judy moore. who is the co-author of "medicaid politics and policy." so he literally wrote the book on medicaid. going to moderate our plenary seeings which is medicaid at 50. past, present, and future. and our panelists will be, namd president, tom bet lack of arizona, and former medicaid directors deb bacharach of new york, chick milligan of new mexico and maryland, and vern smith of michigan. so, with that, i am going to turn over the mic to judy. we're having a very relaxed talk show format and i'll pad for time while vern gets mic'd up -- he is good. with that, judy, thank you. we look very much forward to the next session. thanks, everybody. >> thank you. well, i think that we're going

to try to have a good time this morning. i think that secretary burwell set us up as talking about the engine of transmake and we want -- transforation. i know that most of my panelists -- my co-panelists this morning feel that medicaid was really pretty much underappreciated for an awful lot of years. now if john oliver is talking bit, we know we're in the mainstream, and i tell you, that wouldn't have happened in the '60s and '7s so or maybe even the '8s so and possibly not the '90s. so we have come a long way in terms of michigan healthcare delivery, financing, coverage of people, children, think

medicaid's history is not as bleak as people give it short shrift for. that's what we'll talk about this morning. we'll do this as a facilitated discussion. when matt put this panel together, he thought we would get representatives of all the decade's of medicaid, but truthfully i then vern and i have to go pack for the '60s and the '70s. these folks too young -- maybe the '8s, too, vern -- but we will try to have a facilitated discussion this morning. i'll throw out some questions and ask one of these folks to give me some impressions and we'll have a very informal discussion, and then towards the end of our time, we'll turn to you and ask if you have some questions or comments that you want to throw into this discussion. so, we'll try to cover some of the main themes of medicaid over the 50-year history of this program, and look towards the

future and what this building over the last 50 years is going to mean for the future. so all of that said you have heard about tom betlatch. the current arizona medicaid director. to my left is deb bacharach. i won't tell you a lot about these people because you can read about enemy your materials. deb is now partner in -- on the other side of me here is vern smith, the dean of the medicaid program as far as i'm concerned, who was the michigan medicaid director for many, many years, and is now managing partner at health management associates, and chuck milligan on the end, who has been a medicaid director in a lot of states and a lot of places, and is back in new mexico as the director of the united healthcare community plan there in new mexico. so, we are going to talk a bit

about the history of the program. on the slide which i think we'll have them put up -- there it is -- i have listed the four kind of eras medicaid as dr. david smithed, my -- 65 to '80 a was a period where the program really ran on the statutory basis. that is, the medicaid program represented what was written in the statute pretty much. in the latter part of those year there was little built -- bit of changes of interest to some states but there was kind of a classic approach to implementing that statute. in the '80s and early '90s there was enormous growth and change. a lot of legislative change in the program.

we started serving children and moms in a much better way, and there was some tension but nothing like the third period, which we call in the book, siege and response. a lot of threats to the program. a lot of criticism of the program. a lot of conflict over the program. and i'll -- still continuing some growth of the program, and a lot of changes and new interesting things happening in the program. then from 2009 on with the passage of aca we're moving towards universal coverage and continuing that transformation and many of the other transformations mentioned this morning. with that kind of. bit of background, let me go on and start with -- everybody's favorite medicaid subject and that's eligibility. it's where it all started.

eligibility change and redesign over the 50 years of the program and i'd like to throw out particularly to deb, who works a lot on these issues, always has, in their tenure around medicaid, but is looking with states to the future of what they want to do in eligibility redesign and also to vern who saw the very beginnings of this program and had to live with eligibility difficulties in a much more welfare constrained system to start us out and say a few words, lefts start with you, vern. >> sure. it's great to start with eligibility. medicaid is always known as a complex, confusing program, and of all the aspects of medicaid the one that is most confusing and complex is eligibility, even to the extent that supreme court justices have weighed in on this, going way back, not just the recent supreme court, but

justice powell famously referred to medicaid as byzantine. the eligible part he was referring. to chief justice burger revved to medicaid as complex, a morass of complexity, a maze, that's eligible. the beginning, medicaid was the health benefit for persons on welfare, and that was pretty much it. and as i was looking back through my files -- my old files, i've come to appreciate why i'm hereafter because i'm hold. >> and you have files, and i. >> and you have good stories. >> afound a memo from the first administrator in 1971 when it was created, and to sect califano, which i learned last night that dianne rowland actually wrote this.

this is in 1978. it says: medicaid is the healthcare financing program for the welfare population. and that was true, completely true. goes on to say. medicaid embodied the problems of all the problems of the welfare statement and the healthcare system, which is something we have lived with for the entire period of time. just to illustrate this, because it came from welfare, we had all the data, the statistics, on the recipients, what everyone on medicaid was referred to, all the recipients. renew how many of these mothers were married, divorced, separated, or deserted. this an ear re of the deserving poor and that was what we had through medicaid, through the early years. that all began to change in the 1980s. and we came up to the significant pointin' 1997 when medicaid was delinked from

welfare officially. stale work in progress in many ways, but all of these things took place over time to kind of take us from where we were then, a healthcare program for people on welfare to who we are now, where at least in my state, in michigan, just looked it up, fewer than 15% of medicaid beneficiaries are on welfare and that includes all those on ssi. so, the program is completely changed. it's no longer -- it is that but it is way more than that now. >> so, deb, comment a bit on how you see the program now and into the future, and having to live in many ways -- at least in some ways -- with the legacy of the welfare roots but what states are doing to address that and what more we need to do to address that in the future. >> i think judy's question and, vern, your history, reminds us that we do have welfare roots

and that fast forward, we have -- i keep saying we. what everybody on the statement would say, once a medicaid director, always a medicaid director so the we is, we medicaid directors. we're now in the health insurance phase. we moved out of the welfare space but there's always that tension pulling us back. so let's say on the good side. what did the aca do it? it gives state the option dish'll use the word option of expand -- come back to that later -- dud did something equally dramatic. it imposed federal rules -- we. come back to federalism tension -- imposed federal rules to make it easier for people to get on and stay on medicaid. when i started in medicaid, you needed four consecutive pay stubs had to have a face to face interview and be fronted. we have knew shifted out of that mold of we don't trust you, we

don't want you on, to, we want you on, and the rules align with the marketplace, not with the welfare program. so we have created a foundation of coverage, paradigm of coverage which enables us to do the kind of payment and delivery system reform that virtually every medicaid director is now focused on and the secretary talked about and we couldn't do that if we couldn't get our population covered and covered in a stable manner. all of which relates back to the change in the eligibility and enrollment process. and i think that's a huge legacy of the affordable care act. whether your state expanded or didn't. >> there's one missing piece in all of that and that is we still have 90-plus percent of individuals on s.n.a.p. in medicaid and the results for medicaid is 600 bins rules and 6,000 business rules for s.n.a.p. so, for all of us states that

are out there trying to work with partner vendors around building an integrated system, it is still very problematic to in essence capture many of the same folks and have this veer complex business rules we're steel killing -- dealing with because there's a lack of alignment with s.n.a.p. and medicaid. so without getting too much into the weeds, another significant step that needs to be taken in terms of trying to make this more meaningful and less of a burden. >> judy, do you mind if i jump in? >> please. >> once a medicaid director, always a medicaid director unless you're tom and then you're always a medicaid director. >> bringing up the average. >> the point i want to make is that employer-sponsored insurance took off in world war ii. employer sponsored insurance, unions had gotten very strong. there will wage controls in world war ii, employers couldn't

raise wages and so health benefits became a way of attracting workers as loophole for wage controls. so there was a very strong bias toward employer sponsored insurance at the time in 1965 that medicare and medicaid came along and medicare and medicaid came along then as who doesn't have access to employer-sposhed insurance in for medicare it's retirees and people with a long work history and then became personally disabled and in medicaid it's a lot of the welfare families that there was a social judgment made that typically moms of these afdc households shouldn't be working. they had kids to raise. there were people with disabilities that didn't have a work history that should be on medicaid. so it really became -- medicaid became a health benefit attached to a government pay benefit. sort of an esi analogy, with employers you got your salary

and health came with it. with medicaid you got your well fir check or ssi check, method okayed came with it. but then there was this judgment, this very strong social judgment, that if you were just simply a poor adult, not a welfare household, not a permanent disability, you ought to be working. that what's social judgment, and get your health benefits through esi, and that cohort of low income, unemployed, not permanently disabled, not ssi population over the years becomes the medicaid expansion population. so it really -- part of the origin of medicaid as a benefit was it was always an ancillary benefit to some sort of a cash benefit modeled analogous to esi, and that framework that is the kind of the trailing benefit. it's not a benefit in itself. it's tied to a cash benefit,

