with anthony kennedy in 1987, clarence thomas in 1991, ruth bader ginsburg in 1993, steven ruth bader ginsburg in 1993, steven breyer in 1994, john roberts 2005, samuel alito in 2006, and hellenic pagan in 2010. watch watch thursday at 8:00 p.m. eastern on c-span two. >> the former director of the congressional budget office, douglas took part in a discussion about the children's health insurance program, known estimate. the program is up for reauthorization in congress this year. this discussion was discussion was hosted by cq roll call, is 40 minutes. >> we have mark which was president and the ceo of the ildren's hospital, doug former cbo director, we were joking about bearing the mark of the last four being the cbo scores

and withstanding criticism and we also have the former director of medicaid into services and bill hoagland who is a favored reporter bipartisan, very helpful and a former budget committee. >> thank you very much for coming. we really appreciate everyone being here today. when we planned this conference we thought we'd be a little farther along in our discussion. we thought there'd be some conversation going on and there has been a few private conversations but not as much action as you'd expect all those many months ago. as you think about children's health coverage what are some of the key aspects that you're thinking about press a mark i'll let anyone jump in mark? >> happy to start. the chip program is a key part of children's health coverage.

6 million kids in tip and it's an important program. that being said we want to focus on the big contacts which is we have over 30 million kids in the medicaid program so we think of tip as a 15% solution, a good solution but the lion share of the lipids in the medicaid program which is tied up with the repeal and replace campaign. that's how we think of the broader picture on that site. >> anyone else want to jump in smart. >> i thought this was the year that we would figure out what we want for tip. dad had this weird family glitch and the we had that program that would need to be authorized and i thought we would get reformed and better integrated into the landscape. i live a life of delusion and now what were going to see is how this american health care act plays out and will think about where to build in.

when i think about tip i think about where we've come from since tip was created in 1997 it's been a remarkable effect this past year we've reached a.where 95% of children in the united states have health insurance coverage and that is marked progress from where we were just a few years ago. since my time in the aca we've seen that progress accelerated and as well, it's it's very compelling research that the outcome for kids who have medicaid or chip coverage. children who were served by chip go on to be healthier and i adults and stay in school and go to college. they have higher earnings as adults. clearly, a lot of return on investment from covering those pits. the challenge is even though chip is not a hot issue right

now, medicaid is in the american healthcare act is $880 billion over ten years and the likelihood of that effect on children is high. children represent about half of all beneficiaries of the medicaid program. even though to chip is in front and center children's coverage certainly is. >> this particular program came into existence in a crisis in someway because the kids out in 1997 balanced budget agreement negotiations that we had and i want to emphasize that this was a bipartisan agreement and it remained bipartisan. so even in this partisan with the affordable care act this particular program still has the will to you to be bipartisan. this is an advantage to make

sure that the expansion of it, even even though the reauthorization expires this year. >> people are concerned that the republican bill will make chip authorization work. can someone walk us through that president. >> yes. [laughter] the issue is that the aca, so-called, six to 18 -year-old in the medicaid program is appealed. many of this could put this back in the chip programs and it will make it more expensive. i've seen no evidence among republicans that they somehow want to reverse that and keep them in the medicaid program. i think that's true, it it matters the mechanics of the rip apart. when they get to the reauthorization, any higher price tag in this environment. >> absolutely. it makes it that much more challenging. >> dug the expert as far as the

budget but i'd like to clarify in my own mind, is that chip is not an entitlement. congress that reauthorized it with 355 billion and it was a fixed number. while there might be the interaction that teaches. have to change that 35 billion. if the need not go up if it's in a fiscally conservative mood but it could mean that there are less dollars for the children who are eligible. that's my competition. >> i'm not going to get exactly right but the weird interaction is that if you don't give the states the money they still have to deliver. they need to step back and think what they want from this program to get it right.

