role music played in his book, "country soul: making music and making race in the american south." on sunday at 2:00 p.m. eastern on american history tv, the history of cotton in memphis during the mid 19th century and then a visit to the national civil rights museum. watch c-span cities tour, memphis, saturday at 7:00 p.m. eastern and sunday at 2:00 p.m. on american history tv on c-span3 as we explore america. >> c-span, where history unfolds daily. in 1979, c-span was created as a public service by america's cable television companies, and today, we continue to bring you unfiltered coverage of congress, the white house, the supreme court, and public policy events in washington, d.c., and around the country. c-span is brought to you by your cable or satellite provider. each weekend, this segment

of the "washington journal," we take a look at how your money's at work in a different federal program. this week, we're focusing on the medicaid program and to do that, we're joined by the government accountability office's healthcare director, carolyn yocom. we're going to talk about medicaid expansion and its cost to states and the federal government, but first, ms. yocom, remind us how medicaid was expanded under the affordable care act, who became eligible for inclusion under the expansion. >> okay. the big category of people who are now eligible for medicaid who weren't before are nonelderly nondisabled adults. medicaid had always traditionally covered children, people with disabilities, and people who are elderly, so that's the new population. >> how many states have so far taken that expansion? >> i think it's about 37 right now. >> and what does that translate to in terms of number of new people who are being covered under medicaid? >> well, it's up to about 70

billion -- million, sorry, up to about 70 million right now. >> so what is the cost right now of medicaid per year? >> well, right now, adults who are in the medicaid program are about 15% of the costs. the medicaid expansion component of that is about 10%. because there were some adults who were already covered by states who had chosen to do so. >> what does that translate to in terms of dollars and cents of the cost of medicaid last year. >> well, it was $596 billion last year. so, about 15% of that -- 10% of that would be about $59 billion. >> and how does that compare to pre-expansion? >> pre-expansion, the growth has been about at 10% increase. so, medicaid has been growing all along. the primary areas of growth are people with disabilities and people who are elderly. those are the largest components of growth in medicaid. >> and in this segment of the washingt"washington journal" sp

lines for medicaid recipients, want to hear from you, your experiences in the program, especially if you've been covered under this expansion. 202-748-8000 is that number. all others, 202-748-8001. we're coming off the 2018 elections, medicaid expansion was on the ballot in some states. idaho, utah, and nebraska approved ballot measures to expand medicaid, so what is the process from here? >> well, many of the things under the affordable care act a state had to do regardless of its decision to expand medicaid, so they had to do a new eligibility determination that was basically tax based, and they also had to build and coordinate with exchanges where people could purchase federal insurance, either subsidized or -- sorry, purchase private insurance, either subsidized or on their own. so, the big change for a state who has decided to expand right

now is two things. one, making sure that they have eligibility systems that follow the rules under the affordable care act for this expansion population, and then secondly, there is a different amount of federal contributions, so they also have to make sure they're getting the right amount of money for those individuals. >> so, let's explain that. what was the cost sharing deal that states who chose to expand under the aca took when they made that expansion? >> well, initially, it was actually 100% federal funding for any state who decided to expand its medicaid program for that particular population. over time, it's going to go down to about 90%. so, it is a higher matching rate. generally, states' matching rates are more like 50% to about 70% maximum. >> that 100% payment by the federal government, do the states who are newly expanding their medicaid programs, do they get that right now?