with a long part of that early period of medicaid really as aned a at junk to a dominant esi model at the time. >> ladies first. >> go ahead. >> this like the republican debate. >> that does that say about judy's moderating. >> right. right. i was thinking about the -- grabbing time. so i think that -- comes back to the question judy asked, the so-called work requirements. so, we have all talked about how we're trying to make -- that the system is moving toward medicaid as health insurance, on one side we're aligning with the marketplaces. we recognize that a lot of our beneficiaries are in s.n.a.p. so we're trying to align across, but that welfare history comes back to haunt us with calls for

work requirements, or calls that people should be on medicaid for no more than five years. i think that we -- okay. personally issue think we have to resist those calls because it will undermine medicaid's effectiveness as a health insurance program. i think that's why cms never granted waivers to permit those type of requirements in the alternative expansions, and if do think they undermine the far reach of method okayed, medicaid into the future, as health insurance and driver of health system reform. >> can i jump in on that? i think that one of the aspects, we have 50% of the population in the age bract of the 19 to 64-year-old adults which ill relatively a new population in terms of who we are serving and medicaid has historically done a

great job of creating systems of care for new borns, low birth weight babies, the elderly, and we have to take a closer look at what are we doing to engage folks that are in that 19 to 64-year-old. so we can sit here and debate what the policies look like, but part of the evolution of medicaid post aca is what are we doing to create systems of car and connect those individual in the medicaid program to other social services and to look at broader systems of care for that population. >> and this might be a good place to just emphasize that medicaid has been for people on welfare from the beginning, and the others, but as we got into the middle -- after 20, 25 years, around 1980, people began to look at what this program was doing and who it was serving, and especially the role it was playing with women who were

pregnant and small children, and this literature -- >> that's where i want you to go. >> okay. so, this transformation from a welfare program to a health program began in the 1980s with this literature that says, we have kids that aren't faring so well. we have women who are bearing children who aren't doing well. the infant mortality rate in this country was high, and there was a lot of concern about that, and one vehicle for doing that was to provide medicaid coverage for million who are progress -- for women who are pregnant and infants. so in 1986 medicaid had a coverage that began for pregnant women and infants up to age one, and then it became mandatory up to the -- up to 133%, and then children ages zero to six, all kind of congressional action 86, 87, 88, 89, and then it was

optional for states to extend coverage for kid above age six at poverty level, and then, very significantly -- this is just a stroke of genius -- that the congress, congressman waxman in particular, said this is a time when we can coverage -- we don't want these kids at age six to age out of medicaid coverage, and made it such that every child born on and after october 1, 1983, would continue to have coverage. so, kids no longer aged out and new cohorts of kids came on every year, and as a result of that we reached a milestone which for me is one of the significant milestones in medicaid. on october 1, 2002, we reached the point where every child, up to age 18 in america, had been born on or after october 1, 1982, and on that day, america covered every child in america

that was poor up to the federal poverty line. kind of an underappreciated milestone but i think very significant along the road as we go. >> and as vern points out, medicaid has had a lot of years to perfect the coverage of children and moms and kids, and that's partly reflected in the numbers that people have spoken about today, the number of births and children covered. does anybody want to weigh in on what the future holds for medicaid and the coverage? do you think we still have lots of interesting things to learn? do you think we just need to consolidate our gains and keep doing this work? >> i think one of the discussion points is what's the future of chip, and so in arizona, going back to the great recession, we have had a freeze in place, and when you look at our marketplace enrollment number wes have the highest percentage of children in the united states by far enrolled in the marketplace coverage so there's the whole discussion around family

continuity and other things like that, that are important. so i think that's part of the policy debate going forward, is what happens to chip. >> and i would say part of it, too -- i know we'll be talking about integration later on -- but a lot of the kids who are in most disturbed or juvenile justice involved, or special ed, have individualized education programs, part of the school systems. the think part of where things are going to continue to go is how medicaid can retreat a lot of other safety net programs for kids in state custody and in special ed and what this meaning of a medical home if you have a lot of school-based therapists and nurses touching a child as well as you have a pediatrician and how do you link care at a more cross-program level. >> actually, i think it would be

a good place to move on to integrated services and i think this is another area where medicaid in the past has not given credit for having pioneered some of these approaches. not that they have been universal, not that they have perhaps continued, but a lot of states, even as far back as the '70s, have tried to integrate services with housing and with mental health and so forth. i think it's been done on a much more systemic way right now and, therefore, that means it's more likely to really move the way we deliver care. tom do you want to weigh in on this one? >> sure, i can start it out. i'm sure everybody has opinions around this. i think the challenge around integration goes back to when medicaid was created, state governments already had in place programs to serve meant health, serve the elder and

developmental disabilities and we just medicaidizeed those silos silos silos and the those structures without thinking through, what does that mean from a broader system perspective, how we actually want our delivery systems to look and what is going to make sense. and so you still see today where many of those populations and services sit outside of the purview of the medicaid director, but you're starting to see some robust conversations around what makes sense from a delivery system perspective and where do you look at integration. started at the statewide policy level and what type of integration and then from a payer, low fee for service or -- you're seeing that across the continuum of services and populations, and then what can we do to incentivize integration at the provider level as well to improve the delivery system for visiteds simple real use look it's as three tiers and this continual evolution of going back to sort of the historical

remnants we started with, and advancing that forward through a more thoughtful process of what systems should look like. >> anybody else want to -- >> well, just to comment on the general direction, in the surveys we have the privilege of doing with the kaiser family foundation and mamd, we have a series of questions on what is going on with delivery system reform and payment system reform and son. if there's one thing that characterrite medicaid programs today it's a focus on what they can do to make their programs better in the sense of achieving better outcomes and so on. there are just examples after -- many, many examples that you can cite. arizona is exemplary, and there are 49 other exemplary states. it's amazing what states doing now, and if you want to look at one place where medicaid is the leader in the healthcare system, look at medicaid.

it is definitely, definitely leading. trying things that folks haven't tried. having the ability to be flexible and one state learns from another and it's truly remarkable. >> i do want to comment about this. so, i want to just contextualized for a second. because of the population medicaid serves with kid with various forms of -- they've been through abuse, severe and emotional disturbances, a lot of adults, the most -- the highest rate of really severely mentally ill adults and others, there's been a lot of integration and tom touched on this. some has been medicaid maximummization, how to get funs in to serve needs that the state was pick upping entirely threw state safety net program but there are -- and there's been a lot of work to integrate

services at the medicaid member level, but i want to sort of -- a couple comments. one are there's a lot of real and ongoing challengeness this area. a lot of state and local agencies that their core has always been getting grants. they haven't had a claims-based insurance-based system. how our state agency partners get engaged with medicaid when they're more accustomed to giving a grant to for example, core service agency, or working sort of more autonomously of an insurance model or medicaid model. how those come together is an ongoing discussion. from a governance point of view, a mission culture point of view. i think the second point i want to make is the trend for those of you who have kind of trying to kind of guess where the puck is going with all of this stuff, the trend clearly is

integration. integration at -- i want negligence three levels -- one of is at a clinical level so that you have -- if there's a psychiatrist or a area trix or a school-based iep, they're integrating at a clinical level with the child's pediatrician, so there's one treatment plan, everybody knows what is going on, across pair sources, across agencies, across types of care. so at a clinical level there's that piece. there's integration at a provider level, which is coming along a lot more. you're seeing a lot of federally qualified health centers focus on integrateing behavioral health. you're seeing a lot of hospitals get very engaged. that's have readmission and other standards that they're learning more about for medicare

and medicaid, they're identifying the fact that fully 50% of their emergency department visits have some underlying behavioral health condition which is a shocking news for a lot of hospitals that haven't paid attention. so you have at a provider level greater emphasis on integration, and then at the payer level, how you finance it to drive those incentives, and it is clearly the trend, and there's clearly room to go, but medicaid is driving those trends. >> so may i jump in? , i have two points. first is both tom and chuck alluded to this. in some sense we have met the enemy and it is us. right? at the state level, we have got these silos that we have been living with. the medicaid director with authority over physical health. then a substance abuse agency, enemy health agency and probably developmental disability agency, and then we often have the

