we have had several states testify here today. governor perry wrote a letter on the subject. i would like that part of the record as well. so ordered. >> mr. chairman, thank you so much. i want to thank all seven witnesses for bearing with us. my question is over a concern that i have in regard to the exchanges and the authority of the secretary in regard to will making. i am going to direct my questioning to the secretary of health services in wisconsin, mr. dennis smith, and hopefully we will be able to get all this done in five minutes. the recently released information regarding health care quality for exchanges on november the 27, it specifically mentions a section, 1311 of aca, which directs quality health plan issues and improvement strategies as directed by the secretary,

specifically subsection 8 of 1311 would allow the secretary to prevent physicians treating patients in exchanges unless they implement such mechanisms to improve health care quality the secretary may require. physicians must follow quality directives as defined by the secretary or lose their business. mr. smith, are you aware of this provision? >> i am not familiar with that section. >> let me ask you this. in this provision, you may not know this either, but the word quality is not defined in the statute. it is safe to assume that the secretary, not just secretary sebelius, but every secretary to follow, would be able to define for regulation what that word

quality means. yes or no? >> i believe that is the correct interpretation. again, we have tried to introduce quality performances into a variety of parts of our programs, both in managed care, both in the fee-for-service world, and this is another one of our concerns that we will have states with standards, and the federal government with standards. >> this is a huge concern. i know what quality means with regard to the specialty of gynecology as defined by the american college. it is the same thing for the american college of surgeons. they define quality. if the secretary decided to use this provision in the law under 1311 h -- she or any secretary

could use this provision to determine, for example, mammographies for women under 50 are not helpful. would a physician be able to treat patients in the exchange if they prescribed a mammogram for a 49-year-old woman? can you answer that? >> i do not think i can. >> i can answer it for you. the answer is no. if the secretary decided that physicians who provide abortions were not providing quality health care because they endangered the life of the child, could the secretary run those who provide abortions out of business? i'll answer that for you too. the answer is yes. i believe that this language

would allow the secretary to control what physicians prescribe, what health care patients can access. is there a single person in this room who thinks that the secretary should have that kind of authority, whether it is a republican or democrat? i have a bill, 6320, which repeals this clearly dangerous provision. i plan to reintroduce this bill in the 113th congress. i hope that this committee in a bipartisan fashion can work together in this effort. look, i do not know whether this section was an intentional provision or an unintended consequence. i would rather like to think it was an unintended consequence. this is the thing you get in a 2700-page bill that you have to

pass and then finally find out what is in it. maybe you like it, and maybe you will not. this clearly is a provision where any secretary of health and human services can pretty much determine what the quality of care is for physicians, providers, in one of these exchanges, in the 50 states and territories and the district of colombia. when each specialty society has a clearly defined what is quality care, yet the secretary can now say, well, you're not providing quality care, as determined by me under section 1311, and therefore, you are out of business. you cannot be part of a panel in the exchanges. this is clearly wrong and has to be repealed. mr. chairman, i have probably gone a bit beyond, but i yield

back. i would remind my colleagues, my bill repeals that section. hopefully, we can get that done. >> the gentleman yields. the chair recognizes the gentlelady from wisconsin, miss baldwin. five minutes. >> thank you, mr. chairman. i am very proud of the work we did in this committee to pass the affordable care act because access to affordable health care is an essential pillar of middle-class economic security. many states are making very impressive progress in moving health care reform forward. we heard maryland and arkansas, two great examples of two states who have put politics aside and are doing the very hard work involved in implementation because they know it is the right thing to do for the families and small

businesses and others in their state. while the states have moved forward and others have, i have been concerned about my home state of wisconsin and the way it has been holding back. earlier, wisconsin returned an early innovator federal grant that would have enabled our state to build a wisconsin-run health insurance exchange. building a state-based exchange in my opinion would have provided families and businesses with more choices for the quality coverage that our state has been known for providing to our citizens for years. i am committed to bringing people together and working collectively to make our nation's new health law works for my home state and other states. our state has a strong tradition and history -- the secretary talked about that, about being a national leader in