or they're coming in midway through. >> they're coming in midway through the deal so they're closer to that 90%. >> when does it hit 90%? >> i believe in 2020. >> what are some different ways that states have sought to cover their share of the payments? >> most of it has been through, really, state revenues. about three fourths of state spending really just comes from state sources like taxes, sales tax, those types of things. there is about 25% that comes from other areas, and there's two broad categories. one is healthcare providers. they may tax a hospital or other and come up with revenue that way for the state share, and then the other is local governments, county governments, city governments may also contribute. >> what state has a unique program for covering this contribution. >> they are all unique. the amount of variety across the

states and the way they finance and operate medicaid is really amazing. some states are 100% managed care. others do combinations of everything you can think of. >> explain what managed care is. >> managed care is where you essentially are contracting with an organization to provide all the services for a set payment. generally, it can be a per member per month but it has been a way for states to manage the cost and have a little bit more predictability of the cost. >> a map from the kaiser family foundation shows the status of state medicaid expansion adopted in 37 states, including washington, d.c. you can see on this map here, the states with the blue and gray stripes, those are states we were talking about with the ballot measures to expand their medicaid programs. the orange states here are the states that have not adopted medicaid expansion at this time. we're talking about the program, want to hear your experiences in

the program, especially if you're one of those who started receiving coverage amid the expansion under the affordable care act. 202-748-8000 is the number for medicaid recipients. 202-748-8001 for all others. we're talking with carolyn yocom of the government accountability office. how long have you been covering healthcare issues there? >> since about 1998. >> and how much of a focus of your work now is the medicaid program, particularly? >> it's pretty much close to 100%. i also look at the children's health insurance program, but almost all medicaid. >> taking your call. charlotte's up first, a medicaid recipient in st. louis, missouri. good morning. >> good morning. i wondered if you could tell me why -- what the difference is or the concern that people have with managed care versus the people that -- the concern

people have with managed care because i hear so many bad things about it and i'm just unsure if it's a good or a bad thing. and then also, if you know the difference between spin down or if you could explain to me what spin down is too because i have that through medicaid on my medicaid coverage and i don't really understand how they calculate that. thank you. >> okay. >> charlotte, thanks for the questions. >> you're welcome. well, first of all, managed care can be a great way to provide services in the medicaid program. gao's concern and the things that we have raised about managed care have really been a lack of information. we don't always know how the money is spent or where it goes, and we don't believe that the risks are being accounted for. in managed care, you can have a risk of people -- of the money going out the door but the services not actually being provided, and gao would like a

little more assurance that the money is going out the door and the services are being provided to those who need it. >> what are some of the big managed care providers out there that people might have heard of? >> oh, they might have heard of united healthcare, amerigroup. these are two that come to mind right now. >> how many are there, total? >> there's a fair number that are participating in managed care. i couldn't give you an exact number. >> are those you mentioned, though, do they make up the majority of the managed care program? >> there's more than a couple big players. and it can be regionally based. there are programs that operate in particular parts of the united states. to get to charlotte's question about spend down, yeah, spend down is what happens when you are -- you're not in an expansion population, you're in a different category of medicaid that has always been covered. and what happens is you have to

spend down your income and resources in order to meet the income and resource qualifications for medicaid. i can't get too specific because each state does -- has different levels in which they provide coverage, but essentially, what they're doing is tracking that your income and resources are low enough that you then qualify for medicaid. >> another medicaid recipient, greg, is in texas. good morning. >> good morning. >> good morning. >> i'm glad to have this -- it was the most embarrassing thing for me in the world to self-medicate because i thought it was mainly for people that didn't want to work and was lazy, and when i had my insurance, i had the worst health -- that insurance help i can get paying shurninsurance. when i got on medicaid, i got the best help from the best doctors. they just fight to try to get the approval from the insurance

companies but medicaid takes care of me better than i ever been taken care of and i'm an old man and i've been embarrassed to need it. another question i would like to ask you about the medicaid thing. i don't have nothing against people coming over here, but it's so many people coming over here that's having babies, in my neighborhood, they have babies every six months, putting a burden and a stress and they got husbands that's working and they're using different identification to claim all this benefits and hurting the people that really do need medicaid and all that stimulus check, they give them $7,000 every month for kids that they don't -- going and buying cars and all this other stuff, in the black community too, and we need to -- we got to cut down on that. the medicaid is the best thing that ever happened to me. >> that's greg in texas this morning. do you want to talk through a couple of the issues he brings up. >> well, first, i'm really glad to hear that medicaid's done its job for you.

