early, you could see the party head back toward biden. if it is late in the process, really late then where it is a most like to late, filing deadlines and this, i wonder -- i do not think, i do not see a circumstance that sanders actually wins the nomination. so the guy within the existing field i would look at is om alley. o'malley, are there any signs of life in his campaign? anyone if you think of

who could plausibly win the nomination, someone who will be 53 years old next year, rather than somebody who will be 75 years old. somebody who has been a two-term governor of a state that sort of was widely considered in the mainstream of the party and politics, where bernie sanders has been, he is a unique character. but let's face it, he has not member, most effective liberal democratic senator. an effective senator, ted kennedy, there are boatloads. but he has chosen to be a voice, but to actually do stuff, get agenda,one, drive an that has not been sanders so

much. i know that his supporters are passionate and they believe in him, that is great. the thing is, what a party -- would a party moved to him, the democratic party, and a pinch, i have a hard time seeing that happen. anyway, thank you for coming out here. [applause] [applause] ♪ >> tonight on c-span, you look

at the impact of legalized marijuana. in colorado and other states. , as debate on marijuana forum hosted by the steamboat institute. >> at the beginning we heard people say, it costs too much in the stores, not the cost the same in the stores. if you think about it, where do adults want to go? if they want to access it, they want to find someone who has it and hope they have what you want and they are actually going to give it to you and you are going to be safe? or do you want to go to the store? we are seeing sales going, they started low and they have been getting higher, because people are more accustomed to this

system and there is a reason why more people are buying marijuana from the store, because it is preferable in every way. >> if you are a producer in another place, mexico or some want thece and you heat off of you, lower the overhead by reducing the amount of security you need to operate underground, guess where you will come, colorado. we know is happening because we know how much is being exported out of the state. >> you can see the debate on ali gazillions in -- on the legalization of marijuana tonight on c-span. this weekend, along with our comcast cable partners, we will explore the history and literary life of sacramento, california. on book tv, and author shares the story of her families

survival of the depression, being swept off to internment camps. in her book, dandelion through the crack, she talks about the open resistance to prohibition and how it furthered the reputation of the wettest city in the nation. and we will talk about the book, none winded, all missing, none -- whose life is full of adventure and tragedy, recruiting the image of her husband, custer. >> elizabeth was the first to come to his defense and say that is not what happened. i know george, he could not have done that. she stood up for him and championed his actions, so it was elizabeth who is at the top of all of this, not only because she was a woman and people were paying attention to what she had

to say, because she was his wife, but because she outlived all of them. elizabeth does not die until 1933, she is therefore the 50th anniversary of the battle of little big horn. she is therefore all of history. so she can help shape what is being said about her husband, so it does not go so far to the other end. >> on american history tv, we will tour the mansion once owned by railroad tycoon, cleveland stanford. -- hero union civil war negotiated deals at the mansion helped complete the transcontinental railroad. term was our last two-year governor, elected and served in 1862 and 1863 and he was part of a group of men that were merchants and they were

politically active and had similar ideas and stanford was their first candidate that was successfully elected as a governor, he was the eighth governor and the first republican governor of california. >> then we will visit the japanese-american archival collection at second to state university, which includes letters, photographs, diaries from japanese-american communities following the attack on pearl harbor. and sacramento city historians share artifacts related to the 1849 gold rush, that brought three-hitter thousand people to california. >> we are in the center for sacramento history and these are the original records for the city and county and we go from the beginning in 1850 all the way up to the present. when you talk about the whole experience of coming to california, to search for gold, you'll need supplies, you probably would have gone and had your portrait taken.

one important thing you would toe acquired here is a map figure out where you need to go. this is a great map of the gold fields. this would have folded to fit in the pocket, everything was lightweight, compact and easy to travel with. this would have been essential and it is dated 1849 to show miners where to go. you can see how quickly the business of producing these things was. people were quickly making money off of the people who were looking for gold. >> this weekend, watch c-span cities tour for sacramento. and sunday afternoon at 2:00 on american history tv, watch the c-span cities tour, working with our cable affiliates and visiting cities across the country. >> landmark cases, a guide to

the landmark cases series, exploring 12 supreme court decisions, including mulberry versus theson, brown board of education, miranda versus arizona, and roe versus wade, landmark cases, the book features introductions and highlights of each case. it is written by tony mauro and published by c-span. landmark cases is available for $8.95 plus shipping. get your copy today on www.c-span.org. marks the 50th anniversary of medicaid and earlier this week health and human services secretary, sylvia burwell discussed the benefits of the program.

her remarks are followed by a panel discussion. this is two hours. [chatter] good morning. good morning, everybody. my entrance was music, i am not sophisticated enough to dance on my way up here, nobody wants to see that. good morning, everybody. welcome. this is the fifth annual national association of medicaid directors fall conference. this is the highlight of the year for those of us in the medicaid world. as i said, this is our fifth meeting and every year we try to do a little better, be a little bigger, outdo ourselves and put

together an agenda that is provocative and keeps people coming back and by the fact that i see 900 people, i think we are doing ok. thank you for coming. salo, i am the executive director here and it is a pleasure to have all of our friends and family here to talk about medicaid for the next couple of days. we have a terrific agenda. accommodation of thought-provoking sessions and deep dives into the breakouts, where you'll hear from medicaid directors all over the country on many issues of great importance. i like to say that this is our best conference ever, except next year, we will be better. i want to take a moment to stop and say we should note that this is the 60th anniversary of the

medicaid program. coffees and say happy birthday. [applause] [applause] i guess it is also the 50th anniversary of medicare, but you know, they have their own thing. but it is really exciting because the 50th anniversary really is a celebration for us, 50 years of innovation. innovation at the state level and how the program runs, in terms of improving quality, access, and programs that is the health care safety net, the largest health insurer in the country and a program that provides health and social and long-term services to all the list --sickest, for a most medically complex patients. so that 50th anniversary is a theme that we will we've

throughout the next couple of days and you will see that and i think you will enjoy that. so, we are delighted that amongst the 900 people we have here, we have medicaid directors theagency staff from 48 of states and territories, that is a terrific turnout. some came very far to get here and we appreciate that. , and avery excited couple of minutes, to welcome visit, theepeat secretary of the u.s. department of health and human services, sylvia burwell. i also want to highlight a couple of the other major things we have going on over the next couple of days. after the secretary, we will move right into a panel looking -- past,id and present, future.