>> as i sit between two budgets here and i won't get into the budget elements but from a problematic.about the movement of the kids into the medicaid program is a simple process to make families to know. which program do their children qualify and it brought with it greater affordability under the american healthcare act. we lose that at the same time we have to grapple with the mechanics. >> they say you can charge those premiums and co-pays and things you can always doing medicaid and they have a reflective economic incentives. that drives a little bit of this >> one other issue that will be dealing with is the fact that the healthcare law, obama care, did provide states with a 23% increase in their federal funding.

that was continued in their last authorization in 2015 and there are some conservative who have artie said that they are concerned about that and they want to scale it back. what do you think that means and how do you expect congress to address that smart. >> i like to offer a comment. we wanted a four-year reauthorization in 2015 as many of you will a call. we up getting two. to some degree felt that was offset by getting a higher rate. that was pointed out. it's going to be tough to get more money out of the process. i think the number of years that we get on reauthorization should be important. to getting to reauthorization makes a constant political progress and you get reauthorized. we would like to see a longer period of time and i do think that the 23% may be hard to keep. big picture big picture it's not that much money but the chip is not that it program plus or minus the 23% that in this

environment almost anything that more money is a problem even though it's not that much more money from a federal perspective, from a state perspective they budgeted for that for the chip alignment a year ago. now they're in their state legislative sessions and there's a lot of uncertainty about matching rates will hold and that creates a challenge for a state that's trying to plan its chip program. >> former cbo director and if you had alcohol in by. [laughter] the budgetary outlook imperative from last year is one in which left on autopilot, the federal budget goes to running a trillion dollar debt to presumably the top size government. that's a daunting fiscal reality. number one, and if same way i'm sure the governors hate the idea of callbacks medicaid expansion,

i get that but if there is very little money, it's hard for me to defend providing a more generous mat base for higher income kids in lower income kids. you just got a face up to that and figure out what we want out of this program. >> my sense is that, attend 23% -- we have to get the reauthorization quickly. while we debate the affordable care act and bill on the house, quite frankly, we need to move quicker on reauthorization. >> or at all. >> and when we thought before the debate started there was some sense that% would phase down as the affordable care act came up and now, i do think, given the fiscal issues it

outlines that the likelihood of that 23% remaining is questionable and it probably if there is any sense in this, will phase down. >> they're going to be in a bit of a bind on this. they'll be facing lower medicaid spending over time, compared to lower law and changes in. when they got that money that they put that money into children's coverage or did they give it to provide for other investments and other things for smart. >> money is fundable. date budgets have been tight. there's a little bit of sun rise on the landscape. it's just very tight. it's not locked away and unavailable. they're going to have a real problem, they've artie budgeted

for it and in general they don't have the resources. it's a challenge. >> my sense of the 20% is buried. you can see that if you look at the money it's temporary. other states are more reluctant to make an investment in the clearest example of a state is the dollar is arizona. they close their chip program several years ago and reopened it in part, because of the federal match was about a hundred% in their cases. it'll be interesting to see what happened in arizona without that , the 20 to that 23% did bring the funding high to about 9394%. there were several states that aren't putting any money into the program. one person i have is how this

gets done and as we have so much focus on the american healthcare act as the committees and jurisdictions are focused on that and some of the committees have to deal with fda reauthorization, do you think that this gets left to the end smart is this an afterthought and do you think that it will get wrapped up in the fourth trading that might be happening on the larger healthcare smartconnect i'd like to comment on timing. the horsetrading go to my colleagues. this should be authorized now. the state budget start to pickton mid-summer so they need to know where the money is sitting. down in september the issue really is the current debate we

have a very short attention and time frame in washington. unless you're within 30 days of losing the program, people don't get their attention focused on it and the idea th were worried about that will expire in september, is not reall resonating. i will report that we've had great activity by republicans and democrats for chip. by its popular five-part untreated bipartisan and we don't expect. se, but it won't go forward. the devils and the details and what that is and what the funding changes might be. >> i was going to -- i think the congressman earlier today that there's a lot on the platter that has to be done. today we hit the statutory debt limit rescheduling of that. we are running on a continuing resolution from april of 28, i would argue that given the state budget and the way that their formulated that this might be

