activity, but that was
taken at the end. All I want to do is--give me 1 minute.
Mr. Burgess. The gentleman is recognized.
Mr. Green. First of all, I was in the legislature in 1991,
and I am not sure but--after that I ran for Congress. But the
State of Texas is going to be in special session. Is that not
correct?
Ms. Snyder. That is correct.
Mr. Green. In the next few weeks. Having been there and
done that, nobody likes special sessions in summer.
But the other issue is, Texas did not expand Medicaid. Is
that correct?
Ms. Snyder. That is correct.
Mr. Green. OK. And the other issue is third-party coverage.
That is not unusual, because if you have an auto accident, the
hospital has--in Texas, I assume everywhere else--has a right
to put a hospital lien on that, whatever you win from your
lawsuits. So I don't have any problem with Texas doing that
under Medicaid, so that is pretty common.
But that is not going to solve our problem with Medicaid in
our terrible program we have in Texas. And even there, when
Democrats were in the majority, Texas has always have been very
conservative. Our Medicaid program is nothing compared to some
others.
And, in fact, I will give one example. After Katrina, the
Houston area received a quarter of a million people. We brought
them in under our Medicaid system, although the state
legislature was out of session. We were able to get Federal
money to do the state match for those folks, and over a period
of time, they either went back to Louisiana or they became
Texan. And that is when I found out that Louisiana actually
gets 75 percent Federal reimbursement, and Texas receives 67
percent. And I would hope maybe our subcommittee could look at
that and see why is it more expensive than Louisiana.
Mr. Burgess. Will the gentleman yield?
Mr. Green. I would be glad to.
Mr. Burgess. I do not know all of the intricacies of the
formula that CMS uses to calculate, but it is based on the
average state income as well and probably reflects that average
state income in Texas is somewhat greater than the average
state income in the State of Louisiana. And that is probably a
fiscal fact for which we should both be extremely grateful and
thank our lucky stars that we live in Texas.
Mr. Shimkus. Would the gentleman yield?
Illinois is a 50/50 state, so I just want you to put that
on the record.
Mr. Green. Thank you, Mr. Chairman.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
Let me just continue on the unanimous consent requests that
I was doing. I also want to ask unanimous consent to submit for
the record copies of the Congressional Record volume 141, issue
207, Friday, December 22, 1965, where Senator Patty Murray
introduced to the record over in the Senate a letter to
President Clinton asking for the participation in a per-capita
cap arrangement.
Mr. Green. 1995.
Mr. Burgess. Did I say 1995?
Mr. Green. You said 1965.
Mr. Burgess. 1965. 1995. Time flies.
I also want to submit for the record a New York Times
editorial from 1997, February of 1997, called ``Making the
Budget Bearable,'' where they point out that the President
offers an important reform of Medicaid proposing to control
future spending by placing a cap on the amount of Federal
spending per enrollee and allowing states to place enrollees in
managed care without going through the frustrating process of
begging for Washington's approval.
Without objection, so ordered. Those things will be entered
into the record.
Mr. Burgess. Pursuant to committee rules, I remind members
they have 10 business days to submit additional questions for
the record. I ask that witnesses submit their responses within
10 business days upon a receipt of those questions.
Without objection, the subcommittee is adjourned.
Mr. Green. Mr. Chairman, we could be here all day, but I
also wanted to remind you, in 1995, I think the Senate
Republicans wanted an individual mandate.
Mr. Burgess. That was actually in response to a request for
a block grant.
The subcommittee stands adjourned.
[Whereupon, at 1:14 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[all]