counties who had a level of responsibility on mental health and substance abuse, and now we want to integrate. 0 so we start with we have to work across our own agencies and agree on how we purchase and deliver care. i think we see it playing out most particularly in medicaid managed care. i i want to shift us a little bit if it's okay to medicaid managed care. that is the dominant delivery model in states. not in every state but it is increasingly the dominant delivery model. and when we started out, say in the 90s we were serving moms and kid, we carved out substance abuse. we carved out enemy health -- mental health and delivered physical health care to moms and kids. tom as to usually to the '90s themselves rate-setting wasn't that sophisticated. by the early 2000's it's starting to change, we can focus

on more of the network adequacy and marketing tactics and think about how to set rates to ensure a continuum of care, comprehensive care, and actual care management by our health plans. so, then we start to move in the populations that have mental health challenge, substance abuse disorders, elderly, right? and now we have to move in this services they've need. ah-ha. integration becomes critical. what do we do about social determinants of health when we are moving the homeless into managed care and moving more people in if we're an expansion state. and so we have now really for the first time are using our contracting power to say to plans this is what we want, and to impose on plans the requirements that will enable them to hopefully successfully serve individuals with serious behavioral health problems. so we're now in a better

position, we still have our silos to some degree at the state level. we still have the counties. still health mental health agencies that aren't adept at taking -- contracting with plans but we starting to integrate at the plan level and requiring it at the provider level through our managed care, and i bet, tom, you can speak to this. >> let me say this -- >> first judy speaks. >> i have to be the older historian because i go back farther than tom. actually, in my opinion, medicaid really invented managed care in the way that we know it now. there was a hmo bill in the '70s and there were long-standing prepaid health plans, but medicaid through some extremely bad decisionmaking and

very bad plans in the '70s, set the stage for what happened in the '90s and the more recent yeares, and arizona bears a lot of the respect and responsibility for having invented a lot of how we do managed care in this country in my opinion, especially in medicaid, but in other places as well. so, now that said, i'm happy to turn it over to tom to talk about the medicaid managed care system in arizona, which really has taught us all how to manage and contract and provide services in a way that makes sense. >> well, as the last state into medicaid, we came in with sort of a fresh look at how we wanted to deliver services and that included really leveraging 1115 waiver authority and established maintainedder to managed care that was an integrate it

delivery system for individuals like the elderly and the physically disabled, which really at that point in time was early innovation in me medicaid managed care and we learned a lot of lessons in terms of what not to do and tried to share some of those lessans with states that they're looking to roll more frail and challenging populations into managed care, but what is really been, i think, wonderful to watch is the evolution of medicaid managed care from moving to strict um requirements into discussions where we're talking about value-based arrangements. we're having conversations about the social and economic determinants of health, where we have health plans coming forward with equity they have to keep on reserve with us, saying that they want to invest those dollars into buying homes for -- not homes but being able to partner with nonprofit

organizations to provide housing for individuals that are homeless, and so you really see the significant shift, i think in managed care, as part of the evolution of dealing with not just moms and pregnant women, but looking at more challenging populations, and it's really been something that has been really fantastic to watch in arizona, but not only that, nationally. so, we now have 70% of the medicaid population in managed care representing 45% of the dollars and that dollar amount continues to grow, and i think what is interesting as well is not only has the approach around medicaid managed care had a positive impact for those state that rolled that out. it's also changed the dynamic for states that have historically relied on fee for service. states like oklahoma and connecticut taking approaches around managed fee for service programs and coming up with care management strategies as well. so, it really has been something

that when you look back at the history of medicaid, you see evolution around managed care. >> there's been a lot of good -- there's been a lot of bad and ugly in managed care, and vern can reflect back on some early managed care activities he remembers, and then i'm going to call on chuck. so we'll all get our chance to speak. >> managed care is the platform on which a lot of the system reform is happening right now. but a lot of the experience of managed care came in medicaid but really began in the '70s. michigan signed the first contract with an lmo in 1972 before the federal hmo act, and by 1980 i think 90% of all medicaid beneficiaries that were in managed care were in just three or four states. but california and florida in particular, new york maybe to a certain extent, but there were certain things that happened that were highly visible and

highly negative. there were people who enrolled or were enrolled in managed care and received no services, who were systematically denied services. there were mlrs less than 50%. and when those -- some other scandals also that came out. that resulted in some initially basic -- i mean, it's funny to look back on this now -- 1976 social security amendments put basic requirements. there were three on hmos. no industrial nantz based on medical need. you had to maintain medical records to show which provider provided a service, and the state had -- was given the authority continue suspect the records. that is it. >> that was it. >> that's it. so we have come a long ways now. learning from that experience, and some of us in the states were happy to share that experience with arizona, so you can benefit from that.

>> appreciate that very much. in. >> the federal government was a very big part of -- in the '70s in designing and developing actuarial systems and enrollment systems and a lot of things that still form the basis for a lot of the contracting of -- between states and managed care organizations. chuck? >> so, vern having just pointed out that michigan was doing stuff before arizona even had a medicaid program. in 198 2. i guess the wagon train took 17 years to get to arizona. am going resuscitate arizona in my comments for a second. there were a abuses, as a lot of states get into managed care early and threat ones have what mentioned are marketing abuses where the plans were really try to cherry pick members and weren't doing -- they were doing

direct outreach, calling people at home, and misleading folks about enrollingment and led to a lot of federal oversight activities, but one of the things i do want to point out about why i do think that medicaid was the leader in driving quality and driving really the tripling before the tripling was defined as a term, is that in medicaid, states did not have the ability to really kind of narrow network the way even early employers did. states did not have the ability to use cost sharing to try to deal with quality. states couldn't say we're going to -- out of pocket and so states had to really focus on, this is your provider network. thissing this benefit design youch don't get to play with your benefit design. there's a lot of mandatory medicaid benefits so you can't say, like carriers could say to

an employer, next year to keep this price point, you have to put in all of these new benefit design requirements and cost sharing requirements and narrow network requirements. so medicaid very early on focused on how do you get the most value for a benefit package that you don't get a ton of play with, cost sharing you can't really engage the members that way with that kind of hammer. so what that meant is states were really very early on focused on high performing providers, on ncqa, on looking -- using data before other pairs started looking at encounter data to look at access, volume of services, mix of services, outcome of services, states were very early on requiring their health plans to get ncqa accredited, and now -- this is the part i want to give a shoutout to arizona -- one thing that arizona is leading the country in right now

is saying, okay, it's the managed care organization is getting cap addition, what are you doing downstream to have the providers similarly focus on outcomes about preventive services, about care coordination, about linking -- making sure people get their meds. 0 so ashes is requiring their management care organizations to have value based contracts downtown stream so that providers have skin in the game about outcomes that -- in other words, that it doesn't look like managed care simply on the cappation payment from the state to the nc0 but all the way down to every provider, the provider has a pay for performance shared savings type of incentive to get good outcomes, and to drive provider engagement in delivery

system reform and quality and this is another example where arizona is leading the way... but we won't see how you will pervade-- pay providers. the next step is how do we align our requirements with those imposed on the q8.

why shouldn't we be re- requiring through state basic stages or through our insureds-- in search agencies with some of those requirements because they're contracting with the same provider and our impact is that much greater if we start aligning across medicaid managed care and qhp and i think as medicaid gets smarter that is where it's a driver. >> if i could say one thing, we have come so far, medicaid has some-- come so far. medicaid programs are so much more sophisticated now and what they asked for and what they put in the contracts for managed care and i just point to my own state of michigan, the most advanced rfp p tournament for health plan in the history medicaid in my judgment on this, i don't think there has been a time before when health plans were required as part of their proposal process to commit and

describe how they would address social determinants of health, how they would address population health, how they incorporate the value -based purchasing. it's a model and i think it sets the bar at a higher level, which folks will find a way to build on. >> i want to bring us back to the thoughts that these kinds of innovations that we have been discussing here go way way back in the medicaid program. we are more sophisticated about how we do these things now, but before medicaid, managed care contracting and quality measurement and a value -based contracting and all of that, appeared on the scene and was developed in arizona, or wherever, it didn't exist other places, so we really have, as a program, a medicaid program has been innovative starting in the 70s and going forward and we are still on the cost of doing more in the future, so i don't

want to beat this dead horse, but it is my belief, my strong belief that this program has been innovative and led the way over the years in many many different ways and we will continue to discuss a few more and then turn to you all and ask if you would like to say something. one of the ways medicaid has driven data, which the secretary mentioned and which has always been a serious serious problem in the program, and systems work is through it and i think that frankly, the whole world of healthcare and healthcare delivery has suffered except for medicare. medicare did have a data system and no more about its people and that's unfortunate because we always got compared to medicare, but in terms of processing claims, for example, and of the development technology in that area, medicaid was ahead of

medicare, so i will ask bert to say a few words about that and then i think we could look at where we are headed in the future on this subject as well. >> it is really true, medicaid was more sophisticated than almost any health insurance payer or purchaser early on. in the beginning medicaid piggybacked on whatever, whoever could be that-- blue cross plan or whatever is a came on, but states began to look at what they could do and it's interesting to compare where we are now in terms of performance metrics and performance outcomes in the 60s and 70s, the performance metric that medicaid programs look that was how fast you process they claim and what your overall administrator costs were and we knew to the 10th or 100 when it cost us process a claim. we knew how fast we paid that claim. i remember before medical study

being paul allen, the medicaid director at the time was introduced as medicaid doesn't pay much, but you pay fast. we were the best. that was really significant in terms of fostering provider participation and access to the program to have a program that paid very well. medicaid decided to develop its own claims payment system. it built a model, an exemplary system in the largest computer system in the country say the pentagon at the time, it was the first-- first michigan system. claims came in by paper in those days, but usually they were keyed in. michigan had the first optically scanned system. we were able to process like six claims a second, a million every