something that organizations has put out a proposal to expand for four years. i would say that when we come up with the continuing resolution in april that that might be an opportunity for the extension and uncertainty going forth for the next year as we resolve these other major debate that we have going on that's an interesting idea. another way it could play out in a profitable way would be to fold into subsequent legislation in medicaid. they talked about a three track strategy. that does raise a horse training possibility and i would be really concerned the chip traded off against medicaid since 90% of the children covered by both programs are in medicaid and there's a lot that we like to

see happen for those children and we'd like to continue strong benefits which we have had is underpinning for coverage for those kids. i would worry about a scenario in which we have to think about both at the same time. >> what you think about the idea of china to cr ? with the advocacy groups talked in support ? if you were in favor of chip. if it to the cr that would be terrific. i would say when we raised chip most everyone looked at us and asks what we are worried about. quit worrying about it. for the most part, there's a been a little bit advocacy on chip to date and more on medicaid because that came square into the crosshairs in this budget process and much larger pool. that said i would echo, attend

the comments around it being a political football. there are 6 million children in chip. as a vehicle for one sign negotiation. that would be tragic. >> with respect, i don't don't see it ending up in the cr. it is a bipartisan popular program and schumer will not let something like that because that he couldn't threaten not pass it. i don't that will work. in the end, one way or another, there will be a flat out one year extension and in a moment of, zero we have to do something, they'll do it. the right thing to do is to get the leadership that they're just getting into place to quietly convene the folks outside of the and around the american healcare a and quietly conve and say, les do the

expansion related to the 2018, what we need to get done. that strikes me as a productive strategy that will allow them to tailor it to whatever happens on the larger healthcare reform front. i think you really do need the administration to block that kind of leadership and only they really sit down with both sides and figure out what to do. >> you're a part of the obama administration seen chip. >> i think there's a lot set for the one year and come back to it approach. here's why: what we've been struggling with the reauthorization since the aca pass, it's the question of what is tran2's role. chip. chip has always worked in concert with medicaid. it stands on its shoulders. but now the marketplaces in congress is never formally landed on it question is it better for kids to go into the

marketplace? the changes that were contemplating our fundamental. it would make sense to do a one-year extension and see what the healthcare landscape looks like for medicaid in the marketplace and come back to a serious conversation about chip next year. >> i would like to make a comment. one of the reasons why chip remains relevant was because of the marketplace and the product and exchanges network aquacy, these were adult centric. these weren't very robus products for children. chip is robust for children. i don't think we thought as much evolution in the exchange product as we'd hoped in terms of the pediatric nature of them and whether or not the narrower

networks will be well served for kids. that remains an outstanding person as we think about whether or not we can get rid of a chip and it with a broader commercial offerings, whether it's a private sector or medicaid. >> i just want to add. i don't think that children should be brought into this into trading. children should be protected, particularly this populace. there are three other programs that authorizations expire this year one of them being the national service corps, it expires the other one is the maternal infants and children's home visitation program, and the fq ha, ha, the community health centers. all those three. you could almost package the extension with those other programs and use that as leverage. >> i know that number three is the aca, the money was actually put up if it's only a one-year extension that does get you into

an election year and make things essentially tougher. what you think about that smart it could be extended longer than one year. >> what i see is that in the end the extended because of the time and they don't really have something that changes it. maybe if longer than a year, maybe they they think in 2018 they can really do something that is genuinely bipartisan and maybe left on. [laughter] >> , that will be determined by how this health care debate plays out. we only have two years on the elastic authorization and that was considered pretty good. i would not be apprised to see a be a year and at some.will have to sort out with the program and