that is always the best news that a place like gao and others can get. with regard to people who are not citizens, medicaid does have a citizenship check and so an individual who is not a citizen of the united states only gets, really, emergency care at most and sometimes not that, depending on the different circumstances. so, it's -- i understand the concern you're raising, but for the most part, citizenship is one of the basic requirements for medicaid. >> the caller said originally he was embarrassed to go on it, thought it was for people who didn't work. can you talk through work requirements for medicaid services, how many states have implemented those and the status of that. >> yeah. we are just starting work on that, so i can tell you what we're going to be looking at. we are going to be looking at what kind of approvals are out there for beneficiary and work

requirements. we're also going to look at the administrative costs associated with implementing that. so, does it take extra money to implement work requirements. and then how the centers for medicare and medicaid reviews work requirements and makes approvals. so -- >> c-span viewers who are long-time viewers of this program know what the government accountability office is but for somebody who maybe hasn't heard about it, can you explain what you do there and what your role is when it comes to oversight of these kinds of programs. >> gao has a very special role in the federal government. we are an investigative arm of congress. we work for both parties, and we pride ourselves on our work being nonpartisan and fact based. so, our focus is to provide congress and the american public with the facts they need to better understand the program. >> joe is a medicaid recipient in new york city. good morning. >> yes, good morning. thank you so much for c-span.

and i just want to echo what you just heard from the gentleman in texas. >> what's that? >> my experience with medicaid, i'm close to medicare age, but i've had insurance from fortune 100 companies, i've had insurance from start-up companies, i've had probably, like, over a dozen different kinds of health insurance in my lifetime, and i got to say, the obamacare expansion of medicaid really saved my life. and it's the best insurance i've ever had. >> joe, thank you. i'm really glad to hear that. it's gratifying to hear that the program is working for people who need it. one of the big areas of uninsured individuals in the united states prior to the affordable care act really was people in their 50s, potentially employed, potentially not, but without access to employer-sponsored insurance. >> you managed -- you talked

about your concern about the transparency of managed care programs. where else has gao expressed concerns about medicaid? what do you think isn't working? >> well, we've expressed another area of concern as -- there's probably two broad areas. one is improper payments, making sure that the payments are going to the right place. and on a fee for service level, those improper payments are about 12%, so when you're not in managed care but paying on a bill by bill basis, that money has been 12% error rate is what we have and what cms has identified and reported. >> how does that compare, historically? >> well, that's up. yeah. that has been growing. we do have some work coming out that is looking at those improper payment rates and sort of what's going on there. a second area is medicaid offers states a lot of flexibility

through what they call demonstrations, where you can expand the program and waive particular aspects of the program in order to provide services a little bit differently. this can be a really good thing because it's a 50-year-old program and healthcare has changed over the past 50 years. the downside, though, is that states have used some of the mechanisms here to shift some of the cost more over to the federal government, and this is a partnership program. we think people -- both states and federal need to come to the table with a better sharing of the dollars. >> again, gao.gov is the place to go for all these reports that you're talking about, available if they're out already. carlos is waiting in ft. lauderdale, florida, medicaid recipient. good morning. >> good morning. i want to congratulate mrs. yocom and the program for

being for us, talking about this subject. i just turned 65 and i'm concerned about -- i'm a medicare recipient and i'm concerned about the future of medicare, and we're covered under the medicare, and i'm concerned about the future, about how our medicare benefits will be affected if medicaid and one in the future might be -- you know, they might cut -- the government might cut the funding for that, and i think -- and i would like to recommend that i think we -- the government needs to segregate the costs of medicare and i think since medicare recipients pay into medicaid, i think, you know, that should be separated so they know, you know, to try not to affect us and then if you divide into other groups, who receives medicaid, who is receiving, i think the government can