48 hours and those were statistics before every legislative session. [laughter] >> really, drove down the cost of processing the claim by half. it was a significant. paul allen was invited to go speak everywhere in the country on this, so much so that after he said one more thing about how good michigan was doing at a medicaid state only, lean into the microphone and said do you know how many people it takes to change a light mall-- labeled in michigan medicaid? two, when to change the bulb and the other to go around the country telling how well you did it. [laughter] >> where are we in terms of systems at this point? it's a much bigger question now because we really need to be integrating and look at the marketplace. you brought up some of those kind of things. the feds have got-- there really

is more data and that's for helpful. we need that to run the kind of program we are running now, but where do you think we need to be going in this area now? >> so, i-- there's a couple of things that i think medicaid and public sector purchasers are driving a lot. one come i do think that as medicaid becomes part of a more seamless insurance model, the push for health information exchanges, the push for more adoption of electronic health records a provider's office and meaningful use, i think that the development of all claims databases, i think part of where medicaid is going to help drive and medicare is part of this innovation center, but i think where things are really going now is how to drive delivery system improvement where medicaid is really largely kind of the venture capital, if you

will, of driving provider changes in behavior or real-time data sharing about when people hit the ed, whether electronic health record looks like and so i think a lot of where medicaid is pushing in terms of technology is how that 70 million person program that half a trillion dollar budget is going to drive adoption of better clinical care through the use of the health ie's and so on and then with it indicate specifically on a standalone basis i think the data is going to be used a lot more for health outcomes, how we really look at change in health data over time. how we use more of the diagnostic data, more of the, p-- people maintaining their functional status. are we helping people maintain their chronic illness, so i

think it will be much less about claims payment and more about health outcomes. i think the bigger trend honestly, is out medicaid will tie to other-- how it's going to link to other payers through h ie's and the hr to drive real delivery system practice transformation. >> if i, -- cam, it quickly. we hear from all the medicaid directors that an mis purchase is still a struggle. i mean, after so many years that continues to be a challenge for medicaid programs and so even though i may have been a medicaid director forever, i have vowed not to stand up-- at some point time someone else will have to take that on, but you see more states moving to a partnership model and we provided for a number of years.

you have michigan illinois partnering, west virginia and the virgin islands, so there is the ability to get it to scale through a partnership like that and it takes a lot of work in terms of working between two sovereign states of how that will evolve, but it is still a challenge. medicaid directors are frustrated. it consumes too much time. in terms of standing up a basic infrastructure and the second point i make is to follow-up on a comment you made which is h ie we spent billions of dollars but electronic records out there and there is still a significant lack of connectivity around that and having viable h ie in a region or in a state to read is incredibly important and medicaid has a role in not, but that also is a challenge for medicaid programs and opportunities, but it's a challenge in terms of seeing the connectivity that we all desire in healthcare. >> deb, can you play off of this idea of the systems aspect of

moving forward and delivery system and speak a bit about your work with this and whether that does become a package that needs to be looked at together. >> yes, it does and i think it even goes much broader than the it system support. i picked up on something chuck said and he said medicaid is a venture capital of delivery system reform. well, this is that capital and more. but, i think that is the problem that's only one sort of the capital. where is the capital? where is the dollars to invest in delivery system reform? let's look at is bringing to the states and as tom reilly said some states, more probably in the future, but probably gnomic-- nowhere near 50. through this waiver, this

different waiver, the federal government is matching costs not otherwise match of all. and it's allowing states to bring in additional federal dollars and in some sense it may have gotten smarter over the years and it's not just allowing states to take the money with a promise of your doing good things, a promise of supporting safety net hospitals and what the-- what's required and we all start with new york, but we see it play out in other states now is the state needs a concrete vision for delivery system reform. delivery system reform in medicaid that will drive systemwide reform, but it starts with medicaid. these are medicaid dollars. was the core of your vision? is a pts, and aco, and rc zero, what is the integrated model that is bringing new partners together, hospitals, maybe

health plans, community mental health agencies, social services agencies at the centerpiece the funding screen for testing new initiatives. funding that eat hr where necessary. funding community health centers and testing those new models. also, what is the key sustainability? here are the capital dollars, but at the end of the day the state has to show a sustainable planet and it as states that what we want speer did we want it to be sustainable because like it or not those it district dollars will go away at some point when we come back to the operating dollars. can they sustain these delivery models, so i think it is hugely important and one less comment 2 pounds. not every state will get the dollars, but it's important to learn from the states that do that can be used across the country, the challenge then is

where at the dollars. >> anyone else want to weigh in on this subject? it's an important one for the future. one thing we have not talked about this morning that i think we really need to talk about-- did you want to say something more? >> no see next line term supports. you know, it's kind of interesting as i sit here and think over the 50 years of this program that it has changed in the long-term supports and services, but it's changed way more slowly, i think, than other parts of the program. i think we are on the edge of much more meaningful change. long-term services and support instead of long-term care. would someone like to talk a little bit about this where we have been aware we are going? >> i'm happy to start.

lets me define a couple of terms first-period long-term supports and services is really a spectrum that includes nursing facility care, includes institutional care and places like intermediate care facilities for people with intellectual disabilities, includes a lot of inpatient psych and-- but it mainly now includes a lot of community-based services and so there has been, i think, a very strong institutional bias in medicaid going back a long way in some of its policy related, going back a long way, nursing facilities were mandatory. it was mandatory benefit and home services was not. the way the financial eligibility rules work for medicaid, if someone was spending money or would be spending money on a nursing home care, you could count that as a medical expense and so states

that had spend down rules you could say i'm spending on medical care and therefore i'm eligible for medicaid, but if you are spending money in the community on room and board, that's not a medical and you can even get a medicaid eligibility card. you're not eligible. there were lots of other sources of bias. there has been a very strong trend in recent years to move towards community-based long-term care and long-term services and support. it has a lot of drivers, one of the drivers is the olmstead decision i cannot 1999, which made it a civil rights issue to be able to go into the community and be integrated into the community, so that people weren't segregated in on institution with other people who look like them and have the same disabilities, but to be in the community where they could see friends, great friends, go to church, work if they could work, beat parts of a

neighborhood. there were other drivers related to a lot of advocacy. there were a lot of advocate groups that also viewed this as a civil rights issue to be able to be treated like other people, to be in their own apartment, their own home. they wanted to have self-direction, self-determination. one of the advocates i talked to in my first stint as a medicaid director said this is not a new slogan, but he said don't design anything about me without me because this is my life. so, where we have seen ago and i want to sort of thai a couple of things together, in the development of community-based home and community services, medicaid has really-- this was to me one of the early places where medicaid was driving us in social determinants and social

issue because home and community based waiver services were really often nonmedical services that were dealing with someone's challenges that had a medical outcome if they were not met, but it was really more about housing and homemaker care and meal preparation and so there has been a very strong push, and i think olmstead was a driver. i think advocacy from a lot of community advocate groups was a big driver and i think the fact that the baby boomers are aging into a lot of these programs and they are not shy about advocacy in general has led states to be really innovative in moving more long-term service support financing and design into the community where you have got a lot of money going towards really nonmedical services. this building environmental modification that people hear