advancing health care reform. it is my hope that we can continue in that proposition by expanding our medicaid eligibility so that those who need health coverage the most have access to it. secretary smith, you mentioned in your testimony, and i read governor walker's comments yesterday, that he has not yet made a decision as of this moment on whether our state will participate in the medicaid expansion. is that correct? >> that is correct. >> i want to tell delve a little deeper in terms of the timeline for making that final decision. i know you had some press availability yesterday in our state. you made some comments that concerned me. you said the math will not work out, and yet the state has not

yet completed its financial projections. you made comments about still continuing to build a model. yet, you say it is a straightforward calculation. based on those concerns, what is the timeline that you contemplate for doing that? and having the decision move forward with the administration? >> thank you. if i can clarify, my comments about the math were very specific in terms of whether or not the federal government would balance out the childless adult population. we have about 21,700 childless adults -- even if we get 100% for them, that is not going to offset the costs of all the new people who would come into the program. that is what my comments were about.

>> in terms of the timeline for the overall calculation that you need to do, how soon can we expect to hear? >> the governor -- he will include in the governor's budget whether that decision, whether or not to expand. >> when the governor's budget is released, that is when he will announce the decision. thank you. i just want to repeat that i believe it is crucially important that our state expands the coverage. according to the kaiser commission on medicaid and the uninsured, over 200,000 wisconsinites would gain coverage under the expansion. if it is uncertainty that we are concerned about, surely those 200,000 people deserve the certainty of knowing that quality and affordable care will be there for them. we know the impact for those

people. accessing preventive care, that can forestall more expensive and costly and sometimes deadly illnesses. 200,000 people who we hope would be living healthier and more productive lives, they are better able to manage chronic illnesses that they might experience. with 100% federal funding for the new medicaid population for 2016, then phasing down to 90% funding, our state could save one quarter of a billion dollars in medicaid costs. they could save another quarter of a billion, $250 million, in uncompensated care costs. on that topic, although i see i am running out of time, i was going to ask director allison to talk more about some of the

other savings that you have realized in your state of arkansas. given that i have run out of time, we will follow up in writing afterwards. thank you. >> we will recognize the gentlelady from illinois. five minutes for your questions. >> thank you, mr. chairman. first, i want to thank the director for working with cook county on a waiver that will allow for the county to early enroll more than 150,000 individuals who will be eligible for medicaid in 2014. you have given us the opportunity to get a headstart. thank you very much. i want to set the record straight on a couple of things. there was some talk about the costs for illinois. the federal government is going

to provide almost $157 million to illinois to support insurance coverage for 898,000 illinoisans. that would reduce our uninsured population by 50%. illinois will save $953 million in uncompensated expenditures, and there'll be some increase in the cost for illinois, about 1%. look what we are getting. it is a miracle to me. i also wanted to point out that in terms of the overall increase in insurance costs, yes, costs have increased, but less than they have since the affordable care act was passed. the aca saved an estimated $2.1 billion in health insurance premiums through the medical

loss ratio and rate review provisions. almost 13 million consumers received a check because insurance companies spent too much money. rate review saved consumers about $1 billion, in individual and small group markets. these are victories. a number of people have talked about the problem -- that somehow the affordable care act messes up your opportunities to get rid of fraud and eligibility requirements, etcetera. i wanted to talk about pennsylvania for a minute. my understanding is that in the late summer, the pennsylvania department of welfare began informing hundreds of thousands of families by mail that they had 10 days to provide necessary documentation in order to keep their children enrolled in medicaid. if a family missed the deadline

or even if they met the deadline but the department of public welfare failed to process the paperwork, they would drop the medicaid, and in fact, 89,000 children were dropped. here's my point. are some of these problems an excuse and the opportunity to set up barriers to actually bump people from the rolls? i think it is completely unfair. mr. alexander, you have an opportunity to answer. not only do you have 10 days to keep your children on medicaid, but if we cannot process your papers, then we will bump you from medicaid, and that happened to 89,000 children. i think it is a fraud to do that to children.