actually go and try to control the costs or reduce the costs. so i think that's my recommendation and i thank you. >> okay. >> carlos, thanks for recommendations. >> well, medicare is financed and paid for separately, so in some ways, the money is already segregated, carlos. medicaid comes from state revenues and from federal expenditures. medicare operates pretty much via trust funds that are set up and established especially for those programs. there are people who qualify for both, and they are called dual eligible people, so they are -- they qualify for medicare and for medicaid. under those circumstances, medicaid pays premiums and cost sharings for the medicare program, and medicare does what it always does. >> anna is waiting in ohio. good morning. >> good morning.

>> good morning. >> good morning. i was wondering how many illegals are on medicaid and how much it is costing the american taxpayer. >> yeah. as i noted before, anna, citizenship is a requirement to the medicaid program. you have to show proof of citizenship and also a social security number in order to be eligible. >> is that for the children on the program as well? >> yes. >> ralph, charlottesville, virginia, good morning. >> thanks for c-span. i have a question for ms. yocom if i could. the medicare -- medicaid program, i think there is a lot of abuse and fraud in the program, and i'm a tell you why, in virginia, i know several cases as well as you talk to community members that knows several cases of individuals who are not disabled and have two or

three children and are on medicaid and not working and now i know of a situation where an individual just got a job after two or three years in virginia, the two children are on medicaid, and the individuals are cared for by the mom, and the mom is under a government program whereby she's receiving medicaid for the children and that's illegal, so there's a lot of illegal stuff going on with medicaid and i think it has to be corrected, and i would like to know the percentage you had mentioned that the percentage of people on medicaid were elderly and disabled, the majority of them. it's hard to believe that that amount is the majority, because children make up a large amount of that cost and medicaid, and i think those percentages are -- that you have given, i can't see that as well as a lot of community members cannot see that, and i'm not saying that people don't qualify for

medicaid, but that has to be looked at totally, who qualifies and who can get medicaid and it's a lot of people that are not disabled. i have no problem with that and i don't have a problem with elderly. but we need to pull out the fraud and abuse and there's a whole lot of it going on on every state in the union. >> got your point, ralph. maybe these numbers will help before carolyn yocom expands on them. this from the gao. medicaid enrollment as of 2017, 30.6 million children, about 13.7 million from the expansion enrollees due to the medicaid expansion under the aca, 10.2 million other adults, 8.3 million blind and disabled americans, 5.4 million elderly. >> thank you. and overall, children are -- less than 20% of the cost, but almost 50% of the population in the program.

children can be pretty inexpensive to care for. they need immunizations and they need regular check-ups but it's not always a very expensive proposition. you are correct to be concerned about eligibility. one of the unfortunate things that has happened since the affordable care act was passed is there have not been public, open reviews of eligibility determinations. instead, estimating improper rates due to people who were not eligible for the program, they froze a rate of 3% and just have not been reporting it. gao's been very concerned about that. this is the first year where cms is once again going to be testing and measuring medicaid eligibility, so it's been four years, though, since we've had a number that's actually real. >> about ten minutes left in this segment of the washington

journal. if you're a medicaid recipient, 202-748-8000. we want to hear your questions and experience with the program. all others, 202-748-8001. pat is a medicaid recipient in willis, texas. good morning. >> good morning. actually, i'm not a recipient. i just happened to be calling in. i had a -- well, i guess my general question is, what is the eligibility to get on medicaid? i had a -- i know of a friend who came down with cancer and he didn't have any personal insurance, but he was above the level to get on it, and then he eventually died of cancer without any treatment at all, so i'm just curious what are the entry levels that people need to be able to get this type of coverage? >> yeah, it's -- it's complicated. medicaid has different eligibility levels depending on