about, wheelchair ramps and grab bars. there's a lot of work going into buying microwave ovens and window unit air-conditioners to keep someone at home instead of going into a nursing facility. you hear about attendance where helping people with bathing and dressing and using the toilet are homemaker services about just keeping the home clean and dealing with housing issues. nutrition and food issues, but it has been a very slow trend over the years. partly because the nursing home lobby has been very strong, partly because there's a lot of bias in the law towards institutions about financial eligibility rules and covered benefit rules. but, you see more and more for all populations that have lt ss deese, whether it's seniors, younger adults with physical disabilities, and-- individuals

with intellectual disabilities, mental illness, much more focus on doing design to address social needs that boyd medical costs in the community. so, i think the trend is in the right direction and a lot of states are picking up the pace, but it's been, to me, it's one of the earliest places where medicaid really saw a connection between avoiding a nursing home cost or a hospital cost if you just help someone get their meals at home safely. >> what a great summary and really there are two points are out on top that. we we've reached a milestone and we now spend more money on home and community-based services that are nursing facilities and institutional care in medicaid. that was achieved this past year and i think that's an important milestone and i think the dynamics around the politics can

be understated enough to read my friend john mccarthy zero's talks about he has more nursing facilities in the state of ohio, then high schools and it's hard to overcome that dynamic as you look to transform the delivery system. >> yet another place where medicaid innovations way way back in the program, which warned widespread and words universal, but help us learn and get us to where we are today, which is where people think we ought to be. >> can i just-- one really quick shout. the waivers began in the early 1980s, so part of this history we are talking about and mccain about largely because in iowa, a young girl, katie beckett, was in a hospital and there was no way to go home and retain medicaid eligibility and services. senator grassley and others got advocacy from katie's mom, julie beckett, and the waivers were created because there was a

need, there was good congressional action and then states in varying rates picked it up, but this is a trend that as tom said we just finally crossed a milestone that more than half of the funding is going to the community, but this is a trend that started in 1982, i believe. >> i neglected to pick up the gizmo that's going to give us a couple of slides when i walk by this podium, so now i'm going to get that. one of the ways that these changes and innovation are made in the medicaid program is through people like yourself who are dedicated to running an excellent and ever-changing program. so, i want to do a quick commercial format and his staff at the fourth annual medicaid operation surveyed because in

order to calm push all of the things we have talked about here today that the past has been setting us up for all you need to have a lot of people and a lot of administrative capacity, so i went to quickly go through these and then have as have a brief conversation about administrative capacity before i turn this over to you all for questions and comments from the audience. so, these are just a few slides from a study that is on the internet this morning. you can go and look at it if you want to see the whole thing. it's interesting to note first that aca implementation is not at the top of everyone's list right now. they are moving onto other things things. these are new strategic directions. they have, in fact, developed in most state agencies knew strategic direction for overwhelming numbers for the

coming several years. payment reform and delivery reform are at the top of the list and you can see the different kinds of payment and delivery system reform efforts that you all are engaging in. lt ss is a major priority, obviously for the reasons we have been discussing. this one is kind of sad. this is the list of barriers that exist to implementing reform and become any of them really had to do with resources, people resources, obviously are a big deal, so with that as background and with you all having all run medicaid programs and tom still running the program, i would like to wrap up our conversation before we turn it over to the audience with some comments about what you think the future holds for medicaid in the management administrative world.

i will be happy to start. first of all the slides are dramatic especially that last one. medicaid has always been underappreciated for the role it plays in the lives of so many americans especially vulnerable americans, those with real serious health care needs. but, in the same way a staff of medicaid programs appreciate more what they do to make this all happen and i really do think that a tribute has to be made to the staff, the directors, the leadership in the state for all that has been done. you know, many-- there is no program in all of state government or maybe in all government everywhere provides better value for taxpayers than medicaid does. serves a vulnerable population, the cosper cares less than anyone in the rate of growth is less than anyone else. it serves a population anyway

that really really provides great great value. the folks that do it all justo get the credit that they really should. in our office we used to have-- i just thought of this, a sign that said nothing quite focuses the mind is facing the gallows and medicaid is a financing system. medicaid spends a lot of money because there is always one of the constants of physical pressure and states have responded to that by developing these programs, getting better value for all of the state dollars that they send in the process of doing that state medicaid programs have saved the federal government hundreds of billions of dollars because of medicaid at the state level is really driving these processes, these programs to provide great value. >> i'm glad you brought up the

issue because we didn't get the money here and it's really not acceptable when talking medicaid. >> i agree with everything that burn said and i suspect all of you do and we provide tremendous that you, but were the two biggest obstacles to running medicaid well in new york and i suspect another states was staffing and pitcher matt rubel's. staffing enough staff. i have 700 people reporting to me. the medicaid inspector general has 700 people reporting to him. what is wrong with that picture? procurement, which also goes to some of our it issues. in new york if you can get up procurement through in 12 months it's a bloody miracle, 18 to 24 was more likely, and those issues aren't going away quickly. although, i do think medicaid is more appreciated now, certainly with the expansion it's more

appreciated. medicaid directors are more valued, but that's not going to change our staffing and procurement rules. i think one shot we have is with our system. if we can start to align medicaid on one end with the snap program and shared dollars, shared system and on the other end with the exchanges and look at a system that supports exchange eligibility or marketplace eligibility and medicaid, if we can start to use those systems well, i think we can be more efficient, which will be helpful. >> we have a special breakout session dealing with medicaid leadership that we will delve more deeply into and a paper that was done by andy allison and other thoughts around medicaid leadership. at the end of the day medicaid organizations are mission driven organizations.

people earn medicaid because we have the ability to make a difference in the communities in which we serve and it's part of what making-- makes coming to these meetings so invigorating is this meeting with their peers and talking about what's going on within our state. it's exciting to see the innovation, but i know what drives us also at the end of the day is not only the ability to improve outcomes, but to deal with that sustainability issue. for those of us that look through the great recession and we had to cut provider rates and cut benefits and cut eligibility , there's got to be a better way to manage a system longer-term than having to go through those very difficult decisions and we will go through those cycles again and we will have to face difficult decisions, but hopefully we are making some investments now in terms of really modernizing our system and evolving it so we can have a more sustainable system. i get the opportunity to speak a

lot to college groups i say how i is medicated impacted your world and they really don't know and than i say in the state of arizona tuition has doubled in the last six years because of the cost of healthcare and how it squeezes other state priorities and so looking forward sustainability is one of the significant overarching issues of medicaid that directors face. >> so, i want to actually put out a little bit of a call to action to all of you. the last time i looked about a year and a half ago and what happens in a lot of states is at a state personnel classification system the people on medicaid are kind of compared to people doing health-related jobs and other agencies and state government might be a help the part or some place else and what has happened in medicaid and i think you have learned some of this in this morning session is the complexity of the program is growing. there is a lot more work about analytics and quality measurement, a lot more need for healthcare economics, for actuaries, a lot more need for

people who can really manage very very complex contracts and contract vendors such as me and i think what that means is that the skill set is changing over time. people who are needed by state medicaid agencies to help run the program to try value, to look at the data, to do clinical work about what is the right hepatitis see coverage policy, to help drive the right payment levels, the right provider payment incentive design. did these are people with healthcare economic backgrounds, actuaries, chief medical officers. these are people with really high skills dealing with big datasets. they are compared in government to job description and other agencies. healthcare contract manager role that you are looking at someone in one agency that is managing a

1 million-dollar grant and then the same person in the same class vacation on medicaid side managing a 500 million-dollar contract with complexity about brought networks and access requirements and data requirements and pay per performance, so from state budget department, from state legislatures, they are kind of reluctant to take on what aroused a classic asian systems, but i think that that is needed. so, as all of you do your own kind of government relations work, government involvement work, governors offices, state budget offices, help them understand that your success, state success, medicaid success, medicaid beneficiary success depends on the states following through on the requirements of these programs in these complex times and i think that would be

a well-- you would be well served helping carry some of the water for your state medicaid agencies to help them drive a sustainable affected program because it's in their interest. it's in everyone's in the room interest and i won a close on this quickly. i'm going to really botch this quote i'm about to do, but teddy roosevelt had a quotes, man in the arena and it was a quote about how for critics to stand on the outside of the arena and look him and say i could have done better, i should have done better that the credit belongs to the people in the arena, the ones doing it, sweating it out and sometimes they win and sometimes they lose, sometimes they do a great job and sometimes they fall on their face, but the credit goes to the people in the arena, and that is certainly the medicaid agency staff. that is certainly all of you and us so help the people in the

arena. so, that is my call to action to all of you this morning. >> with that, let us go to you in the audience. do you have questions or comments would you want to share a good story? i have to say, we could go on for hours and hours with very good stories, not even really trying to keep this on track. >> i see the hands of two former medicaid directors. >> thank you. that was a great panel. recovery in missouri medicaid director and now with aetna and i was like to say it was the best job i ever had the big emphasis on the had, but terrific panel. i am so amazed that you are didn't talk about provider taxes, volunteering contributions in terms of great trends.