on the 50th anniversary, we will have directors who span the past five decades talk about where the program has come from, where it is today and where it is going. we will also have, later this afternoon, a fascinating panel that will be cms administrator surrounded by a couple of his fairly famous predecessors. know, they are never shy about sharing thoughts and views on the health care system. we are very excited about that. and another big plenary that we have tomorrow morning is an in-depth focus on what i call the really set in philosophy of medicaid, essentially followed money. so we have a session looking at the 5% of the population that

drives its to percent of our costs. , mental eligibles health disorders and the ways we are trying to approach issues around homelessness and those with social determinants of health. terrific sessions. and we will close the session tomorrow with a closing plenary by vicki mangino. that will be terrific. so let me just mention one other thing and i will enter is the next session. one of the exciting things, why it is pleasing to have a lot of people show up and talk about medicaid and i hear that john oliver had a session on medicaid on his show earlier this week, i have not seen it. perhaps, do not show it to your kids, but it is exciting to see medicaid in the mainstream like

that. i think what is really excited about what we are doing is that in many ways, we are standing on the cusp of a new era of the program and what it does. ande medicaid agencies directors and staff are ushering in a new dawn of rethinking how the u.s. health care system works and you will see that and ask couple of days, and you will see it in some of the products we put out, including our fourth annual operation survey, which should go live on the web right now. with an in-depth look at the issues that directors are facing, the types of projects they are tackling, and the ways in which they are trying to drag the rest of the u.s. health care system into this new era. we are trying to take some of the failures of the broader health care system and over

alliance on fee-for-service, siloed delivery models, a method of payment that desensitizes volume as opposed to value. what you can see from states all over the country is that these are the things we are trying to fix. we are trying to improve the health care delivery system, we are trying to make sense out of the payment incentives that exist and quite frankly, these things are hard. these are not easy. the health care system in this country is 18% gdp and trying to change that is difficult, slow going, but it is vitally important. so i hope you will join me in the next couple of days in appreciating and celebrating the work that is going on in medicaid, especially around those patients who have not been served well in the broader health care system and who

medicaid is trying to, striving to improve the experience for. and medicaid, as you know, it is complex, it is hard to talk about. in this half the births country, a third of all kids, the majority of long-term care, hiv treatments, the majority of mental health. it is a complex program and we will spend with federal partners half $1 trillion this year and that is going to go up. and this is a testament to the challenge of the jobs of the medicaid directors and the testament to their success, that they are able to bring --ionalization to a distance dysfunctional system and try to improve the medicaid experience for consumers. to with that, i am going

hopefully gracefully exit the stage and turn the microphone fromto the board president the great state of arizona, who has been a real leader in medicaid in terms of leadership, in terms of investing in the program, thinking about medicaid as a real 21st century solution. join me in welcoming ben to the stage -- stage. morning, everybody. on behalf of my peers i would like to welcome you all to the 2015 fall conference, you may notice new faces amongst medicaid directors, 41% of directors are new within the past year. the average tenure for a

medicaid director is one year and five months, but despite that, when you look at the operational survey you see that states are aggressively pursuing new initiatives to modernize and continue the evolution of the medicaid program and this conference is really an opportunity to highlight a number of those areas where we are looking to improve the overall delivery system by leveraging medicaid in our local communities. daysgenda over the next really highlights the important areas for medicaid directors, progress with the duels, quality for kids and pregnant women, value-based purchasing, i.t. systems and a number of other important topics. threaded item that is throughout the agenda is one of the most healthy things in the

program, that is the retention of federalism, the role of the federal government versus the states and the conversation we have had in this country for 240 years, is something that plays out on a daily basis in terms of the medicaid program, what is the role of the federal government and the role of the state? we have a number of items to focus on that and continue those important conversations. conference, iis think it is important to remember at the end of the day why we are here. that is to improve the lives of members we serve and i had the opportunity recently to go out and meet with a nonprofit provider and at the end of the meeting i was walking to my car and an individual approached me and she talked about the challenges when she was trying to advocate for someone who is

facing significant depression issues, was potentially suicidal and she talked about the struggles in navigating the pragmatism -- fragments and that exist. she was able to get that person into care and they are doing well. and before i could say anything, a second individual approached and talked about how important medicaid was to them. they showed me their arizona medicaid card and they said they no longer needed medicaid, that it was there when they needed the health care coverage, that it had saved their life, but now they were employed and had coverage, but kept the card to remind them about the importance of it in their life. that was a poignant moment in terms of having this aspect of, there is still a lot of opportunity for improvement in the system, but individuals on the program, at the same point,

they do so good in serving communities and individuals in the program. so without further ado, i would like to take the opportunity to introduce secretary burwell, who is the toy second secretary of health and human services. secretary burwell is committed to ensuring that every american has access and to the building blocks of healthy and productive lives. she has led complex organizations, both from the public and private sectors, most recently she served as the budgetr -- i am a poor director myself, and a lot of other important roles throughout. secretary burwell was a rhodes scholar, she hails from west virginia and lives in washington dc with her husband and two children.

please join me in welcoming secretary burwell to our conference. [applause] [applause] secretary burwell: thank you, because i know all of you are good with numbers, i will mention come on that tenure point, the average is a little ahead of me. i am not quite one year, five month. it is wonderful to be here, as you all know, medicaid turned 50 this year and we have been spending time looking back at decades of progress that we have all made together. you may not know that i also turned 50 this year. i just hope that i am aging half as well as the medicaid program. [laughter] i also want to recognize and

have had the who i privilege of knowing and working with in the 1990's. we were both at omb. since i spoke with you last november, i -- we have continued to make progress for the nation's health care system. last week, the president signed a budget deal that will help states avoid more than $1.5 costsn and -- in supporting care for those with disabilities and older americans. in the past year, we have seen the expansion of medicaid in pennsylvania, indiana, and alaska and i want to congratulate montana who yesterday became the 30th state to take up medicaid expansion. [applause] [applause] thank you to the leaders of those states who are here today who are also working with us on solutions for expansion.

last year, i talked about families across this nation, more than 70 million americans who depend on medicaid. over the last year, i have had the chance to meet more americans whose lives have been touched by this program. tina hicks is a single mom who reached out to my office to tell me about her struggle. she is a health aide for seniors , but she herself has no insurance -- had no insurance for years. she talked about how she was working through pain but did not see a doctor because it meant she could not pay another bill. she was finally able to get coverage and it is a good thing she did, because after a screening she learned that she had precancerous cells and she had them removed. that may have saved her life. when we asked her about covers, she said and meant the world to

her, i have two sons that love me dearly and i know that they depend on me. you all know people like tina, people for whom medicaid is a lifeline. it is not about today's checkup or this year's finances, we are actually learning that medicaid curse -- course for life. ,s we learned last year long-term studies have quantified the incredible impact we have always known this program has. the long-term benefits that can go well beyond health improvement for those who have coverage. children who have access to were more likely to complete high school and graduate college than similar college who did not -- children who do not have access. they were less likely to be hospitalized as adults and by

the late 20's, women who had coverage as children had higher earnings. yale and the by treasury department, estimated that the federal government will recoup half the costs of child medicare just through higher earnings. medicaid is a key component of our mission to bring affordable, quality health care to all americans. ata wentvisions at the into effect, bringing rates to lowe's -- historic lows, we estimate that 17.6 americans -- million americans have been covered -- medicaid is good for families and good for communities. there is simply no greater resource for helping some of our neighbors find quality

affordable health care. we know that if every state expanded 3 million additional americans could have access to coverage. these are often working families and many are veterans. we are working hard to make this case and will continue to work with states to find solutions that work for their needs. alaska is one of our most recent examples, to help meet the needs of the state and native populations, we updated policies at the indian health service we are also preferred access to care with some services like transportation are financed and to better coordinate care. expansion is a priority because the opportunity it offers is so important. we know that these situations are complex. the people you serve are some of the most vulnerable, most diverse, and often have the most

