line up well with some of the thinking occurring in texas so to give you a high overview, healthy indiana plan has five goals. they want to reduce the number of uninsured low income indiana residents. the reason is called the healthy indiana plan 2.0. it replaced a prior plan that had a small number of beneficiaries. so it allowed for a more aggressive approach to that population. it wanted to provide a value-based decision making approach through a health savings account. this health savings account is referred to as a power account. it wanted to promote disease prevention on that. and it wanted to use private market coverage mechanisms to do that, not state hhsc departments. finally they wanted to have a

work requirement that people who are receiving public assistance are actively looking for work and also have resources for that. so let me just finish here on highlighting just a few of the things that we think again might give a picture to some of the elements of what's in the healthy indiana plan. about a year ago there was the discussion of a plan called the texas way which had many similarities between the healthy indiana plan. it's not been presented or passed through our legislature. and likely won't in its current form, given, obviously, the new realities of our political situation. but there are some things in this plan that get people's attention. as i said, it does require health savings account approach

and it uses incentives to -- around funding of a health savings account and the use of that for co-pays, deductibles and other things in order to allow one to manage their care. certainly the criticism of it is it's not a very large account in the indiana scenario, and does it really -- is it significant enough to change behavior? again still the question out there. it includes incentives to work and generally they do this through giving additional contributions into the power account if individuals go through certain job training requirements and other job search programs that they have. it also imposes financial

penalties. so if you've heard, one of the challenges texas has had with federal medicaid is they've been very clear that it doesn't allow -- the rules do not allow texas to manage very well an appropriate utilization. an example given has been an in appropriate edd utilization. in the healthy indiana plan they actually provide co-pays for nonemergency use of the edd. you'll see here again they're not significant so one might question whether they have certain impact in terms of changing behavior. simply because the population may not even be interested in the consequences of not paying these co-pays, right? from the hospital's perspective it's seen as a difficult scenario because it's hard to collect these co-pays even though they are nominal amounts on that. i think another item, though, is that it does require personal accountability for health and wellness and this is one of the

areas that the benefit plan, for instance, if an individual does certain things for preventative health like gets mammograms on schedule and vaccines and things of that nature then they provide contributions into the fund as well as they give expanded coverage for dental and vision care on that and, again it's that approach to try to provide incentives to get people to do some of the right things in these programs. and so -- and then finally an element that's not a part of the healthy indiana plan but clearly a part of texas is how do we fund it? you have to have tax dollars to generate igts, to pull federal funds down, we don't like taxes in texas and so, you know they say everything is bigger in texas but taxes. right?

although property owners in texas would not concur with that. some of you are shaking your head and smiling. you know exactly what i'm talking about. although we don't have an income tax in the state. and as i said the state is sig right now. and as i said, the state is looking at an lppf approach to try to look at provider fee approach to funding that. and so that kind of concludes my prepared comments. i would end kind of with this quote which i found very helpful throughout my career. everything looks like a failure in the middle. everyone loved inspired beginnings and happy endings. it's just the middle that involves hard work. and i think we as providers and as a nation have a lot in front of us to try to figure out what our funding for our medicaid health system looks like.

and as one individual who counseled me years ago said, most things in life aren't as bad as they look or as good as they look. somewhere in the middle. you just have to figure out how to work your way through it. that is our challenge moving forward. so i'll end that. if you have any additional comments? >> i don't. we've got a few minutes for questions. who wants to stump the panel? >> thank you for your presentations. my question would be, my state recently completed a new waiver and extension with cms. i know there are at least one or two other states kind of running down here in trying to wrap up discussions on extensions or changes to their waivers. i guess my question would be could a new administration come in and say, well, that's great. you have a five-year waiver but we're going to shorten that or make some unilateral changes or even revoke it at a certain point based on new policy

objectives. how should we think about these things that have already been approved? >> certainly any administration has got a broad authority to kind of help to dictate how the medicaid program operates. they spend more than half the money. having said that, i would be -- i would be surprised to see the incoming administration go back and renege on deals that were made. i think generally what you -- they would look at how do we start changing things moving forward? you know, how do we -- how do we allow more healthy indiana 2.0s, how do we allow more different approaches but not actually going back and saying, and you didn't say what state you were from, but, hey, you know, you just agreed to something we don't like. we're going to take it away from

