File name: JAC Budget hearings 2013_20121212_075713.dcr Folder: C:\Documents and Settings\happropriations\Desktop\JAC Hearings 2013 0 ~ 12/12/2012 8:03:36 AM ~ Start Recording 3 ~ 12/12/2012 8:03:39 AM ~ December, 12, 2012 23 ~ 12/12/2012 8:03:59 AM ~ 048 - WDH- Department of Health 48 ~ 12/12/2012 8:04:24 AM ~ Nicholas As we go through Department of Health, the Medicaid option, health exchanges, format of budget -- hard number cut of 4$ and how presented in the budget bill is different, may want a summary sheet. Take us through the budget. 9:54 ~ 12/12/2012 8:13:30 AM ~ Jones: P. 4 of agency budget (v. 2 page 405 of IPAD) B sheet is summary. Structured differently than others Points out that the headings are different -- first two columsn 2) 2014 appropriation budget bill -- not full appropriation -- Agency has two appropriations in 48 B. This represents 1/2 of appropriation. Difference is $19 Million less than in 2013. Per LSO staff want it to mirrow 2013 appropriation. Funding eallocation on p,4 are net to zero -- represents reallocation. Proposing to move funding between divisions to reflect where reduced funding reside. In 2012 budget session, the timing of when reductions occurred arbitrary. Agency have authority to determine reallocation and then provide to this committee for review. 2014 budget allocation in column 2 represents reduced funding buy you can see where applied. CE sheets show unit budgets. It reflects where reductions occur by object code. 15:26 ~ 12/12/2012 8:19:01 AM ~ Nicholas Most budgets column 2 represent biennial budget -- the standard budget. In this instance becuase of the hard number, we start with it in column 2. Column 3 represents movement of one area to another. Then IT and supplemental requests follow. 16:57 ~ 12/12/2012 8:20:33 AM ~ Jones: Description accurate except column 2. Consequence of embeded reductions. Not every unit is reflected in this representation only those that were changes. CEs represent all units in the Department reflecting budget reductions where occur. PDFs of sheets available 18:53 ~ 12/12/2012 8:22:29 AM ~ Nicholas Get back whern return 19:15 ~ 12/12/2012 8:22:50 AM ~ Jones 1012 pages of PDF 19:34 ~ 12/12/2012 8:23:10 AM ~ Nicholas l Three are departing 19:59 ~ 12/12/2012 8:23:35 AM ~ Bebout - Summary sheet reflect changes 20:21 ~ 12/12/2012 8:23:57 AM ~ Jones correct 20:27 ~ 12/12/2012 8:24:03 AM ~ Berger: Apologizes 21:06 ~ 12/12/2012 8:24:42 AM ~ Forslund Introduces senior staff 22:43 ~ 12/12/2012 8:26:19 AM ~ Forslund asked by chairpersons to present a summary of Medicaid expansion report. Look at Affordable Care Act and look for opportunities for savings and downsides. Report provided last week. Prepared a power point presentation,(handout 046).2 24:47 ~ 12/12/2012 8:28:23 AM ~ Berger who needs copies of handout of powerpoint 24:57 ~ 12/12/2012 8:28:33 AM ~ Forslund Also gave two page summary as handout. 26:07 ~ 12/12/2012 8:29:43 AM ~ Berger copies of two page handout will be made 26:56 ~ 12/12/2012 8:30:31 AM ~ Forslund only working off power point. 2010 Patient Protection and Affordable Care Act, ACA, expand health care coverage: 1) individuals require to purchase insurance 2) employer mandate 3) health benefit exchanges and 4) expansion of Medicaid program. 28:33 ~ 12/12/2012 8:32:09 AM ~ Meier: requirement for employee participation 28:47 ~ 12/12/2012 8:32:23 AM ~ Forslund fifty 29:07 ~ 12/12/2012 8:32:43 AM ~ Meier 49 or less not required 29:20 ~ 12/12/2012 8:32:56 AM ~ Forslund yes his knowledge outside Medicaid is less 29:46 ~ 12/12/2012 8:33:22 AM ~ Meier developed anything to inform employers 30:04 ~ 12/12/2012 8:33:40 AM ~ Forslund no, agency tasked with Medicaid componenet 30:33 ~ 12/12/2012 8:34:09 AM ~ Forslund constitutional challenges to parts of ACA. Ultimately SupremenCourt (3rd page of powerpoint presentation outlines issues). Court struck down portion that required expansion (page 4 of handout). Decision as interpreted as making the expansion optional (p.5 of handout) . Legislature will consider in upcoming sesson 33:27 ~ 12/12/2012 8:37:03 AM ~ Esquibel was told that states with poverty rate will not be taxes 34:22 ~ 12/12/2012 8:37:58 AM ~ Wallis tied to employment? Less than 50 employees and less than 101% of poverty level than taxed? 