challenging health conditions. that is why it's important to get this right. as secretary, i don't go anywhere between the months of november and january the without mentioning the health insurance marketplace. just a few days ago on sunday, we kicked off open enrollment. although people who are eligible for medicaid can renew coverage all through the year, we have the potential to capline on the public attention on health insurance right now. i hope you will join us in his spreading the word about health care.gov and this opportunity for even those in the medicaid and chip space. as we build on this mission of helping more americans find quality, affordable health care, there is another role that medicaid needs to continue to play. it was mentioned earlier. that is the engine of transformation. we are in an exciting time in health care. as you know, four years,

americans struggled to navigate a health care system that has failed to put the patient first. doctors have been paid for the amount of tests that they ordered, not the quality of care that patients received. over the last few years, there has been a growing consensus to change that. we have a plan to transform our system into one that works better for the american people. it's a system that delivers better care, spends our dollars more wisely, and puts patients at the center of their care. it builds on three strategies. first, we need to change the weight we pay for care. -- the way we pay for care, so that we encourage quality, not quantity. second, we should improve the way that we deliver care. that means better coordination and more integration of health services. that means engaging the individual patient and empowering them to take control

of their health decisions. it also means ensuring that beneficiaries can access care. so that people can get the services they need to improve their health and well-being. and finally, we needed to better organize and use data and health information in care settings. we need to increase transparency and cost and quality and make sure that electronic health information is useful, both for the doctors and the providers, as well as the patient's. we are working with the federal level to support these changes, but it's already happening in many of your programs. we have seen programs in 19 states and the district of columbia. missouri's home health programs, according to recent analysis, these programs have helped create a 12.8% reduction in hospital admissions and and 8.2% reduction in emergency room use

for health home enrollees. states are leaving on a chair stating programs like -- share savings programs, like minnesota. that aims to improve quality and lower cost through innovative care and payment approaches. in 2014, the program saw a savings of $61.5 million. other states are exploring degraded care models, outside share savings, and bleeding -- and inflicting alternative models. we want these patients to work. we are providing resources and technical assistance to the medicaid innovation accelerator program in the state innovations model program. these programs will help advance innovations in medicaid to raise health outcomes, lower-cost, and improve the way that we deliver care. and with new 1115 demonstrations, we can further improve care by supporting an entire continuum of services for

physical and behavioral treatment. in august, california became the first state to take this step. we are hopeful that other states will follow. many of you have heard that we have set goals with medicare to tie payments to how well, rather than how much providers care for patients. we know many medicaid programs are leading the way already in and lamenting -- in implementing these payment models. some of you have joined us in these goals. we hope all of you will move in that direction. hhs is working closely with namd to chart a strong and ambitious course for tying payments to quality in medicaid. as we go forward, i hope that each of your states will set and reach your own goals that make hours look downright sluggish. -- ours look downright sluggish. we will be there to support you.

when you work for a community as diverse an important as the 70 million americans that you serve, promoting quality, patient centered care is more important than ever. that is one of the reasons we created the health care payment learning action network. we are bringing public and private partners together to move forward in this transformation. i want to thank the national association of medicaid directors for your partnership and participation in that effort. we will continue to look for opportunities to create a better, smarter health care system. i know a lot of you all are thinking about how to foster a health care system that supports the development of innovative pharmaceuticals and provide affordable access to medication. today, wed, at hhs are announcing that we are going to sponsor a forum later this month to bring together the stakeholders, including states, to share information on how we can address this complex

problem. as we move towards a system that is quality driven and patient centered, medicaid is one of our most important drivers of that innovation and transformation. we want to accelerate that process, and frankly, we want to work together to be sure that people everywhere understand that medicaid is leading in a smarter spending and quality care. that is why your partnership is so important to us. you all are on the front lines of care delivery in the transformation of our health care system. we want to hear from you on what works and what doesn't. how we can support your efforts and how we can work together to better deliver impact for all those that we serve. we won't always agree, but we can always find common ground when working for the american people. i want to thank you all for the work that you do every day.

it means so much to so many. i want to thank you for being our partners, because we are stronger with your help. together we can do more. together we can help our communities overcome obstacles. chart a better path for wellness, and even save lives. together we can build the kind of health care system that the american people deserve. thank you all, and i look forward to hearing what happens over the next few days. [applause] >> that was fantastic. thank you so much secretary burwell. i would also like to point out that in the five years we have been doing this, she is the first hhs secretary to come

present to us. now, even though she has been in her position less than the medicaid director tenure of 1 year, 5 months, she has now done this twice. it's a testament to her leadership and we very much appreciate having her here to kick this off. a couple of quick things before i introduce the next panel. in keeping with the same of things and acknowledgment, a number of folks that i want to make sure we acknowledge. first and foremost, all of the namd staff who are so critical in putting all of this together. from soup to nuts in terms of content and everything else. i will ask those of you who are here to stand up. andrea? kathleen nolan. lindsay browning.

.nd it jack rollins [applause] back at the office live tweeting what we are saying. thank her for that. meetings and events have been outstanding in terms of putting together the logistics for a 900 person breakfast and meeting. hopefully and making the experience for all of the exhibitors and sponsors and participants as smooth as possible. you all in the lobby there. i want to thank not by name, because i don't want to put a target on your back, but all of the namd board for your leadership throughout the year and all the years.

in helping the staff stay focused on what is truly important for medicaid directors and agencies. the current leadership with tom and john mccarthy of ohio has been very strong over the past year. we very much appreciate the whole board. i don't want to make you stand up or call attention, but thank you to all of you. then i want to begin to acknowledge some of the many sponsors who helped make this conference happen. i will think a couple now -- thank a couple now, some more later, otherwise i am standing up thanking people for 20 minutes, and that's not dynamic conference-going. i want to thank for sponsoring tonight's reception, rsa medical. i want to thank the diamond sponsor and the sponsor of this

morning's breakfast. all of the other diamond maximus, including sellers dorsey, wealth care how care plans, blue cross blue shield of illinois, montana, mexico, and texas. and i thank the sponsors of today's lunch which is cgi. so thank you. again, lots more sponsors who we will acknowledge soon. i wanted to give those folks up there. enough of me. i want to introduce the next panel, which i think you will find absolutely terrific. let me invite up to the stage now, and i will tell you who they are as they come up. judy moore, who is the co-author of "medicaid politics and policy." so she literally wrote the book on medicaid. she is going to come up and

moderate this session, which is past, present,: and future." president,e the namd and former medicaid directors. with that i am going to turn over the mic to judy. we are having a very relaxed format. you.that, judy, thank we look forward to the next session. thanks everybody. judy: thank you. think we are to try and have a good time this morning. i think that secretary burwell set us up by talking about medicaid as an engine of transformation. what we would like to talk to you about this morning is how

that engine of transformation might have been running for a much longer time than people give it credit for. i know that most of my panelists, my co-panelists this morning feel as i do, that medicaid was pretty much underappreciated for an awful lot of years. as john oliver is talking about it, -- if john oliver is talking about it, we know we are in the mainstream. that would not have happened in the 1960's and 1970's, and possibly not the 1980's and 1990's. so we have come a long way in that sense. in terms of moving health care delivery, financing, coverage of people, children -- i think medicaid's history is not as bleak as people give it such short thrift for. we will do this as a facilitated discussion.