it was, you know, the '90s and there are many many stories all of which would need to be handled after hours in a bar, but i would love to hear in particular vern because i know he was a major leader in that and anyone else to just comments and it's a serious question, there are lots of fun stories, but i think it really goes to the key questions about long-term financing of the program, federalization and when we have states continually trying to figure out how to tax something new in order to keep a critical program like medicaid going and the downside of the provider-- excuse me? >> federal issues as well. >> yes, and thank you for a great panel. >> former chair of the director of medicaid association. and it tinier in the use of provider taxes. [laughter] >> than a trailblazer in that

would be one. i would say medicaid is sustainable in many states now because of the use provider taxes and even though in some ways they are controversial, a state that doesn't do these things which are completely legal and would be approved by the federal government in our state we said that in medicaid director doesn't do these-- you have to do it without the use of these and every state now except one does a provider tax or fee of some kind. the medicaid program could not be sustainable. >> can i make one additional-- i agree with that and i think we-- i think in the future provider taxes are critical. intergovernmental transfers sit alongside them. very important revenue stream. i think they bring up the

question that we will have to look at in the near future is supplemental payments and how they are used to fund this and you peel payments and how those fit into value -based purchasing and brings us back to who is putting up the nonfederal share and that will become an issue that all states will have to look at going forward. >> i'm currently involved in litigation with 36 legislators, so i will not, at all on anything related to assessments. >> one of the areas of integration that we didn't cover that much this morning was integration between medicaid and medicare. personally i think that until the federal government moves far enough to allow the states to fully manage an integrated funded package up care for what we call the dual eligibles, all of these experiments being put out there are going to fail. that there is not enough

flexibility for the states to fully manage that benefit and i would be interested in your reaction to that controversial statement. >> i certainly agree it's a topic we should have covered in our time up here. it's an important topic given the population served. there is some promising just the fact that states and the federal government are partnering to try to take this on. after 50 years that we actually have some demonstration in place has been an issue that medicaid directors have highlighted for decades and really had no progress, so it's at least appreciate the fact that some states have been able to try to stamp something that. it's far from perfect. it's a struggle as a state that made the decision not to pursue the demonstration, but to go to a different route. it's an important issue for many states. it's trying to figure out what the right path forward is, but it's clearly something we need

to have that continued conversations around. what is the solution for duals to come up with a model that will best serve their needs? >> other questions? we definitely did not cover everything. those are not the only two things. [laughter] >> a couple things. vern, one in terms of the provider taxes, i agree it may be a sustainability issue. i think it also leads to questions whether the whole financing mechanism is a sustainable mechanism in terms of state financing of an ever-growing program. but, the other thing i want to say and i hate to sound too negative, but lots of great information, none of which i really disagree with, but over the last two years i hear more and more and more from the political side about how medicaid is a broken program.

which, i don't think it is, but that certainly is the perception out there were at least the rhetoric. how do you all think we can get the message out in a way to the public outside of this room about all of the great things that medicaid really does do and the importance of the program as a whole healthcare system? >> good point. good question. anyone want to take that on? [laughter] >> i want i guess the pickup on the the two parts. i agree with respect to the provider taxes i agree with what donna and her vern said it was an essential part of financing and helped with sustainability. i do think that in some ways a lot of reliance on provider taxes can chill delivery system

reform because a lot of providers that are receiving the benefits of the taxes they are generating are harder to engage because they feel that they are a different card of partner with the state and they have veto powers in some markets in some situations, but i think with respect to the comment about medicaid being broken, i'm reminded almost of the yogi berra comment about restaurants been so crowded i don't-- or no one goes there anymore because it's too crowded. i mean, 70 million-- one of the things that has dramatically reduces the stigma of medicaid. people are the mainstream delivery system now. i don't think that medicaid is broken. i think what that is a proxy for today, about financial sustainability over time. i think what that is a proxy for is, can we sustain whether its

federal funds were state funds a coverage program like medicaid and i think that is playing out with a lot of the 1115 waivers, so for me the way of dealing with the medicaid being broken comments is to continue to work on the sustainability model for value -based purchasing. >> i also think it leads partly to the complexity of medicaid. we had to deal with policy makers that medicare and medicaid still, so i think part of it is when you're having to explain this a very intricate complex program, then the date also be able to explain the value and the personal aspect associated with medicaid. to have a better feel for what it means in terms of the impact of medicaid within our communities. >> it's-- this is a great question to get to write here at the end. it reminds me, michael is a

medicaid director and utah, but early in his career just happen to know a caseworker who did some of those home visits to make sure there wasn't a man in the house and that's how far the program has come and this just really reminds us that this program is not broken when you look at what it does. it is the fiscal issue that is a challenge. it's facing the gallows. what are these fiscal pressures that are facing the program works but, this just reminds been a conversation i had some time back. there was a family with three children, one of whom has needs that require constant doctor visits and expensive medications and they asked me to help coach them through healthcare.gov. they encountered all the issues that everyone knows about. then, one day when i walked into church and this lady came running over to me with joy in her eyes and she said, vern, i

have to tell you the news, we were approved for medicaid and she started telling me what she had learned that week about what it covered and how her child was going to get all the medications and healthcare that he needed and she was feeling so secured with tears in her eyes she said to me, vern, do you realize how good medicaid is. [laughter] >> i thought in that moment, that describes what's happened over 50 years to this program. it's mainstream and makes a difference. it's not broken for the people who use it. >> and what we hope with the affordable care act in 2010, when medicaid was the foundation of the new health coverage paradigm emma before the 2012, supreme court decision i thought we were on our way to the end of medicaid as broken and medicaid as a good health insurer. the supreme court waylaid as somewhat, but i think the aca creates a foundation to move us

forward and to often we hear medicaid is broken as the excuse for someone that doesn't want to expand medicaid. so, the facts the damned are it's broken so now i don't have to expand it. >> with that we will and appeared to die thank you much for your attention. [applause]. >> that he'll has a story today on news that the supreme court plans to consider a challenge to obamacare as birth control mandate. the justices will take up multiple cases involving the mandate including one from a group of catholic nuns known as little sisters of the poor. they are willing to deliver a second major blow to the health law in two years to read it will be the fourth time obamacare is before the supreme court here give meantime, president obama earlier today announced that his administration has stopped for

the developing a plan to build a keystone xl pipeline from canada to mexico with the president famous tate department has decided the keystone x-- pipeline would not serve the national interest in the united states and i agree with that decision. you can see the president's announcement tonight beginning at eight eastern on c-span. are c-span road to the white house 2015-- 2016 stockton jackson mississippi dish we. the mayor spoke with students from the boys and girls club. a few jackson state university cheerleaders also pose for a photo. you contract the bus as it travels across the country, follow us on twitter and instagram using c-span bus. c-span has the best access to congress. watch live coverage of the house on c-span and the senate on c-span 2. watches online or your phone as c-span.org. listen live anytime on our c-span radio app. get best access from behind-the-scenes by following c-span and our capitol hill

reporter on twitter. stay with c-span, c-span radio as c-span.org for your best access to congress. >> earlier this week, the secretaries of state pam patterson and victory in newland testified at a foreign affairs committee hearing and how that policy has adapted to that exasperated factor of questioned military involvement and also discuss ongoing us and thai crisis military operations, the continuing record sheet crisis and the efforts of the us to work towards a post assad regime. it was just under two hours 45 minutes.