what did you think? >> thank you very much for your comments. when we arrived, and i arrived at the department, we had hundreds of thousands of cases that had not been processed in years. they were left piling up in county assistance offices. it is our duty as a state, where mandated by federal law, to follow the law -- to follow the laws that you passed. >> ten days? >> we went through meticulously to make sure that we checked that every family that was eligible was eligible, and whatever family was not eligible was not eligible. this was not about children because we determined that as a family -- we're talking about families and individuals, not just children. >> my understanding is that the 89,000 figure represents only

children. >> there were much more than 89,000. let's get to what we did do. we meticulously went through -- we sent them notices through federal law, we followed the law, and the regulations. >> ten days? >> we sent them notices. it was more than 10 days. if they did not reply, then they were terminated. if they did not reply within the accounted time -- we give them every chance possible. even after that, we have done outreach. >> what if you could not process? my understanding is that if the department failed to process the paperwork within 10 days, they were dropped? >> that is incorrect. by law, it is a 30 day time period. we give them ample time. it was extended past 30 days

for them to be able to contact us. we told all of the families that if you come in and contact us, we will get you right back on the program. the point of the matter is, congresswoman, when you come into a department like this and you have hundreds of thousands of cases that have piled up, there is a problem. we have a process that is given to us by congress. we follow those laws. we have state rules and regulations that we need to follow. if somebody tells us not to follow the laws and the pass laws to that effect, then we will do that accordingly. we followed all of the rules and regulations. we reached out to the families. every one that is eligible for medicaid, we want to be on medicaid. if you are not eligible, then we do not want you on the program. there is a difference.

we are here to serve the truly needy, eligible families and children. >> can i just say, with respect, i have different numbers. i would like to submit them for the record. >> the chair would entertain a glance at those records. >> thank you very much, mr. chairman. i want to talk about two issues. these involve estates and dish payments. a major concern when crafting the aca was that my state, new york, as a do-gooder state, was not penalized. also for dish, i wanted to make sure that york city was not penalized. the new york medicaid program already covers most categories of individuals beyond the expansion threshold in the

affordable care act. however, it is projected that after the aca is fully implemented in new york, 10% of our residents will still remain uninsured, which means that dish funding will still remain important. ms. mann, i know you and i spoke about this a few weeks ago. i just want to reiterate how important this is for states that already have broad eligibility for medicaid programs. as you know, that is a very big concern of mine. i hope these requirements will not punish these states.

let me ask dr. sharfstein and dr. allison, can you talk about how declining funding for uncompensated care and dish influenced your decision to push the medicaid expansion in your states? >> just to give one example from maryland. we have a unique way of funding uncompensated care, about $1 billion a year in uncompensated care goes into a pool on the hospital side. there is about a 7% assessment that goes on in every single person's hospital bill in the state for every service that pays for that uncompensated care. when that goes down because more people get covered, everybody benefits. small businesses, individuals, the state, it is one of the factors that we used to see. maryland is very explicit. you can see the specific savings that will accrue across the state. it is eliminating a hidden tax.

>> we estimate -- so far, we have found about $90 million per year that the state has spent on non-medicaid programs for uncompensated care. we estimate that at least half of that would be diverted to the state general fund as an offset to the medicaid expansion, which is not very different from the urban institute's assumption. >> as i mentioned before, new york has worked hard to ensure that low income and vulnerable new yorkers have access to health care services by expanded eligibility for medicaid beyond the federal requirement, even prior to the expansion in the aca. i know that federal support for newly eligible populations is incredibly generous and the law includes provisions to benefit these states. the reality is that new york will not see the same federal

support as other states. regardless, i am proud of the fact that new york intends to further expand its medicaid program to meet the aca threshold of 138% of the federal poverty level. it is estimated that new york will save $2.3 billion a year as a result of this enhanced federal medicaid support. with the government providing 100% of the funding, newly eligible populations for the first three years, and providing at least 90% of the funding beyond, i cannot understand why any state would choose not to provide health care coverage for its neediest citizens. let me ask dr. sharfstein and dr. allison -- you stated, expanding medicaid is the best decision for maryland providers. can you elaborate on the input received from health care stakeholders regarding the

expansion? >> after aca was passed, there was a process that involved hundreds of marylanders, the business community, health care providers, and there was a consensus that it made sense to expand coverage. it improves health outcomes, and it would have a great impact on the economy and health system. maryland has moved from that point based on the input we received from across the state. >> dr. allison, what input did you receive from stakeholders regarding the expansion in arkansas? >> virtually all stakeholders have come out in favor of the medicaid expansion. they understand the good it would do for their patients. they understand the harm it would do to them if it were not expanded.