34:59 ~ 12/12/2012 8:38:35 AM ~ Forslund: A person of 101% will be required to have insurnce 35:18 ~ 12/12/2012 8:38:54 AM ~ Moniz As far as employees go is it full-time? 35:34 ~ 12/12/2012 8:39:09 AM ~ Forslund Full time 35:40 ~ 12/12/2012 8:39:16 AM ~ Moniz Employers may convert employees to part-time 35:57 ~ 12/12/2012 8:39:33 AM ~ Forslund correct -- may move to part-time or drop insurance and force employees into exchange. Employers will be taxes. 36:28 ~ 12/12/2012 8:40:03 AM ~ Moniz tax less than providing insurace 36:52 ~ 12/12/2012 8:40:28 AM ~ Forslund yes, Employers will have to decide if employee recruitment and retention is affected with drop of insurace coverage 37:36 ~ 12/12/2012 8:41:12 AM ~ Wallis where taxes collected is a portion returned to state 37:58 ~ 12/12/2012 8:41:34 AM ~ Forslund tax is being returned through paying for people who are on the Medicaid program who were not on before 38:24 ~ 12/12/2012 8:42:00 AM ~ Esquibel if employer chooses to go the route of dropping insurance won't get tax breaks as small employer 38:56 ~ 12/12/2012 8:42:32 AM ~ Hastert at Johns Hopkins seminar portion of employers increased in providing insurance in Massachusetts and ahowed employers see as benefit 39:51 ~ 12/12/2012 8:43:27 AM ~ Forslund Last estimate 83K individuals were uninsured (page 7 of handout). 5% set asided included in 138% figure. 41:25 ~ 12/12/2012 8:45:01 AM ~ Steward give it in dollars for poverty level 41:46 ~ 12/12/2012 8:45:21 AM ~ Forslund gathering that information now 42:01 ~ 12/12/2012 8:45:36 AM ~ Berger will get a copy 42:08 ~ 12/12/2012 8:45:43 AM ~ Forsulnd discussed breakdown on page 7 of handout: eligibility for Medicaid if exanded, federal subsidies and not eligible for either 43:51 ~ 12/12/2012 8:47:27 AM ~ Forslund : Department of Health tasked for Medicaid 44:33 ~ 12/12/2012 8:48:08 AM ~ Bebout on 19% of 83K those above the 400% have elected to buy no insurance. Those who don't buy insurance will be taxed. 45:39 ~ 12/12/2012 8:49:14 AM ~ Forslund need to understand who is currently eligible for Medicaid. Two requirements must be met 1) financially eligibile and 2) categorical -- children, very low income adults, pregnant women and individuals ABD. Regardless of income you don't receive Medicaid coverage. You must meet categorical requirement plus be under the federal poverty level 47:27 ~ 12/12/2012 8:51:03 AM ~ Wallis 100% or 138%? 47:48 ~ 12/12/2012 8:51:24 AM ~ Forslund depends on category 48:07 ~ 12/12/2012 8:51:43 AM ~ Forslund groups to consider, required coverage and optional expansion, page 9 of handout 48:51 ~ 12/12/2012 8:52:27 AM ~ Forslund those eligible enrolled but once madate comes in to effect, come out of the woodwork. Required to be covered. Receive only a 50% federal match. 50:08 ~ 12/12/2012 8:53:44 AM ~ Wallis talking about extremently low income and one of categories 50:40 ~ 12/12/2012 8:54:16 AM ~ Forslund yes 50:49 ~ 12/12/2012 8:54:25 AM ~ Bebout what is the cost 50:56 ~ 12/12/2012 8:54:32 AM ~ Forslund it will have to be in budget and is in the supplemental budget request 51:15 ~ 12/12/2012 8:54:51 AM ~ Hastert get caught up in costs for ACA. He would like consideration of the cost of doing nothing. 51:57 ~ 12/12/2012 8:55:32 AM ~ Forslund it is not covered in powerpoint but in the report, uncompensated care costs for hospitals in Wyoming. Recent figures show just shy of $2 Million in calendar year for emergency room care. These costs are passed on to full paying patients, cost shifting. 53:16 ~ 12/12/2012 8:56:52 AM ~ Forslund newly eligible children in Medicain are those whose family incomes 100-133%. This results in federal match of 65% Page. 12 of powerpoint handout 54:43 ~ 12/12/2012 8:58:19 AM ~ Forslund best guess of Medicaid cost study for those coming onto Medicaid program -- study on website -- Enrollement is estiamted at 10.6K This must be put into budget. It represents 6 months cost in the supplemental budget. Next year would be two years 56:41 ~ 12/12/2012 9:00:16 AM ~ Esquibel goes up to 88% for children in 2015? 