>> this hearing will come to order. so, this hearing is on us policy after russia's escalation in syria. it's now nearly five years into the syrian conflict. that conflict has claimed more than a quarter of a million lives. there are 14 million people right now that have been driven from their homes in syria. now, through it all the administration's response has been a series of steps that were micromanaged by the white house that were very ineffectual and when i say ineffectual, we had a situation here where we had hearings during the time, one year period in which as isis

began to move out of syria and take major cities during that period of time as we were calling for airstrikes, as our ambassador in my dad was called for airstrikes, there were 14 major cities that felt isis fell out a time when a pickup truck on it opened a circuit road, these are clear target six even taking out, but a choice was made. sometimes indecision, the decision not to make a decision is itself a choice. the choice was made in the united states not to stop isis then when it could have been stopped. that choice was also made not to arm the kurds. three trips out here by the foreign minister of courtesy and asking for the antitank weapons come artillery, that they

needed, 30% of their troops, 30% of their brigades women, females fighting on the frontlines against isis on a 600-mile front and the decision was made not to arm them. so, isis now stands where it stands gaining ground as a result of our failure to act. today, the president still has to put forward the broad overarching strategy needed to defeat this brutal movement, this movement of terrorists and frankly, to secure vital us national security interests here. but, instead it is now russia that is taking the decisive role in shaping serious future and not in a helpful way. vladimir putin, assad-- stop assad losing ground, so russian jets have teamed up with iranian

ground forces to solidify the syrian dictator and the focus of the russians and iranians joint offensive is not isis. it is not their strongholds, but it is the opposition forces backed by the united states and saudi arabia. russian bombs, according to the ngo groups that report on this and they say over half of the russian attacks have now been on civilian targets, russian bombs, markets, schools, villages and the russians at one point were bombing war targets, more targets in one solitary day then we hit in a month. our air campaign there is even more anemic for those of you that have followed what has happened.

as a consequence of a russian moving into these operations. the administration claims that it lacks targets. yet, the special forces it is sending to syria won't even be spotting targets russian attacks on the opposition and the slowdown in coalition airstrikes has actually allowed isis now to gain territory. isis is expanding. let no one be under the delusion that russia is focused on isis. while the president characterized russia's moves as a sign of weakness, it is assad who is growing stronger. moscow's efforts shows no sign of slowing. russian cargo aircraft have been seen running iranian weapons to syria, a violation of the un arms embargo read a violation i assume is not going to be called to attention or challenged, but

it is a clear violation of that agreement. this is especially troubling as we begin another attempt to restart talks between the regime and opposition on a new constitution on elections and here's why: russia claims its goal is a united secular and democratic syria, but it's efforts to prop up the assad regime prove otherwise. how do we expect the opposition to sign on to any sort of cease-fire as long as russia and iran are demanding that assad, who has murdered over 200,000 civilians, for those of us in this hearing room we have heard in the past, 50000 photographs of people tortured by the regime that kind of conduct by this regime means it's lost all

legitimacy with the syrian people. so, the russian plan is to have him stay in power and ask at the outset that he stays in power. the statement from vienna, didn't even demanded that the assad regime stop using barreled bombs, some filled with chlorine gas. that would have been a minimum step that the russians could have supported, but there claims , they provided the air force originally to assad, so a diplomatic solution is only possible with a strong coherent, moderate opposition that can serve as a bridge from assad to a new post- conflict government. yet, the administration has done little to help opposition. it people train and equip program is now defined. washington bureaucracy and over deference to the shield let iraq he government has held up

desperately needed weapon ship to the kurds. no one believes friday's announcement of 50 special forces will be decisive. smillie, it is president obama's responsibility to step up and outline a plan to engage our partners and allies and bring stability to the middle eastern he is the commander-in-chief, but here's where i starts as i have already said, we have urged for the longest time decisive airstrikes against isis. we have urged for the longest time the arming of the kurdish men and women out there on the frontlines with the weapons they need to turn back isis. if we want an opposition to negotiate from a position of strength, why not help create sanctuary areas in syria? this would help the syrian people escape both the assad regime and the islamic states. this would also allow for more effective humanitarian relief and even though the exodus. we must also push back on russia

and iran's destabilizing intervention in this conflict and that means passing tough new sanctions on iran's terrorist proxy has mola because that is taking over homes in this region that used to be inhabited by sunnis as the ethnic cleansing continues. so, we need to pass the legislation as the house has done and take action to uphold the un arms embargo on iran in the face of violations. everyone but the white house seems to know the status quo cannot stand. general david petronius recently testified to congress that syria is a geopolitical turnover and like a nuclear disaster the fallout from the meltdown of syria threatens to be with us for decades, he said. the longer it is permitted to continue the more severe the

damage will be. those were his words. i will now turned to the democratic side for any opening statements. yes, lois. >> thank you mr. royce. thank you to the witnesses for being here today and i know you will be able to well handle the questions that will be asked of you. mr. chair, i want to just express a different point of view. thank you for this hearing. i think you have raised some good questions and you have expressed the great frustration that a lot of us feel about syria. i mean, it's horrific what is going on. but, i mean, some people would say that isis or whatever we call them today came about not because of something president obama did, but someone would

argue that it was a previous administration, decision to go into iraq erroneously that started this mess that we see today with a failed occupation of iraq a new government that was not inclusive. you have a void and then use the isis, from that boy. but, what to say this: i don't want to lay the blame game. i think what's important now is just to focus on the here and now and what we need to do. i don't believe-- this mess in syria in the middle east is not the fault of our presidents. there is a lot of blame to go around, but i'm going to put it on terrorists more than the president of the united states and i would be interested in hearing what are two witnesses had to say. thank you. >> would the gentle lady yield?

>> yes. >> we have time left. i just want to set a framework here as we head to discussion. the administration and frankly, that critics of the administration, i for one did not see the value of pursuing with the vetting of the syrian rebel army. i consider myself. but, the one thing i want to have emphasized in this hearing is that you can't have things both ways. you can't say we should put putting us troops on the ground there and you can't do that unless you are willing to hold that troop and have a huge investment of our troops, so the people say the president didn't come in and he should've come in with troops, you just can't come in, drop them in, pull them out. we did have intelligence on the

ground in syria to make it safe for those troops at the time. number two, we have to be prepared for people to say that those troops have to have the support of tens of thousands of other troops. so, let's not have this hearing both ways. if you're going to take that path with the president, you have to be able to say, well, i support ground troops for the long-term, tens of thousand on the ground because you can't put them in there without supporting them safely, so i hope when we have this discussion today bear that in mind and if it people have that opinion than i respect their opinion, but i don't think that is the best thing for our country at this time. i yield back. >> thank you and i would like to make it clear that that is not the opinion. what the members of this committee called for for a full year of indecisive action was the use of our air power. was a memory that we had had

116,000 airstrikes during the first gulf war against 42 divisions of saddam hussein. these were armored divisions, many of them, and it was very successful during the invasion of kuwait. what we called for here was not introduction of us brigades. what we called here was for the president of the united states to use the authority he had in order to take out the beginning that started in pickup trucks and if you can take out armored divisions, you could certainly from the air takeout pickup trucks from the open desert and the frustration that i'm expressing is over the fact that the one year-- for one year nothing was done as city after city fell to this terrorist organization. but, i should transition to the witnesses today. is partly that frustration and is partly with meeting time

after time on a bart-- bipartisan bases with a kurdish opposition asking for arms and being denied the arms to defend themselves. those are the issues i'm speaking to, but at this time i would like to go to ambassador anne patterson and insisted secretary of state, a member of the senior foreign service and previously ambassador patterson served in multiple positions and assistant secretary of state for narcotics and law enforcement affairs. also ambassador victoria nuland. investor victoria nuland served as the department of state spokesperson and also served as the united states permanent representative to the north atlantic treaty organization from two may 2008 focusing heavily on nato russia issues. without objection, the witnesses

for prepared statement will be made part of the record and members will have five calendar days to submit any statements of questions or material for the record. ambassador patterson, you can begin. >> thank you mr. chairman. thank you for the opportunity to appear before you today to clean our strategy for resolving the devastating conflict in syria and defeating isil their. coming after the president's decision to intensify the campaign against isil, and secretary carries meetings in vienna, the design for political transition this hearing is particularly well-timed. secretary kerry said it best in vienna, our task is to chart a course out of hell. since the start of the syrian war as you outlined, over 225,000 syrians have died and we have the largest rest-- refugee crisis since world war ii. is become a magnet for extremist

seeking to change the map of the middle east, destroy cultures. it is threatening serious neighbor, a rock, jordan and turkey with major consequences for us national interest and beyond. we are pursuing goals, went to defeat isis military it in both salute-- syria and iraq, number two to develop a legal transition that give syria a future without-- to ease the suffer-- suffering of the syrian people and to stabilize our allies as they cope with the massive refugee outflows. our strategy is to leverage military action and diplomacy to achieve a political transition in which syrians ultimately have a government that respects the rights of its people. this political transition is critical to routine isil out of syria and ending isil's ability to threaten iraq from syria. as secretary kerry said in

vienna, there is absolutely nothing that could do more to fight back then to achieve a political transition that strengthens the government's capacity syria, sideline the person we believe the track so many foreign fighters and some as chair and unite the country against terrorism. we cannot defeat isil in iraq without also defeating iselin syria. moving forward we first intensify the military campaign against isil through airstrikes in cooperation with local partners. who have already pushed isil out of office-- [inaudible] cnet we and our coalition partners have launched over 260 strikes in syria and thanks to turkish support we are deploying f-15s to extend our strike capacity. the president, as you mentioned, has ordered the deployment of up to 50 us special operations forces in northern syria to work with our arab and kurdish

partners and we will support them with additional air power. , the united states is providing $150 million a year to the moderate opposition to meet humanitarian needs and provide government support in areas liberated from isil. as the largest single donor since 2011, we are provided over foreign half billion in humanitarian assistance to syria. this includes nearly two and a half million for inside syria, almost 1,000,000,004 programs in lebanon and over 650 million to jordan. we are enhancing military assistance to help our regional allies including jordan and lebanon. thanks to general alan's leadership we are leading a global 65 member coalition, working to crew-- two defeat isil. mr. chairman, to be address head-on russia's dangerous military intervention in syria.