when matt put this panel together he thought we would get representatives of all the decades of medicaid. but truthfully i think vern and i have to go back to the 1960's and 1970's. these folks are all too young. and maybe the 1980's too, vern. [laughter] we will try to have a facilitated discussion this morning. i will throw out some questions and ask one of these folks to give me some impressions. we will have a very informal discussion. towards the end of our time, we are going to turn to you and ask if you've got some questions or comments that you want to throw into this discussion. we will try to cover some of the main themes of medicaid over the 50 year history of this program. and look towards the future and what this building over the last 50 years is going to mean for the future. all of that, you have heard about tom. he is the current arizona

medicaid director. to my left is deb. i'm not going to tell you a lot about these people, because you can read about them in your materials. deb is now a partner. on the other side of me is vern smith, the dean of the medicaid program as far as i am concerned. who was the michigan medicaid director for many years, and now managing partner at health management associates. and chuck milligan on the end, who has been in medicaid director in a lot of states and a lot of places. [laughter] and is back in new mexico as the director of the united health care community plan. about going to talk a bit street of the program. think weide, which i will have to put up -- there it is -- i listed the four eras of

medicaid as dr. david smith, my co-author on this history as i posited them. 1965 was a period when the program really ran on the statute, the statutory basis. that is the medicaid program represented what was written in the statute. in the latter part of those years, there was a little bit of waiting -- waving beginning. there were some changes that were of interest to some states. but it was a classic approach to implementing that statute. in the 1980's and into the early 1990's there was enormous growth and change. a lot of legislative change in the program. we started serving children and moms in a much better way. tension, bute nothing like the third period, which we call in the book "siege

and response." a lot of threats to the program, a lot of criticism of the program, a lot of conflict over the program. and still continuing some growth of the program. and a lot of changes and new interesting things happening in the program. from 2009-on with the passage of aca we are moving towards universal coverage and continuing that transformation. many of the other transformation that were mentioned this morning as well. without kind of background -- with that kind of background, let me go on and start with everybody's favorite medicaid subject, and that is eligibility. it's where it all started. eligibility change and redesigned over the 50 years in this program. i would like to throw out particularly to deb, who works a lot on these issues, and always has in her tenure around

medicaid. but is looking with states to the future of what they want to do in eligibility redesign, and also to vern, who saw the very beginnings of this program and had to live with eligibility difficulties in a much more wealthier and constraint system. let's start with you, vern. vern: sure. it's great to start with eligibility. medicaid is always known as a complex confusing program. and of all the aspects of medicaid, the one that is most confusing and complex is eligibility, even to the extent that the supreme court justices have weighed in on this, going way back. not just the recent supreme court. justice powell famously referred to medicaid as the byzantine. chief justice burger reverted to medicaid as complex, a morass of

complexity maze. that is eligibility. in the beginning, as judy said, medicaid was the health benefit for persons on welfare. that was pretty much it. as i was looking back to my files, my old files, i've come to appreciate my years because i'm old. [laughter] >> you've got good stories. the: i found a memo from first administrator in 19 some seven -- in 1977. i learned that diana rowland wrote this metamo. it says "medicaid is a financing program for the welfare population." that was completely true. it goes on to say "medicaid

embodies all the problems of the welfare and health care system." just to illustrate this, because it came from welfare, we have recipients. on we knew how many of these mothers were married, divorced, separated, or deserted. poor. of the deserving that was what we had through medicaid in the early years. that all began to change in the 1980's. we came up to a significant point in 1997. all of these things took place over time to take us to where we , to where we are

michigan, at least in fewer than 15% of medicaid beneficiaries are on welfare. that includes all those on ssi. the program has completely changed. it is that, but it is way more than that now. judy: deb, comment a bit on how you see the program now and into the future and having to live, in many ways, or at least in some ways, with the legacy of the welfare route. but what states are doing to address that and what more we need to do to address that in the future. deb: i think this question and vern, your history, reminds us that we do have welfare roots. because iing we, think everyone thinks once a medicaid director, always a medicaid director. so we medicaid directors.

but we are in the health insurance space. we have moved out of the welfare space. but there is always that tension pulling us back. what did the aca do on the good side? it gives states the option of expanding, but it did something equally dramatic. to make federal rules it easier for people to get on and stay on medicaid. when i started in medicaid you needed 4 consecutive pay stubs to get a medicaid. you had for a face-to-face interview and needed to get fingerprinted. we have now shifted out of that mold of "we don't trust you, we don't want you on." to "we want you on." we have created a foundation of coverage, a paradigm of coverage

which enables us to do the kind of payment and delivery system reform that virtually every medicaid director is now focused on. that if weot do couldn't get our population covered and covered in a stable manner, all of which relates back to the change in the eligibility and enrollment process. i think that is a huge legacy of the affordable care act. there is one missing piece in all of that, and that is we snap have 90%+ of individuals on medicaid. and it's about 6000 business rules for snap. for all of us states trying to work with partner vendors in building an integrated system, it is still very problematic to capture many of the same oaks and have these complex is ms.

rules -- same folks and have these same business rules. without getting into too much of the weeds, one step forward, but another significant step in the be taken in terms of trying to make this more meaningful and less of a burden. once a medicaid director, always a medicaid director, unless you are tom, and you are always a medicated director. [laughter] -- medicaid director. employer sponsored insurance took off in world war ii. had gotten strong. there were wage controls, employers could not raise wages. health benefits became a way of attracting workers as a loophole for wage control. there was a very strong bias towards employer-sponsored insurance at the time in 1965.

medicare and medicaid came along as okay, who doesn't have access to employer-sponsored insurance? for medicare, it is retirees and those who have a long work history and have begin permanently disabled. in medicaid, it's a lot of welfare families that -- there was a social judgment made, typically moms should not be working, they had kids to raise. there were those with disabilities that did not have a work history that should be on medicaid. medicaid became like a health benefit attached to a government pay benefit. with employers, you have your salary, and health came with it. with medicaid, you have your welfare check or ssi check, medicaid came with it. then there was this judgment, this very strong social judgment that if you were just simply a

poor adult, not a welfare household, not a permanent disability, you ought to be working. that was the social judgment, and get your health benefits through efi. that cohort of low income unemployed, not permanently disabled population over the years becomes largely the medicaid expansion population. part of the origin of medicaid as a benefit was that was always an ancillary benefit to some form of a cash benefit modeled analogous to asi. that framework -- efi. benefit,he trailing not a benefit in itself. it is tied to a cash benefit. that was a long part of that early period of medicaid to and adjunct to a dominant efi model at the time.

first.ladies [laughter] this is going to be like the republican debate. [laughter] >> what does that say about judy moderating? judy: i was just inking about the candidate grabbing time. >> it comes back to the question judy asked, which was the so-called work requirement. we all talked about that the system is moving towards medicaid as health insurance. on one side, we are aligning with the marketplaces. we recognize that a lot of our beneficiaries are in snap. we are trying to a line across. that welfare history comes back to haunt us with calls for work requirement. or calls that people should be on medicaid for more -- for no more than five years. personally, i think we have to resist those calls.

it will undermine medicaid's effectiveness as a health insurance program. i think that is why fema's grants waivers to permit those types of requirements in the alternative expansion. i do think they undermine the far reach of medicaid into the future as health insurance and driver of health system reform. >> can i jump in on that? i think one of the aspects that medicaid, as part of the evolution needs to look at, is for states that expanded like arizona -- we now have 50% of the population in the age bracket of 19-64-year-old adults, which is relatively new in terms of who we are serving. medicaid has historically done a good job of creating systems of elderly,newborns, the and we have to take a closer look at what we are doing to engage folks that are in that