>> ms. mann, did you want to make a comment about what i mentioned before about states not getting punished if they expand their eligibility? am i done? >> we have other members that have been waiting a long time. the gentleman's time has expired. >> thank you, mr. chairman. i appreciate this hearing. with tomorrow being the deadline for states to declare their intentions regarding the aca exchanges, i would like to focus my time on the questions that remain with regard to the functions of these exchanges. my time is limited. [indiscernible] -- how to provide for uninterrupted coverage for those changes within the course of the year is due to

fluctuations in income. the statute is not clear whether consumers would be able to maintain existing coverage or if they will be required to move between private coverage and medicaid if their income shifts throughout the year. this potential could place administrative burdens on consumers and plans, but it could also threaten continuity of care as consumers move between plans within different networks. it could lead to adverse health outcomes for the beneficiary. i guess i would direct the question -- could you provide some clarity on this issue of how these individuals would be assessed and how the system can best maintain continuity of coverage for people? >> it is a very important

question. the affordable care act and the regulations ensure that there will be continuity of eligible if their income changes. the rules in the law are pretty explicit about ways in which there should be no gap in coverage if somebody's eligibility changes from medicaid to the exchange or vice versa. there is the issue of continuity of plan and provider. in our recent questions and answers that we released on december 10, we gave three options for states to consider to try and minimize this disruption of care. one of the first things that a state can do if they are running an exchange is that they can have the same plans doing business on the exchange as they're doing business in the medicaid and chip program. families would have the opportunity to stay in the same plan. we also have premium assistance

options that states can use inside their state. this is a way of ensuring continuity of coverage. they can purchase the coverage for a medicaid or chip eligible person by contracting with a qualified health provider that happens to be doing business on an exchange. if that individual's eligibility changes, they would switch to a tax credit for medicaid, but they would not have to switch plans. >> thank you. another question i want to mention -- my home state of utah is one of several states trying to decide which health exchange approach is best for our citizens. our governor has raised questions with how different approaches may operate. if several states should band together for a multistate exchange, what role would state regulators to play in enforcing

the law? have we thought about that? >> state regulators will have the same role that they do today in terms of reviewing policies to make sure that they are in compliance with existing laws. there should not be a change in state regulators in a multistate exchange. >> is that the same for the federal exchanges? >> yes. >> do state policy-makers relinquish any of their influence in operating an exchange? >> i think we will be interested in working with states to make the exchanges work best for their state, whether it is a federal exchange or not. i think that there are some important decisions that states get to make themselves if they

are in a state exchange or state partnership exchange. for example, one example is just how the thing will be funded. we proposed one funding mechanism which would work in the federal exchange, but states can use a different funding mechanism. >> thank you, mr. chairman. >> five minutes for your questions. >> i appreciate your being here. i know it has been a long day. mr. chairman, i will yield my time to you for questions that i believe you may have. >> mr. smith, and again everybody on the panel, thank you for your indulgence today. we invite smart people to come and tell us what they think about things. if there is an opinion that

needs to be offered, i believe it should be offered. mr. smith, a long time ago, mr. waxman offered some comments to which you wanted to respond. i know we have removed the immediacy of your response, but if you have comments, we would love to hear them. >> i appreciate that greatly. it is great to be with a lot of smart people. the question about the block grants -- i wanted to respond in a couple of different ways. first, chip is a block grant. it was one of the most successful programs that everybody has claimed great credit for. there are different forms of block grants. there is a per capita approach that during clinton's administration, clinton officials supported that type of approach. the block grants themselves for states -- we do believe we can run these programs more

efficiently and more effectively than under federal rules. first of all, more than half of medicaid dollars are spent because states have expanded beyond federal requirements. we have added eligibility, benefits, well beyond what the federal law expands. again, the perspective that if the federal government does not require it, the states are not going to do it, the history is actually the opposite. states have expanded beyond what the requirements are. we believe very strongly that states can be trusted. most of the money is for people who are either senior citizens needing long-term care or individuals with disabilities. in wisconsin, we have lowered the cost of care because we have been able to offer waivers for people into private-sector,

managed care situations. again, regular medicaid fee- for-service is the most expensive type of care, and in many cases, it is the least prepared because the care is not being provided. from my perspective, when i look at all of these dollars that are being spent, under the different formulas that have been offered which guarantee federal dollars, growing by population, at least in medical cpi, i say absolutely, i can make that work. if my federal dollars are guaranteed, i become more efficient. therefore, it actually increases the federal match rate. the state match goes down. absolutely, we can make that situation work. again, i go back to the very beginning, before legislation was put out, in december 2008,