not have to advocate every 12 months every year vicki had it exactly right. there was an open question and what role to play begin with. it really does make sense. >> all of those issues that mark identified affordability, family coverage, ere's a lot work through their really argues for some more thought and time. >> let me be the typical budget debbie downer. even when we did the extensions in the past, we did did find a way to offset the cost. this is a strange one because it's built into the cbo baseline but extending it for three or four years, it does score as a cost. it could easily extend it for four years it could be in the 20 billion-dollar range so the question even though we talk

about this, we i think conservative republican congress will want to find a way to offset that cost somehow which creates another set of issues. >> you hate to offset the cost of 30 million kids in medicaid or 6 million kids in chip but that's what we want to avoid if we can. >> let me circle back to the role of the administration. just thinking about the administration, vicki we have a new cms administrator in place as of this week. what would you anticipate coming out of cms. any changes? she says she wants to have much flexibility for states but you and expect any changes of direction and all smart. >> shirt.

as we saw on tuesday the new administration indicates that their interests are and for stability, secretary price and administrator indicating a strong interest in flexibility a couple of reflections in the letter. one area flexibility is the opiate abuse and i think that something is clearly bipartisan and i would say cross administration support. we had started to programs a waiv and it another process specifically to develop stronger state approaches to substance abuse disorder and the administration wanted to expedite it. that's clearly the right priority. i think they are likely to struggle with competing demands between the approaches that are strong clinically versus figuring out what types of providers they want to find.

it's a growing struggle for us and will remain a challenge but more fundamentally, i have have a hard time identifying how opiate addiction will be meaningfully addressed in the medicaid expansion. medicaid expansion is the strongest arrow that we have in our quiver for addressing the national epidemic of opiate abuse and if that is not there and not strong, we've really pulled the rug out of our national efforts that are adjusting addiction. another area flexibility that the administration has indicated and interested in posing greater programs, cost-sharing and fewer benefits there is reason to be concerned that doing that would create barriers to access and keep people from getting the coverage that they need. those are a few areas of the letter that jumped out at me back are there studies that indicate what happens when cost theories what happens when those

sort of changes happen for smart. >> a lot of research has occurred. it can serve as a barrier for premiums enrolling in coverage, cost-sharing can serve as a barrier for people getting services and from the perspective of a low income family is frequently prompting typical choices. choices between rent and groceries and paid for your healthcare. no parent wants to make the decision that they're going to forego getting a medicine for their child ear infection because they have to pay their rent or keep their electricity on i would offer another implication to decentralizing or deregulating or having medicaid become more and more state based if you will but at least four chronically disabled and sick children the number of national

referrals are far far fewer than the in a number of adult offenders. most states in the union have adult she or in each state but pediatrics is not the case. you have a dozen, 20 states with modest pediatric infrastructure so as a result you attend 20% of the sickest kids traveling across state lines to get two states that have referral centers. the more you get to a state -based system with different kinds of minimum benefit requirements you start to realize the thousands of kids and you still down the small percentage across a large base. >> i think the bipartisan policy center has done some work recently. >> thank you, for the plug. we put out a week ago today

preserving the safety net programs and we issued that, if you can believe it, it's a bipartisan policy the two principles on this are centered on, center bill chris and senator former majority leader and they came together with an agreement between the two of them and it just a recommendation and the recommendation is that we should take this out of the debate of the broader picture right now and simply reauthorize this program. we said for years for reauthorization. we also said to extend the 23 pump out and face it down after that time. we thought we'd have a different outcome on the affordable care act so if we could face it down to the historical rate, or to

the rate of the expansion state in terms of their rates. we also said the main thing and yes of the budget here, we want to offset the cost and focusing on some of the drug rebates in medicaid and medicare program is a way to pour four, fund for this reauthorization. we've issued that report along with that we should reauthorize other programs that i mentioned, particularly in the house bill in the national healthcare service core and that the program connect pretty soon i would love for the audience to get involved and would welcome any questions that they have. in the meantime, estates are looking at a difficult fiscal fiscal situation, are there ways that states are innovating to deliver efficient care and try to save money while still providing high-quality care?