19-64 bracket. we can debate what the policies look like around that. part of the evolution of medicaid post aca is, what are we doing to create systems of care and connect those individuals in the medicaid program? vern: this might be a good point to emphasize, medicaid for those on welfare in beginning -- after 20-25 years, people began to look at what this program is doing and who it wasn't serving, especially the role of women who were pregnant and small children. this literature-- >> that is where i want you to go. vern: okay. so this transformation from able welfare program to a health care

program began with his literature that said, we had kids that are not faring well, the infant mortality rate was high. there was a lot of concern about that. forvehicle were doing -- doing that was to provide medicaid coverage for women that were pregnant. beginning in 1986, medicaid for pregnante women and infants up to age 1. then it became it mandatory up to hundred 33%. alldren ages 0-6, congressional acts in 1987-1989. it was optional for states to extend coverage for kids above age 6. then, very significantly, and

this was just a stroke of genius, congressman waxman said this is a time when we don't want these kids of age 6-8 out of medicaid coverage. and he made it such that every child born on and after october 1, 1983, would continue to have coverage.kids no longer aged out. as a result of that, we reached a milestone, which for me, is one of the most significant milestones of medicaid. on october 1, 2002, we reached the point where every child up to age 18 in america had been born on or after of your first, -- october 1, 1982. on that day, america covered every child that was poor up to the federal poverty line. an underappreciated milestone, but very significant. out, medicaidnts

have a lot of years to perfect the coverage of children and moms and kids. that is partly reflected in the numbers that people have spoken about today. does anybody want to weigh in on what future holds for medicaid and chip coverage? you think we have lots of interesting things to learn? you think we just need to consolidate our gains and keep doing this work? vern: i think one discussion point is, what is the future of chip? going back to the recession, we had a freeze in place. we had the highest percentage of children in the u.s. by far enrolled in the marketplace coverage. there is the discussion around family continuity and other things. i think that is part of the policy debate going forward, what happens to chip. too -- a lotf it

severelyds in the most emotionally disturbed, or juvenile justice involved, or in special ed -- i think part of where things are going to continue to go is how medicaid can relate to a lot of other safety programs for kids that are in state custody and in special ed. what is the meaning of a medical haveyou got -- home if you school-based nurses touching a child as well as a pediatrician. how do you deliver care at a more cross program level? judy: that would be a good place to move on to integrated services. this is another area where medicaid in the past has not given credit for having pioneered some of these approaches. not that they had universal.

-- had been universal. butthat they had continued, even states as far back as the 1970's have tried to integrate services with housing and mental health. i think it's been done on a much more systematic way, therefore that means it is more likely to really move the way we deliver care. tom, do you want to weigh on? tom: sure, i can start it off. i am sure everyone has thoughts and opinions. the challenge on integration goes back to when medicaid was created, state governments already had in place programs to serve mental health and heavily -- and elderly. in a lot of instances, we medicaid-ized dozed structures -- those structures without thinking what it meant from a broader system perspective.

you still see today where many of his population services sit outside of the purview of medicaid director. urc robust conversations around what makes sense from a delivery system respect. it starts with the statewide policy level. then from a payer perspective, what can you do to integrate those payment streams. you are seeing that across the continuum of services and populations. then, what can we do to incentivize integration at the poverty level and improve the delivery system for individuals? i look at it as tier -- 3 tiers. advancing at forward to a more thoughtful process to what system design should look like.

vern: just to comment on the general direction. questions onies of what is going on with system reform and payment system reform. if there is one thing that characterizes medicaid programs today, it is the focus on what they can do to make their programs better, in the sense of achieving better outcomes. there are examples after examples that you can cite. arizona is exemplary, and there are 49 other exemplary states in terms of what they are doing. it is amazing what states are doing now. if you want to look at one place where medicaid is the leader of the health care system, you can look at medicaid. it is definitely leaving. trying things that other folks have not tried. they have the ability to be flexible. one state learns from another. it does something new and

different. it is truly remarkable. >> i want to contextualize for a second. formsof kids with various -- they have been through abuse, severe emotional disturbances -- , there has been a lot of integration. some of it has been medicaid maximization. trying to get federal funds to serve needs that the state was picking up entirely through a safety net program. there has been a lot of work to integrate services at the medicaid member level. a couple of comments. one is that there is a lot of real and ongoing challenges in

this area. a lot of state and local agencies. their core has always been getting grants. they have not had a claims based insurance system. how state agency partners get engaged with medicaid when they are more accustomed to giving a grant to something like a core service agency or working mo re autonomously with a model. how those can come together is an ongoing discussion. from a government point of view, culture point of view. the second point i want to make for those of you trying to guess where the puck is going -- the trend is clearly integration. level so a clinical that there -- if there is a

psychiatrist or a school-based iap, they are integrating with child'sol -- tehe pediatrician so that there is one treatment team and plan. everybody knows what is going on across payor sources, across agencies, across sites of care. there is integration at a provider level, which is coming along a lot more. you are seeing a lot of federally qualified health centers focus on integrating behavioral health and somatic care. you are seeing a lot of hospitals get very engaged. they have readmission and other standards that they are learning more about for medicare and medicaid. they are identifying the fact that fully 50% of their emergency department business has underlying haverhill health conditions --behavioral health conditions, which is shocking

news for a lot of hospitals. at a provider level, you need greater impetus on integration. at the payer level, how you finance it to drive those incentives. it is clearly the trend and there is room to go. but medicaid is riding those trends. in? may i jump two points i want to make. in some sense we have met the enemy. at the state level, we have these silos. we have the medicaid director with authority over physical health. then we have a substance abuse made and see -- abuse agency, probably a mental health disability agency. then we often have counties, that have a level of responsibility with substance abuse. now we want to integrate. across to walk -- work

our own agencies and agree on how we produce and deliver care. i think we see it playing out most particularly in managed care. i want to shift us to medicaid managed care. that is the dominant delivery model in the states. a not in every state, but it is increasingly the dominant delivery model. when we started out in the 1990's, we were serving moms and kids. we carved out substance abuse, mental health, and delivered fiscal health care to moms and kids. --physical health care. that took us through the 1990's. by the early 2000, that is starting to change. we are getting better at it. we can focus on more of the network advocacy and marketing tactics. we are starting to think about how we set rates to ensure a continuum of care and care management.

then we start to move in the populations that have mental health challenges and substance abuse disorders, for our elderly. -- or are elderly. integration becomes critical. what do we do about social determinants of health when we are moving the homeless into managed care? for the first time we are using our contracting power to say, this is what we want and to impose on plans the requirements that will enable them to hopeful ly serve individuals with serious behavioral health problems. we are now in a better position -- we still have our silos to some degree at the state level, we still have the counties, we still have mental agencies not as adept at taking plans --

but we are starting to integrate at the plan level and requiring it at the provider level. tom, you can speak to this. judy: i have to be the older historian here, because i can go back farther than tom in arizona. reallypinion, medicaid invented managed care in the way that we know it now. ll in the 70's.bi there were long-standing prepaid health plans. medicaid through some extremely bad decision-making and really bad plans in the 1970's. that set the stage for what happened in the 1990's and more recent years. arizona bears a lot of the

respect and responsibility for having invented a lot of how we do manage care in this country. especially in medicaid, but in other places as well. that said, i'm happy to turn it over to tom to talk about medicaid in arizona. [laughter] which really has taught us all how to manage and contract and provide services in a way that makes sense. tom: as the last state into medicaid, we came in with a fresh look at how we wanted to deliver services. that included leveraging 11-5 waiver authority through very broad stability and established mentoring managed care. which was early innovation in managed care.