chairman baucus of the finance committee put out a paper saying that the $700 billion in excess spending in the health care system -- for medicare and medicaid, government spends almost half of those dollars. medicare and medicaid therefore do indeed have to be brought to the table. there is a great deal of overutilization. we have been going after the excess costs in health care. that is what we have done in wisconsin. we think we can go even further. >> i was terribly disappointed to hear mr. cohen's response. i sat on this committee with you. the affordable care act was

supposed to bring health care costs down. if we wantd to bring costs down, we would have invited governor mitch daniels to this committee and asked him how he did that in his state. 11% reduction in two years. he did it with a health savings account for state employees which was voluntary. he found out that when people spend their own money for health care, something magic happens. it sounds like from your interpretation of the medical loss ratio, that effect will be lost. it is one more failing of this very large law. i will yield back my time and recognize the gentlelady for five minutes of questions. >> thank you very much for your patience and being with us today. i am proud of the work this committee has done on the affordable care act. i want to see every one of the

over 30 million people who are going to receive coverage, receive coverage, including the 20 or so million who will receive coverage under the medicaid expansion. a large percentage of those are people of color. we wanted to ensure that african-americans, hispanics, asian-americans, and native americans have access to health care. i wanted to go to one of our poorer states that is not about to accept the medicaid expansion, i do not think. now medicaid expansion or state exchange. you mention that louisiana has one of the worst health statistics and has the most health disparities in in nation.

expanding access helps reduce health disparities. their report was released about the cost of health disparities and found the health disparities across the nation more than $82 billion in direct spending in one year. the highest burden is in the south where it cost about $35 billion in one year. are you concerned not expanding medicaid would exacerbate the disparities and leave more people as the sickest in our nation and increase the financial costs in the end? they are going to come to you at some point without having preventive care or health care maintenance when they are very sick and cost the state more. >> thank you very much to focus the attention on what all of

the coverage is supposed to address, which is people oppose the health status and outcomes. in my state and state's nearby, was a great disparity in diabetes and obesity. we have looked at the outcomes on medicaid and we do not see a great bit of difference. we have a system not turning out the kind of health outcomes we would expect for the amount of money we put a in. we have looked at expanding medicaid. let me show you some numbers around it. chairman waxman went through the numbers in louisiana for how many people would get it. he cited 265,000. we look at our numbers, the first year alone 467,000 people would join the roles. 187,000 already have private

health insurance. we would see a cannibalization of the private health market taking healthy risk from a system where people pay some portion of their care and move it into medicaid. hospitals and doctors will see reimbursement levels reduced. this is not an easy way to think through the expansion. >> nothing precludes you from making changes within the medicaid system to address some of the areas that may not be working. where you now see that medicaid coverage, patience do not do any better than patience who are insured. i have heard several panelists say, the law dictates to the states and not allow the flexibility.

can it not fix under the medicaid system. >> we would be working closely with louisiana to do that. there is a steady in oregon that looked at people on medicaid and not on medicaid, considered a gold standard study. it showed the care and well- being and the health outcomes for people receiving medicare coverage were far superior to those not having health care covered and were uninsured. there are lots of issues in louisiana that are challenging for anyone to tackle. the evidence around the country is that you can make medicaid work well for beneficiaries and improve health outcomes. the discretion around assigning the program and determining the delivery system, contracts with

providers, those are positions that are state decisions. >> you mention native americans as a specific population. when we are switched to modified adjusted gross income, in medicaid when the they are exempt from class sharing entirely in the medicaid program. we disregard certain income available to them as members of a tribe. that gets changed under magi. they will become tax credit eligible rather than a medicaid eligible. >>" i do not think that is the case. i hope they will get a chance to respond to that, because i do not think that is the case. >> we recognize mr. sarbanes. >> thank you for letting me

participate today. i just want to say, and thank you for your tremendous work done this. it is incredibly exciting because you are helping to build an expanded infrastructure that will provide more access to millions of americans. over time, it will begin to rein in health-care costs a did show an effective way for the system as a whole. what do you anticipate when we get to the end of this process as a number of states that will do a state basis exchange versus those federally facilitated? >> we do not know yet. there is a dublin on the state basis exchange coming up this friday. -- there is a deadline on the state basis exchange coming up this friday. we have heard from 14 states that want to be state based exchanges. the second deadline that comes