has anyone notomething interesting that we should talk about smart. >> i thought i saw enormous progress in this area and strong interest in the states in building a strong delivery system during my time working with dates. it went all across the board. we had 29 states that were really focused on maternal and infant health and obtaining stronger health incomes for newborns, which is appropriate giving that medicaid pays for half of all bursts of the united states. we states taking on targeting initiatives, accountable care organizations for medicaid beneficiaries. arizona is undertaking new approaches for behavioral health and also reentry, people leaving prisons and incarnation. as well as medical homes for native americans.

there is a lot out there right now. i think the concern is that if you cap federal funding it really cramps down on the state incentive to invest because you're limiting federal funds and i think, i'm concerned that. capita it could discourage that kind of innovation rather than encourage. >> interesting. are there any questions from the audience? anything that you'd like to bring to the panelists? >> yesterday i read an interesting little article that indicated that infant female born in africa, i don't recall

in africa would have a longer lifespan than a similar american baby girl born here. it was by several years. i wasn't planning on using this, and and i didn't take notes. [laughter] given that this is not fake views can each of you perhaps respond to what is the most important thing we can be addressing currently to turn -- not deprive that african girl of a long life but to expand the lifespan of our little girls. >> i'm happy to make a comment. there's a been a number of studies to show that we understand in prenatal care and zero to three care, particularly on wellness, coping, driving skills are really young children and we spend a lot of money for

very care, high-tech intensive care units, high-tech inner imaging we have more of a fix that culture than a make it good from the beginning. until we start to shift that we won't make a difference. we have 80 million kids in the country, third lot it just nation in the world. this is not a boutique european union and were not spending enough that's right. one of the things that i worry about in general in the private sector is the basic insurance model is a one-year snapshot and these are all issues that early investments have a long life payoff. there's we've never come to terms with that. in the concept of federal budgeting, we have the

entitlements all wrong. we spend all of the money taking care at the end of life rather than the beginning and the fundamental problem layer is that we have a shift that has to pay for both for one generation and there's no money. >> i don't disagree with either of the remarks but what i would add to tie it back to the earlier conversation is a, there are are efforts underway in hospitals and states across the country and improving maternal and infant health. there has been some progress about early elective deliveries that the of the problem but is a step in the right direction. in the meantime, i worry worry that were going backwards rather than forward. in the house bill and were going to risk eroding the benefits of the standards that are protecting american kids and we know that the coverage they have now is extending mortality.

i am concerned that the outcomes that you are worried about, rightly, could become more likely, rather than less likely going forward. >> the use were all republican response would be one, we have to have jobs, we have to work on that big picture. more importantly for to benin here this morning, the president has released his american first budget blueprint and exactly quite frankly, it's going in the wrong direction from where we want to go. it is reducing those funding for those particular programs that deal with research. prevention and early wellness programs. those are the wrong programs to be reducing in dealing with the issues that you're talking about. i'll get into trouble with my republican friends for saying but this is the wrong direction to go. [laughter]

>> the expiration of the home visiting program and suggested that that be considered as well as chip. home visiting programs in the united states have had very promising success in helping moms and parents get off to a good start. that's the type of investment that we need to continue. >> we love it when people say things that are unexpected. >> that's a good. it will be changed dramatically in congress. >> it is not a budget. let's be honest. it is not a budget. the press said this morning, where's the other 4 trillion-dollar activity we have here called the federal government and it's only for one year with a little supplemental here and there. the way doug and i talked about

it is that this is one third and normally we do ten years budget, so it's one tenth with one 30th of a budget. it is not a budget. it has no economic, aggregate numbers except for that which is discretionary. it is not a budget. >> bill like that more than i do. [laughter] >> tweet away everyone. >> we have children hospitals in canada. >> yes, indeed. any more questions ? we need to wrap up soon but this is your opportunity, don't be shy. anyone? thank you very much i very much

>> >> [inaudible conversations]