we learned a lot of lessons along the way in terms of what not to do. we tried to share some of those lessons with dates as they are looking to -- with states as they are looking to enroll more populations into managed care. what is wonderful to watch is the evolution of medicaid managed care from moving to strict requirements into discussions where we are talking about value-based arrangements, having conversations about the social and economic determinants of health, where we help health plans coming forward with equity, citing they want to invest so and so dollars into buying homes -- not home, but being able to partner with nonprofit organizations to light housings for -- to provide housings for the homeless. you see a certificate shift in managed care -- a significant

shift in managed care, dealing with not just moms and pregnant women and dealing with more challenging populations. it has been fantastic to watch. we now have 70% of the medicaid population in managed care, it represents about 45% of the dollars. that dollar amount continues to grow. not only has the approach about medicaid managed care had a positive impact for those states that have rolled that out, it's also changed the dynamic for other states. you see states like oklahoma and connecticut taking approaches around managed programs and coming up with care management strategies as well. it has been something that, when you look back at the history of medicaid, you see quite a bit of evolution on managed care. there has been a lot of

good, but also a lot of bad and ugly. vern can look back on the managed care activities that he recovers. then i will call on chuck. we all will get our chance. vern: a lot of system requirements happening right now. experienced managed-care income and medicaid but it began in the 1970's. michigan signed its first contract with an hmo in 1972, before the federal hmo act. by 1980, i think 90% of all medicaid beneficiaries in minutes care -- in managed care were through the states. california and forward it in particular -- florida in particular. there were certain things that happened that were highly visible and highly negative. there were people who enrolled in managed care and received no services, who were systematically denied services. there were mlrs less than 50%.

other scandals as well that resulted in some, initially, 1976 social- the security amendments basic requirements. 3 on hmos -- no the screen nation based on medical need, you had to maintain medical records, and the state was given the authority to inspect records. -- no discrimination based on medical need. that was it. we have come a long way now learning from that experience. states weren the happy to share that experience with arizona so that you could benefit. [laughter] judy: this was a big part with

california in the 1970's in forming actuarial systems and others that form the basis for a lot of contracting of managed care organizations. chuck: vern having just pointed out that michigan was doing stuff for arizona even had a medicaid program-- [laughter] arizona gets the wagon train, it takes 17 years to get out to arizona. [laughter] i am going to resuscitate arizona in my comments for a second. there were abuses at a lot of states get into managed care early. some of the marketing abuses where the plans were trying to cherry pick members and were doing direct outreach. they were calling people at home dinner tables and misleading folks about enrollment. it led to a lot of federal oversight activities. one of the things i want to point out about why i think that medicaid was a leader in driving

aaa before aaa was a term. in medicaid, states do not have the ability to narrow networks the way early employers did. states do not have the ability to use cost-sharing to try and deal with utilization and quality. states cannot say, if you want to hit the ed for inappropriate use, you will have a big out-of-pocket. states had to focus on, this is the benefit design. you don't get to play a lot with benefit design. ke carriersay, li could say to an employer, next year to keep this price point, you have to put in all of these new benefit design requirements. medicaid very early on a focused

on how to get the most value for a benefit package that you don't get a ton of play with. use-sharing that you can't two engage members. what that meant is states were early on focused on high-performing providers, on ncqa, on looking and using counter data before other payers started looking at it. mix of services, outcome of services. states were early on requiring health plans to get ncqa accredited. one of the things that arizona is leaving the country on is, if managed care organizations are getting capitation, what are you doing downstream to have the provider similarly focus on

outcomes about inventive services, about care coordination, about making sure people get their meds, making sure people avoid readmission. requiring their managed care organizations to have value-based contracts downstream so that providers have skin in the game about outcomes. in other words, that it doesn't look like managed-care on decapitation -- on the capitation payment. all the way down to every provider, the provider has a pay for performance type of incentive to get good outcomes and to drive provider engagement and delivery system reform and quality. wheres another example arizona is leading the way. aspectother interesting

is not only quality, but developing networks where networks did not exist. family support for health services. you see this array of services evolve over time that were created by medicaid. i think that's an important aspect not only of the managed care space-- deb: if we take the contracting requirements, we want to see how you pay providers. i think the next step is how to align our requirements with those imposed on the qhp. the qualified health plans in the marketplace. someshould not be requiring of those same requirements ion the qhps, because they are

contracting with some of the same providers. our impact is that much greater if we start aligning across medicaid managed care and qhp. as medicaid gets smarter, that is where we are a driver. vern: medicaid has come so far in the procurement of health plans. they are so much more sophisticated now in what they ask for and put in the contracts for managed care. i pointed my own state of michigan. the most advanced rfp procurement for health plans in the history of medicaid. i don't think there has ever been a time where health plans were required as part of the proposal process to commit and describe how they would address social determinants of health, how they would address population health, how to incorporate value-based purchasing. it is really a model. i think it sets the bar at a higher level which other folks

would find a way to vote and improve on. judy: i want to bring us back to the thought that these kinds of innovations go way way back in the medicaid program. of course we are more specific you did about how we do these things now. before all of that appeared on the scene and was developed in arizona or wherever, it did not exist in other places. program has been innovative, starting in the 1970's and going forward. we are still on the cost of doing more in the future. i don't want to beat this dead horse. [laughter] it is my belief, my strong belief, that this program has been very innovative, has led to the way over the years in many different ways. and we are going to continue to

discuss this more, and then we will turn to you all and asked if you would like to say something. one of the ways that medicaid has driven data, which the secretary mentioned, and which has always been a serious , islem in the program through it. frankly, the whole world of health care and health care delivery is separate except for medicare. medicare did have a data system. that's unfortunate because we always got compared to medicare. in terms of processing claims, for example, and the development of technology, medicaid was way ahead of medicare. i'm going to ask vern to say a few words about that. then i think we can look at where we are headed in the future on this subject as well. vern: it is really true.

medicaid was more sophisticated than almost any health insurance payer or producer early on. in the beginning, medicaid piggybacked on whoever could be the fiscal implementer. states began to look on at what they could do. it's interesting to compare to where we are now in terms of performance metrics -- back in the 1960's and 1970's, the performance metric was how fast you can process a claim and what your overall and mistreat of costs were. we knew to the 10th of a penny how much the cost, we knew how fast we pay to that claim. -- we paid that claim. i remember medical health delegates, the director at the time -- medicaid doesn't pay much, but you pay fast. [laughter]

oft was significant in terms fostering participation and access to the program. to have a program that paid very well. medicaid decided to develop its own claims payment system. and built an exemplary system that had the largest computer system in the country, save the pentagon at the time. michigan. all claims came by paper those days. usually they were keyed in. michigan had the first optically scanned system. we were able to process six claims a second. one million every 48 hours. those were the statistics before every legislative session. [laughter] it really drove down the cost of processing claims. it was so significant, paul allen was invited to speak before the country.