the category of population that we're talking about. for children, generally, the relationship is to the federal poverty level, and it's 133% of the federal poverty all the way up to in some cases there are states that go 200% or 300% of the federal poverty level for children. >> states can set that level. >> yes, they can. with the expansion, that went to that 133% and then for other adults in the program, it depended on the state's discretion on what the poverty level would be set for adults. so, in some cases, it can be as low as 9% of the poverty level before people are eligible. in other states, it has been higher. the other way that people can get on medicaid, this goes back

to the question about spend down that was earlier in the program, and people can spend down their income and resources and qualify for medicaid. the unfortunate truth is if you have something like cancer and spending it down takes a while, it may be difficult to get that care as soon as would be best. >> and what about the requirements for the category of those who are disabled? >> disabled also will vary by state. and there is also a need to be determined disabled. >> what does that mean? >> some states do it through social security programs, the social security disability insurance program. other states do it themselves. so, the assessments that are done also can vary. >> carolyn yocom with us from the gao for a few more minutes, taking your calls and questions. we do have that line for medicaid recipients and burt's on it from portland, oregon.

good morning. >> hi. what is the problem with medicaid and medicare covering alternative medicines? on medicaid, we had to sign a waiver promising to pay for our visit just in case there was no money that day available to cover it. and on medicare, it only covers chiropractors, not acupuncture or naturopaths. >> i don't know too much about this area. i know states with can have discretion in what gets covered. there is a benefit package in medicaid and there can be approvals to expand that benefit package to things like alternative medicines, but it would really be a discussion between the state and the centers for medicare and medicaid services. >> sandra, medicaid recipient in pennsylvania. good morning. >> good morning.

>> good morning. >> i'm on medicaid. i am 62 years old, disabled, i have been for 30 years, i'm on social security disability, which i worked for, and i have a question. how come i get $41 a month in food stamps? i have an acquaintance with five children, five baby daddies, and she gets almost $800 plus cash assistance plus h.u.d. how does this make sense? >> i can't help you with that one. i can tell you about the medicaid component there, but i'm really not familiar with the other programs. >> do you want to talk through the medicaid component a little bit? >> yeah, medicaid has -- in some ways, when someone has worked and is eligible for ssdi, then medicaid operates a little bit like it does with medicare and people who are eligible for both programs in that it can help pay premiums and copayments and

provide additional support. >> bill's waiting on the line for medicaid recipients. gary, indiana. good morning. >> well, good morning to you, both of you. i'm 69, low income, and i'm fortunate to be on both medicare and medicaid. and even though indiana's kind of a split state, we're sometimes democrat, mostly republican, like we got now two republican senators, a republican governor in our state legislature has a super majority of republicans. but the point i'm making, healthcare shouldn't be a political issue. in my opinion, medicare and medicaid saved my life. so i'm going to be a booster of the program and i believe everybody in the united states that's qualified should receive it and i don't think -- there's probably fraud in everything. i don't know how you can nail down a specific. you have different cases, i know they investigate quite thoroughly in indiana, what your status is. they'll even come to your home.

so in terms of fraud, i think it's more like a bullet point thing, an emotional issue, because i really think these two programs are doing a fantastic job and i -- i got as old as i did because of them because i would have died of heart problems. i wouldn't have been able to pay for it even though most of my life i had private insurance through my employer. when i became disabled, my world changed and i wish anybody would walk in a disabled person's shoes for a while that are on these programs and see how just a tough negotiating life is. you know, when i was physically fit and mentally fit, 100%, everything seemed like, oh, well, these people are taking advantage of the system. occasionally i'd have bad thoughts like that but once i grew up a little bit and found out exactly what we're needing in this country -- because i'm a baby boomer and we're getting older. we're elderly and we're getting all sorts of different diseases, some sections of the population are living longer. we still have to tackle things

like alzheimer's. that's a big issue, especially for women. so that's my comments for this morning. >> bill, thanks for sharing your story. carolyn yocom, before we get too close to the end of the program here, we talked about ballot