along as february 15, next year. that is when we have asked states to tell us they want to be a denture a partnership exchange. -- dna parker -- partnership exchange. -- they want to be in a partnership exchange. we will know more as far as how many work with us. >> thank you for being here and congratulations on the work in maryland. we are very proud of that. i wanted to ask you in view of the fact states will be making a judgment on whether they can stand up to a state based exchange, and another basis we will be looking at the partnership model, you spoke with your colleagues around the country who are making these decisions. what are the kinds of it

zaidi's -- anxieties they express to you that you are able to say, look, there is a way to do this. rather it is a certain technical thing or the process of how you get a consensus behind it and get people comfortable moving forward, what are you saying to your colleagues who may be one to get there but are worried a little bit about it based on the maryland experience, it can give them some comfort and confidence they can do this? >> thank you for your question and your leadership in maryland. there is a lot of engagement with the states moving forward on the state based exchanges. there are a number of calls that happened and document exchanges. sometimes it is very explicit like a document or analysis that other states will use directly. we will use something they have done. sometimes it is talking over different situations. a couple of days ago in was baltimore we had a meeting at the exchange board, 75 people

watching. we worked our way through a lot of issues. we have been talking to our peers around the country on how billing would be done. the exchange would take the first payment but the carriers after that. that is an issue where there are different ways to go. we have figured out a way to partner effectively with insurance brokers. we decided to offer dental vision plans an exchange. for each of these things, there is a discussion. i understand there are issues involved. we have gotten energy from talking to people about these details in our state and other states. we have move forward with each part. >> i want to emphasize that from the beginning of this process, obviously a state looking at it without any peers having undertaken the process without cms and others having fully

gotten into it yet, it would appear very daunting. states like maryland decided, we want to get out in front of this thing and other states had as well. we are at a point where the expertise that resides in cms practical expertise plus the expertise that recites in a peer groups states that have started to build the exchanges and created the models and looked at the computer systems and how that will work, it means states that may be did not get us started as fast as they could arnel -- if they make the judgment to go forward they will come to the table with what is called a support group or a network of people who have hammered through these issues. they will be able to get where they need to go faster than you had to do is starting from scratch. that is important in understanding this is very feasible. if people get into this and start working on it, we will get the free market in place.

-- we will get this framework in place. >> that concludes the questions from the members of the subcommittee. we have time i think for two side. the chair will recognize dr. cassidy from our side. >> let's give some reality to an the study was driven by new york solely. in man although it was not significant, the expansion resulted in poor outcomes among those on medicaid. it was not statistically significant, but that was driven by the state of new york. in regard to the do-gooder

states, new york pays physicians less well than does louisiana and texas and only 60% of positions in new york accept medicaid. -- physicians in new york accept medicaid. that is not access. just to clear of the record a little bit. now that we know that the one thing that has been shown to lower costs will not be allowed in the lmr unless it is spent -- the health savings account -- we are now encouraging insurance companies not to sell them or to encourage the person to sell it -- what data do you have on the effect of the increase premium costs on some who say 200% of federal poverty level who is currently employed

with sponsored insurance and dumped into the exchange of mackenzie quarterly that says what 30% of these employers will do have a value of 60%? what do you project will happen to that person? >> we have been modeling the path to premiums in wisconsin medicates as the first of july. -- medicaid since the first of july. >> this is not a computer model. you actually have real live data. >> yes, sir. this is the actual experience. wisconsin has already expanded medicaid coverage. some of our eligibility groups transition to -- 300% above poverty. we have started applying only the premiums, not the additional cost sharing. >> not the $200 deductible. -- not the $2,000 deductible?