so much so that before he said one with thing about how good michigan was doing, barbara mikula leaned into the microphone and said "do you you know many people it takes to change a lightbulb in michigan? it takes two. 12 change lightbulb and the other -- one to >> it is a much bigger question now, we need to be integrated and looking at the marketplace. fed hasght up -- the got more data coming out. judy: this is the program we are running out. where do you think we need to be going in this area now?

chuck: there are a couple of things. medicaid becomes a more seamless insurance model, the push for health information exchanges, the push for more adoption of electronic health records at offices, i think that the development of databases, that is part of where medicaid andoing to help drive this i think we're really things are going out is how to drive delivery system improvement where medicaid is really largely kind of venture capital if you will. provider changes or real-time data sharing, when people hit this ed, with that looks like.

a lot of where medicaid is pushing in terms of technology is how that 70 million person program with a happy trillion dollar budget is going to drive adoption of better clinical care through the use of dhr and so on. and within that specifically, on my standalone basis, i think that data will be used for outcomes, how we really look at change and health status over diagnostice use more data, more of helping people maintain functional status, helping people maintain chronic illness and so i think it will be much less about claims the bigger trend honestly, how medicaid is going , how it willer tiers tother tears --

drive practice transformation. we had our state day yesterday and went around the room. after so many years, we continue to have a struggle for medicaid programs, said even though i was a director, i have vowed not to stand up, i've let somebody else take that on. but you see other states taking on leadership models and we were looking at michigan and indiana partnering, so there are abilities to get people to scale on that. it takes a lot of work to have two states work like that, it is

still a challenge. medicaid directors are frustrated by that, it consumes time in terms of standing up that infrastructure and the second point, that is that each ie. we have spent billions of dollars putting electronic records out there and there is still a significant lack of connectivity around that and in a regione h ie is incredibly important and medicaid has a role in that, but also is a challenge for medicaid , and opportunity, but a challenge in looking at that connectivity that we all desire. deb, can you play off of this idea of moving forward and andk a bit about your work whether it will become a

package? does and i think it goes broader than the i.t. systems, check -- chuck said this is the venture capital of reform. and more. problem thatis the is only one source of capital, if you do not have a district, where is the capital, the dollars to invest in delivery system reform? we will look at what is coming to the states, some states, more probably in the future, but some are probably nowhere near this. thishrough this waiver, district waiver, the federal government is matching cost not otherwise manageable -- mashable, and allowing states to bring in additional federal

dollars. it seems like they have gotten smarter over the years, not just allowing states to take money with a promise of we are doing good things, a promise of support in hospitals, what the district has required, we always start with new york but we see it in other states now, the state needs a concrete vision for delivery system reform. delivery system reform in medicaid that will drive system wide reform, but it starts with medicaid, these are medicaid dollars and what is the core of your vision? what is the delivery model? the integrated model that is bringing new partners together, hospitals, maybe health plans, community agencies, social services agencies, as the centerpiece for testing new initiatives, funding the eh are, funding community

health workers, testing new models, meeting metrics and what is key sustainability? these are capital dollars, but at the end of the day the state needs to show a sustainable plan and of course, that is what we want. we want it to be sustainable, because like it or not, district dollars will go away at some point and then we come back to operating dollars, can they sustain? i think district is important and one last comment, not every state is going to get the dollars, but there are important learnings that can be used across the country to challenge -- where are the dollars to implement the learning? vern: anybody else -- win: anybody else want to

-- weigh in on this? one thing we have not talked about his long-term support and services. it is interesting as i sit here and think over the 50 years of this program, that it has changed in long-term support services, but it has changed more slowly than other parts of the program. we are on the edge of much more meaningful change, long-term services, it is long-term care for starters. talk somebody like to about this, where we have been and where we are going? chuck: i am happy to start. i will define some terms first. long-term services is really the spectrum that includes nursing facility care, it includes institutional care and places like intermediate care

facilities for people with disabilities, it includes a lot and othernt psych places, but mainly it now includes community-based services, so there has been i think, there was a very strong institutional bias in medicaid going back a long way and some of it is policy related. going back a long way, nursing facilities were mandatory, that was a mandatory benefit and home community services was not. financial of the bidding rules , ifligible he rules somebody was betting money a nursing home care, you could ,ount that as a medical expense it you could say i wasn't spending less on medical care eligible for an -- medicaid. but if you're spending money on room and board, that is not medical, you cannot get

eligibility, you are not eligible. there are other sources of bias. there has been a very strong trend in recent years to move toward long-term care and long-term services and support. it has a lot of drivers, one of homestead decision that came out in 1999, making it a civil right issue to go into the community and become integrated in the community, so that people were not segregated in institutions with other people who looked like them and had the same disabilities. in the community where they could be friends, great friends, go to church, work if they could work, be part of a neighborhood. and there were other drivers related to advocacy, a lot of groups that also view this as a civil rights issue, to be able to be treated like other people,

in their own apartment or home, they wanted to have self-direction and determination . one of the advocate that i talked to in my first stint as a medicaid director said, this is not a new slogan, but he said, do not design anything about me without me, because this is my life. seen it go, we have i want to tie a couple of things together, in the developed of community-based services, medicaid has really, this was to me one of the early places where medicaid was driving on social issues, because waiver services were really often non-medical services that were dealing with somebody's challenges that were, you had a medical outcome if they were not matched, but it

was more about housing and homemaker care and meal preparation and so, there has been a strong push and i think homestead was a big driver, i think advocacy from a lot of community advocate groups was a driver, i think the fact that you a lot of baby boomers are aging into this test into these programs and they are not shy about advocacy. to be has led states innovative and move financing and design into the community where you have a lot of money going toward really nonmedical services, building environmental modifications, you hear about wheelchair ramps, there is a lot of work going into buying microwave ovens and air-conditioners to keep somebody at home, instead of

going into a nursing facility. you hear about people who are helping others with bathing, dressing, using the toilet, homemaker services and keeping the home clean and dealing with housing issues. nutrition and food issues. it has been a very slow trend over the years and partly because nursing has been very strong, there is a lot of bias in the law towards institutions about financial eligibility more, but you see more and -- for all populations that have needs, whether it is seniors, younger adults with disabilities, individuals with intellectual disabilities, people with mental illness, much more focused on doing design to address social needs that avoid medical costs in the community. i think the trend is going in

the right direction, we are picking up the pace, but it has been, it was one of the earliest places where medicaid really saw a connection between avoiding a nursing home cost or hospital cost, if you just help somebody get their meals at home safely. what a great summary. we have reached a milestone, we spend more money on home-based services then we do on institutional care, that was just achieved this year, so that important milestone. the dynamics around politics, my friend john mccarthy talks about more nursing facilities than high schools and that is overcome -- difficult to overcome. another place where medicaid innovation is, which is

not widespread or universal, but helped us learn and get us to where we are today, where people are. quick shout out, waivers began in the 1980's, so part of this came about largely because in iowa, a young girl was in a hospital and there was no way to go home and retain services. the senator and others got advocacy from her mother and waivers were created because there was a need, there is good congressional action and states picked it up, but this is a trend, as tom said, we just crossed the milestone where more than half the funding is going to the community, but this really started in 1982.