you. that's pretty unusual, unless there's, you know, historically, we've seen that but it's only been like the administration will come in and say, oh, we really don't like what you're doing from a financial perspective. we really don't like the fact that, you know, you're not actually spending any of your own money. you're just kind of generating dollars through dish or through intergovernmental transfers, that kind of thing, so we're going to try to slow that down. but generally you don't see much retroactive change on coverage or other types of policies. >> the other thing i would add is if you've read the standard terms and conditions for the 11:15 waiver, the stcs, they are fairly complicated. and i think it's pretty complicated to unravel some of those. i'm not sure that scenario that the new administration is going to have enough energy in when

they try to tackle some of their other initiatives. >> hi there. this morning we heard from tom scully, and one of his predictions was that medicaid would move toward a per capita cap, but he cited sort of the uneven implementation of the expansion of medicaid and also the goodies that already exist in states f-map formulas as being sort of barriers to getting that through in congress, particularly because a lot of those states are deep red. i'm wondering if you guys have comments on that or thoughts about per capita. >> he is a colorful character. he is very insightful. yes, i mean, i think he knows as well as anybody that there are a lot of mine fields as you start to get into, you know, fundamentally transforming how medicaid works. the program is so big, it is so complex, it is so intertwined

with other programs and other, you know, core functionalities of the health care system broadly. but as you've seen from texas, there's also every state has an enormous amount of complexity with how medicaid runs and is funded with respect to how the state government itself runs. so to come in and say, well, here's one way of doing things and it's going to be the -- it's going to be a big change for everybody, the -- what you'd seen strewn across the landscape would be significant. any number of issues, you raised the -- the food fights or the formula fights that are going to have to happen. what is the base year for any consideration moving forward?

what are the trend rates? what are the different trend rates? are there different trend rates for different populations, and what are those? are you locking in -- take a look at california and new york. the two biggest states, the two biggest medicaid populations. almost two of the biggest disparities in per person spending in the medicaid program, new york probably spends about twice as much per person as california does. are you locking in california at their historically low conservative or parsimonuous or stingy rates? are you locking in new york at their generous drunken sailor spending rates? these are very real questions. n then as you pointed out, the expansion itself. 30 states have done it. 31 states have done it. 20 or so have not. if you haven't done it are you

locked out? that was a component of one of the original ryan plans. you are locked out. and is that sustainable? is that, you know, what is that going to say to the texases and floridas. would they even want it? but then part of the other question will be, as part of repeal and replace, what are they going to do about the expansion itself? will it be eliminated right away, which i think is highly unlikely. or will it be -- will they look at it and say, we'll keep it in place. we'll be more flexible but over the next ten-year window we're just going to phase out the money so it will gradually phase down from 95% federal to whatever your regular state match is. that, again, these things set into motion a lot of very, very difficult state to state delegation to delegation fights

that are going to have to happen. and any time we've looked at, you know, anybody can look at medicaid and say we don't like how that piece of it works, but whenever those people are challenged to come up with a new way of doing it, you quickly find that it's so complex that trying -- there's no easy way of fixing it and accommodating everybody. it's sort of like, i'm going to badly, you know, paraphrase the -- is it the winston church hill quote that talked about american democracy, which is the worst possible form of government, except for all the others. and in some ways, like you can look at the medicaid financing structure and say, that's the worst possible thing, except for all the others. and anything else you look at would be like, creates winners n creates losers and that's -- when you need to maintain.

keep in mind, the house has got votes to do a lot of things. the senate, you know, can do a lot with 50. they have the tiebreaker. 50 votes by reconciliation. but that doesn't give them were wiggle room. and if you start making big losers out of states that, you know, who comprise that margin of error, it becomes much more difficult. so these are very, very real and very, very difficult conversations that you only really get into and you open up that hood and start looking at how that car actually runs. all right. we are at time. i think you guys need to eat lunch, so thanks for having us. [ applause ] join us on tuesday for live coverage of the opening day of the new congress.

watch the official swearing in of the new and re-elected members of the house and senate and the election of the speaker of the house. our all-day live coverage of the day's events from capitol hill begins at 7:00 a.m. eastern on c-span and c-span.org or listen to it on the free c-span radio app. author and journalist max hastings talks about his book "the secret war -- spies, ciphers and guerrillas." mr. hastings argues the rise of electronic and radio communication made codebreakers equally if not more important, than spies on the ground. this hour-long talk is part of a multiday conference at the national world war ii museum in new orleans. >> good morning, everyone. it's a gre