>> no, sir. in the results today, people at the lower income level because they are looking at a dollar a mountain not thinking of a percentage -- >> we are actually talking about a dollar amount. >> 133% to 150% because the poverty level includes not only in, but the size of the family. your percentage of your gross income. >> please hurry, have one more. >> i apologize. the average now of $200 premiums participation was cut to in half. people are saying, we are not paying $200. >> 50% more people are without insurance? insurance. >> when the working family employer put them on the

exchange and they have a value of 80%, but it may be 60% on the bronze level, they're facing deductibles that no longer have faced before, they are dropping their coverage? >> exactly. >> this is good for the american worker? different. experience? >> yes. >> we speak of percentages in d.c. the kaiser family foundation talks about how much louisiana will get. it will actually cost our state 1.6 -- $1.8 billion over 10 years. >> we expect the figures are understated and do not capture the full cost. >> they probably overstate the amount of taxes that will have -- understate the amount of taxes that will have to be raised for the cost. >> likely. when we looked at the study, we recognized there were very

large ships in winners and losers. some ended up reducing the burden, and some increased. a good part of the discussion today is how states will save money by medicaid expansion, it is just shifting costs from one place to the other. >> i agree with that. one more question. >> we better cut it off. you can submit it to an interesting. thing. -- you can submit it in writing. >> i want to give you a chance to respond to the comments. grant? >> whatever you like. >> a couple of things to say. thank you for the opportunity. mr. smith harkened back to note in the children's health insurance program functions as a block grant.

that is true. what we need to recall, although it is hard to remember back, is in the early years states ran out of money. states were desperate because dollars allotted was what congress thought they needed. it was a set amount of dollars and it turns out the enrollment was higher and the need for higher and states were on the verge of shutting down their programs or putting their state dollars on the table to cover children. grant. it sheriff's risks onto states -- it is a capital amount of money and shifts risks onto states americans -- it chefs' risks vulnerable. it is really not about trust. it is about having a financial partnership that works. i will submit without the financial partnership, we would be moving into 2014 with state's operating 20-year old

legacy systems if we did not provide funding to help states finance eligibility. without the flexible financing, we would not have had the situation where over the years people with hiv and aids or able to get care they needed, expensive care, and able to live healthy and productive lives or poor children with leukemia or opted -- autism were not able to get here to help them. when the federal government says that is all we will do and no more, we risk those kinds of results. what we need, it keeps us all at the table to make sure the program is as strong as possible. we have to get better care at lower costs. the partnership helps us get there. >> i just want to give mr.

allison an opportunity in closing, why is medicaid expansion the right answers for your states? if you had to convince the other three, what would you say? minute and 10 seconds each. time with individuals who would get coverage. you need coverage. i think we all agree there needs to be more value in health care. we need to get excess costs out. i think basic services and health care should not be considered excess. a couple of nights ago i was at a church with about 300 people in the disabled community. a mom got up and talked about what medicaid meant for her daughter born with a heart defect. it was a harrowing story. the little girl ran across and

gave me a hug. it was a moment where we said, this is what medicate stands for. we need health care to work, but it should not be, keep people out first. it should be let's get people in and move forward. >> i would just say congress passed, the supreme court upheld a law that provides significant incentives to states to save the lives of their own citizens, to improve their health, to provide financial protection. i represent a poor state with many who are uninsured and would never be able to afford care. that care makes a difference. it may be we face challenges in the future to make sure this remains sustainable with new commitments we are making, but i would just encourage my fellow states to consider the

opportunity, which has presented itself now. >> thank you very much. >> all time having expired on the committee. there was a unanimous request underside about providing some data about pennsylvania. without objection, i will make that part of the record. i think in fairness to you, i will submit a question about this data and would be grateful for your reply to that. the same courtesy will be provided as well. five business days -- it is actually 10 business days to submit questions to the record. we will ask witnesses to respond promptly. by happy occurrence, we will be here thursday the 27th. without objection, the

subcommittee is adjourned. >> my inspiration was the idea that i wanted to explain how totalitarianism happened. we know the story of the cold war. we know the documents. we have seen the archives that describe relationships with roosevelt and stalin and churchill and ben truman. we know the minivans from our point of view. we have read them and written them but i wanted to show from a different angle, from the ground up, what it felt like to be one of the people who were subjected to this system and how did people make choices in that system and how did they react. one of the things that has happened since 1989 is the reason we used to call eastern europe has become very differentiated. these countries no longer have

much in common with one another except for the common memory of communist occupation. >> more >anne applebaum from her historical narrative, "iron curtain," sunday night on "q &a " on that night at 8:00. >> at 10:00 eastern, efforts to increase homeownership programs hosted by the burping institution. in 30 minutes, the national taxpayer advocate discusses what the fiscal cliff needs for -- means for tax filing season. the doc fix will be explained that at 9:15, i look at how the u.s. population is expected to u.s. population is expected to change over the