neglected -- judy: i neglected to pick up the gizmo that will help us with some slides, so i will go get that. one of the ways that these changes in innovation are made in the medicaid program is through people like yourselves who are dedicated to running an excellent and ever-changing program. so, i want to do a quick staff, thefrom the fourth annual medicaid operations survey, because in order to accomplish all the things we talked about today is -- the past has been setting us up for, you need to have a lot of people and a lot of administrative capacity. i want to go quickly through these and have a brief

conversation about administrative capacity before i turn this over to you all for questions and comments in the audience. these are just a few slides from a study that is on the internet, this morning, you can go and look at it. , firstnteresting to note the aca implementation is no longer the topic on everyone's list, we are moving on to other things. these are new strategic directions that have in fact developed in most agencies, new directions, and overwhelming number for several years. report and delivery reform are at the top of the list, you can see the different kinds of payments and delivery system reform efforts that you all are engaging in.

lds is a major priority, for reasons we have been discussing. this one is kind of sad, these are the barriers that comes with implementing reforms, look how many really have to do with resources, people and resources are a big deal. so with that as background and with you all having run medicaid programs. -- i wouldunning like to wrap up our conversation before we turn it over to the audience with comments about what you think the future holds for medicaid and management and administrative -- the administered world. vern: i will be happy to start. first of all, as these slides are informative, medicaid has always been underappreciated for their role they have played in

the lives of so many americans, especially vulnerable americans with real serious health care needs. in the same way, the staff of medicaid programs have been underappreciated for what they do to make this happen. tribute do think that must be made to the staff, directors, leadership in the state for all that has been done along this line. program and all of state government or all of government that is a better value for taxpayers, they serve a very vulnerable population, the cost for care is less, the rate of growth is less than anyone else, it serves the population in a way that really provides great value. and the folks that do it do not get all the credit than they should. you know, in our office we used know, nothing quite

focuses the mind as facing the gallows. medicaid is a financing system, it's spending a lot of money, because there is always fiscal pressure and estates have responded to that by developing programs, getting better value for all the state dollars that they spend. in that process, the state medicaid programs have saved the federal government hundreds of billions of dollars, because medicaid at the state level is driving these practices and programs to provide such great value. judy: i am glad that you brought up the budget issue. really not acceptable when talking medicaid. deb: i agree with everything you said. and we provide tremendous value,

but what were the two biggest obstacles to running medicaid states,york and other procurement rules and staffing. -- enough staff, 700 people the medicaid inspector general says 700 people reporting to him, what is wrong with that picture? procurement rules, which relates to i.t. issues. in new york, if you can get a procurement through in 12 months is a miracle, 18-24 months is more likely. those issues are not going away quickly, although i do think medicaid is more appreciated now, certainly with the expansion and it is more toreciated, more value directors, that will not change staff and procurement rules. i think one shot we have is with

the system, if we can align medicaid on one end with the snap program and a shared system and on the other end with exchanges and look at a system that supports exchange eligibility or marketplace eligibility, if we can start to use those systems well, i think we can be more efficient, which will be helpful. chuck: on this topic, we have a special breakouts that -- tom: special breakouts fashion around medicaid leadership. at the end of the day, these are mission driven organizations, people are in medicaid because we have the ability to make a difference in communities and it sopart of what makes this invigorating, meeting with peers and talking about what is going on within our states. it is exciting to see all these innovations, but what drives us

at the end of the day is the ability to improve outcomes and the sustainability issue. those who went to the great recession and we had to cut provider rates, cut benefits and eligibility, there has to be a better way to manage this in longer term. then having to go through those difficult decisions. we will go through those cycles again and we will have to face difficult decisions, but hopefully we are making investments now in terms of really modernizing the system and that way we can have a more sustainable system. we speak a lot to college groups and how medicaid and -- impacts their world and they do not know, so we talk about arizona and the cost of health care and how it squeezes other states priorities, so looking forward to sustainability, that is one of the most significant over arcane issues that we face. -- over arcane --

-- put awant to pull call to action to all of you. spacesppened in a lot of -- in a lot of states is, people on medicaid are compared to people who have health related jobs, health department or something. happening in medicaid and i think you learn some of this, the complexity of the program is growing, there's a lot more work about analytics and quality measurement. there is a need for health care economics for actuary, there is a lot more need for people who can really manage very complex contracts and vendors. and i think what that means is the skill set is changing over -- peoples not people

who are needed by state agencies to run the program to drive value and look at data and to do clinical work about what is the right type of coverage policy, to help drive the right payment levels, the right provider team and design, these are people with health care economics background the chief medical officers, people with really high skills dealing with big datasets. they are compared to job descriptions and other agencies that are not like that. you might have a contract manager, health care manager role that you're looking at one person and one agency that is contract, $1 million then the same person on medicaid million mcog a $500 contract with complexity of data

requirements and different measures and performance. so, from the state budget department, from state legislatures, they are reluctant to take on working on stakeout -- state classification systems, but that is needed. if you all do your own government relations work, government involvement work, with state budget offices, help them understand that your success, the state off success -- states success commit it depends on the state being able to follow through on requirements of these programs in these complex times and i think that that would be -- you would be well served helping carry some of the water for state medicaid agencies, to help them drive a sustainable and effective program, because it is

in their interest. i want to close on this really quickly, i will really lost this bothch this quote, teddy roosevelt had a quote about how, you know, for critics to stand on the outside of the arena and look in and say i could have done better, does the credit belongs to the people in the arena, sweating it out, sometimes they win, sometimes they lose my but the credit goes andhe people in the arena that is certainly the medicaid agency staff, all of you. help the people in the arena. that is my call to action to all of you. , do yout us go to you have questions in the audience, do you want to share a good story?

[laughter] could goave to say, we on for hours, sharing good stories. of twosee the hands former directors. david do you want to defer to donna? >> that was a great panel. missouri --rom the from missouri, that was the best job i have ever had. -- panel.lan i am amazed that you all talked about voluntary contributions, in terms of great trends. the 1990's and there are many stories there which need to be handled after hours in a bar. , would love to hear vern

because he was a major leader in that and anybody else to comment , the serious question on it, really, the key questions about long-term financing and the program, federalization and whether states can have programg new in this and keeping it going. federalism issues as well, thank you for a great panel. tom: thank you, donna. a pioneer in the use of provider taxes. ground one a lot of how medicaid has been a trailblazer. i would say, medicaid is sustainable because of the use of provider taxes and even though in some ways they are controversial, a state that does not do these things that are

legal and approved by the federal government, we said, in medicaid director who does not do this is guilty of malfeasance, you have to do it. without the use of these, every state except one does a provider tax of some kind, the medicaid program cannot be sustainable within the funds available from the state. >> i will make one edition. i agree with that. deb: i think in the future, this them, veryalongside important revenue stream. i think they bring up the question we will have to look at in the future, supplemental payments and how they are used, upl payment and how those fit purchasing andd it brings us back to his is putting up the nonfederal share and that will become an issue

that all states will have to look at going forward. tom: i am involved in litigation administrators. one of the areas of integration we do not cover this medicare,edicaid and that integration. personally i think until the federal government moves forward to allow states to fully make a package for the dual eligibles, all of these experience -- experiments are going to fail. >> there is not enough flexibility for the state to take advantage. i would like your reaction to that controversial statement. tom: i agree it is a topic we should have covered, given the population served