moscow deployed forces because its ally, the assad regime, was losing territory and even around support was insufficient to protect it. moscow has tried to claim that it's strikes are focused on terrorists, but so far 85 to 90% of syrian strikes have hit the moderate syrian opposition. they have killed civilians in the process. despite our urging, moscow has yet to stop the assad regime horrific practice of bombing the syrian people. we know russia's primary intent is to preserve the regime. in vienna, secretary kerry brought together all of those who can help in the conflict. iran was invited for the practical reasons that it is an active purchased it that needs to support the political transition. it will come as no surprise to you that this group disagreed on several subjects, most notably the fate of a assad.

they did agree, however, to convene a regime in opposition representatives on the basis of the geneva communication of 2012, which set out goals for the transfer of power to a transitional government in body and to explore modalities for cease-fire in parallel with the pickle process. they also agree we must preserve syria's unity and territorial integrity, ensure state institutions, remain intact, protect the rights of all syrians, usher humanitarian access, if he isil and other terrorist groups designated by the un security council and establish a political process leading to a new constitution in elections administered under un supervision and standards. we will convene parties at at level in the next few weeks to discuss next saps. mr. chairman, no one has any delusions about the difficulty of these efforts. one thing is clear, assad cannot unite and govern syria and we cannot continue to hold the

lives of the syrian people hostage to the desire of one man to retain power. we the syrian people and our original allies need a political transition that ends isil's reign of terror and does lack-- allows display syrians to return home. thank you, mr. chairman. i would be happy to take questions. >> we will go now to ambassador victoria nuland. >> thank you. thank you for the opportunity to join your my colleague, assistant secretary anne patterson today. while syria is in anne patterson's responsibility-- area of responsibility the conflict imperils turkey, the eu and the rest of europe as refugees dream out of syria and had both north and south. russia's new direct combat role in syria has exasperated an already dangerous refugee outflow, straining even a most generous european civility to cope.

turkey currently hosts 2.2 million refugees and by its account has invested over $8 billion towards their care and well-being. this year the turkish coast guard rescued an estimated 68000 individuals attempting a dangerous sea voyage. just since russian combat operations began in syria, greece has recorded its highest level of migration flows with an estimated 48000 refugees and migrants crossing into the country in one week. the western balkans is also stretched thin from increased gratian primarily through macedonia, serbia and croatia read these companies reported average of five to 8000 migrants passing through their borders daily. germany is under strain hand has recorded over 577,000 arrivals

in the last nine months. inside syria, just over the last month while the russians have been active the united nations reports at least 120,000 syrians have been internally displaced as a result of the regime's attacks aided by russian airstrikes. 52800 people were displaced from northern and-- these numbers validate what we already know and what you yourself, chairman, pointed out. while moscow asserts its military action is directed at isil, the vast majority of russian airstrikes are targeted in areas where the assad regime has lost territory to forces led by the moderate opposition. now, russia is fielding its own artillery and other ground assets around houma and holmes, greatly increasing russia's own soldiers bowler ability to counter attacks. moscow has failed, as you said and as assistant secretary patterson said to exact any humanitarian concessions from

the shot racine as the price more russian support. the regime continues to bear obama's own citizens with impunity, perhaps even emboldened by moscow's help. none of this has been cost free for russia itself. in pure economic system the prices air campaign is estimated at two to $4 million per day. this is a time when average russians are feeling the pinch of recession brought on by economic mismanagement, low oil prices and sanctions applied for the kremlin's last military adventure in ukraine. rush and how shelties are also reportedly on the rise. although, the kremlin is again working overtime to mask them and silenced the loved ones of the lost. as the bombs that rush is dropping inevitably hit the wrong targets, and market in damascus, the provincial

headquarters, an ammunition dump of the pre-syrian army, russia and is paying a very steep price to its reputation in the fight against terror. that's why for now, we have limited our own military cooperation with russia to the most basic of aviation d confliction procedures to protect our own aircrews. what would positive cooperation by russia look like? first, russia would turn its guns on isil and stop the carnage in and around serious western cities. as the price of its support, moscow would insist that assad ground the helicopters and planes that he is using to barrel bomb innocents on a daily basis and it would urgently work with us, our allies and the un to turn the statement of principle of secretary kerry, and 17 other ministers and institutions released in vienna last friday into a true cease-fire of power of parallel political transition process and

hasten the day a sods bloody tenure comes to an end. the quality of our cooperation with russia in syria depends on the choices that moscow makes. in the meantime, as the secretary has said and as assistant secretary patterson outlined we are accelerating the work we are doing and to protect syria's neighbors including those in my area of responsibility, turkey and the countries of europe. turkey is increased its own participation in the counter isil fight opening its basis to us and coalition members and conducting its own airstrikes on isil targets inside syria. as we accelerate our own work with turkey and other like-minded partners to roll back isil in northern syria, a collateral benefit could be the creation of a space where syrian civilians are free from assad barrel bombs as where is isil's atrocities. a large number of europeans have contributed aviation aspects and

some are also considering strike operations in syria. we are obviously also working with our allies and partners to address the refugee crisis-- crisis. where provided turkey with over $325 million in assistance through the un and private ngos and we have provided 26.6 million for operations in europe including to help with food, water, legal assistance for refugees including 600,000 now to respond to requests from western balkan countries for equipment and training in the area of border management. as the secretary's diplomatic efforts made clear, it's going to take leadership and resolve by dozens of countries and by the syrian themselves to end the bloodshed there. in vienna last week, 17 assembled nations, the un and the eu reaffirmed the path forward to peace and a political transition. it remains to be seen whether russia, iran and the assad regime will join us in walking

that path you read we look forward to your questions. >> thank you, ambassador newland. i mentioned my frustration without-- how the administration has approached syria and isis and the fact is that we at the state department here, officials in front of this committee two years ago sounding the isis alarm, explaining the action had to be taken. that iraq is and our own officials push for airstrikes early on, and push for those airstrikes when isis was most vulnerable. but, the white house said-- that paralyzed. once the airstrikes did start after a year of watching cities fall in the central bank being taken over by isis, after that we finally saw airstrikes averaging 19 a day, but in

circumstance in which three quarters because it exceedingly restrictive rules of engagement, three quarters of those planes flew back to their basis without dropping their ornaments. if we compare that and consider the first goal for, desert storm , those airstrikes ever did 1000 combat a day. not 19. now, enter the russians. the state department said that this wouldn't impact our air mission over syria. yet, the numbers that the committee put together say otherwise. in october, while the russians did a hundred airstrikes for the full month, mostly aimed by the with opposition, we managed just 100 against isis. assistant secretary patterson, are we ceding the skies to

russia here and in effect allowing the isis for it to grow because after all, isis has gained territory here during this timeframe. spirit mr. chairman, obviously i'm not for dod, but let me try to answer this question. this question came up at a high-level meeting and i will quote to you what a senior military officer said, which is we don't hit targets we can't see and this was in reference to the very bad weather that had overtaken the area last week when the strikes were limited. we can't be compared to the russians in any moral or operational tactical sense. the battlefield, i might suggest mr. chairman, is very different and very complex battlefield mixed in with civilians. there are high standards.

i would suggest the russian air force does not-- is not subject to and we are subject to, which is different, very different than the first gulf war and the amounts of conventional forces. so, that i think is at least a partial answer, mr. chairman, to your question. >> well, from the way i proceeded here especially given my frustration with the first year of this conflict and not utilizing linear power when it could be very effective, we have a situation today where we are hitting the bad guys in this, isis 100 times in the russians are hitting those that are opposed to isis and assad 800 times to read. that's my take away in a broad