57:08 ~ 12/12/2012 9:00:44 AM ~ Forslund correct 57:14 ~ 12/12/2012 9:00:50 AM ~ Forslund what is optional (p.15 of powerpoint) 17.6 estimated enrollment in expansion. He categorizes as the working poor of the state. 58:49 ~ 12/12/2012 9:02:25 AM ~ Meier where is estimate from? 58:58 ~ 12/12/2012 9:02:34 AM ~ Forslund came through Medicaid option study. Used the best guess provided to us 59:41 ~ 12/12/2012 9:03:17 AM ~ Meier: what is the maximum? 59:53 ~ 12/12/2012 9:03:29 AM ~ Forslund asked for number from staff 1:00:08 ~ 12/12/2012 9:03:44 AM ~ Forslund with expansion population federal government will cover 100% of costs for 2014-2016. Then it ratchets down over time to 90% 9p. 16 of handout). No deadline for states to expand. It is up to the states to expand or if ever do. The FMAP does not foat. Why is larger FMAP rate? Pent-up demand is reason. There is deferred maintenance because people have held off. When have coverage get repairs done that they need. Costs are significantly higher earlier than later on. If you elect defer and come on later the state pays for pent-up demand. Range is low - high shared. 1:03:44 ~ 12/12/2012 9:07:20 AM ~ Forslund discusses p. 17 of ahndout showing total new enrollment. 1:04:20 ~ 12/12/2012 9:07:56 AM ~ Forslund p. 19 of handout discusses costs to federal governvernment and costs to state. $99.9 Million is the cost for state for 7 years. Optional population costs reflect racheting down of contribution by federal government. cost to state is $51.2 Million. Next page 20 shows total costs to state of $151.1 Million. 1:06:55 ~ 12/12/2012 9:10:31 AM ~ Wallis why 7 years? 1:07:05 ~ 12/12/2012 9:10:41 AM ~ Forslund: 7 years was directed by legislature. He will show on yearly basis later. 1:07:33 ~ 12/12/2012 9:11:09 AM ~ Perkins basically we are getting AML money bakc 1:07:50 ~ 12/12/2012 9:11:25 AM ~ Forslund it will be a net cost of only required and if expansion includes required and optional it would be net savings. 1:08:55 ~ 12/12/2012 9:12:31 AM ~ Forslund state created several programs over years for persons without health coverage. Some services provide 100% of costs. Page 24 of handout. Example is colorectal cancer screening . Coverage will be made available through private plans. Behavioral health services is another example. Block grants given to community health providers to provide services to an individual. It is second largest item in budget. Propose to move agencies that receive block grants to fee for service model. They would either bill private insurance or Medicaid depending upon eligibility category. The money saved from block grants would be used for wrap around service at 50% and 50 % would be put into Medicaid. 1:14:07 ~ 12/12/2012 9:17:43 AM ~ Meier: like them to work with the Department of Insurance to make coding and billing process as easy as possible. Need detail about what can be switched to private services. Think 2-4 years to sort out what's going on. 1:15:43 ~ 12/12/2012 9:19:18 AM ~ Forslund recongize the issue Sen. Meier makes. His discussion with providers shows need for help. They have committed to training for organizations to retool their business model. Propose to step it down over a three year period. In terms of coding somewhat restricted by Medcais and comply with CMS. Want to make it painless as possbible. 1:17:34 ~ 12/12/2012 9:21:10 AM ~ Forslund Cost of $151.1 and estimate of $198.5 in offsets have been identified. 1:18:26 ~ 12/12/2012 9:22:02 AM ~ Perkins: Offsets where did they come from 1:18:38 ~ 12/12/2012 9:22:14 AM ~ Forslund the study that came out identified offsets 1:19:07 ~ 12/12/2012 9:22:43 AM ~ Richards on IPAD and calendar 1:19:21 ~ 12/12/2012 9:22:57 AM ~ Forslund p. 27 of handout shows required coverage. Still think there are offsets. Over 7 years would have $20.5 Million in offsets. It will costs $10-20M a year for increased enrollement coming onboard. 1:20:19 ~ 12/12/2012 9:23:55 AM ~ Forslund p. 28 shows required and optional groups. It shows net savings over 7 years of $47.4 Million if do expansion. 1:21:04 ~ 12/12/2012 9:24:40 AM ~ Forslund: p. 29 shows net savings of $47.4 Million over the severn years. Legislature need to make a decision about expanding adult populations. 1:21:51 ~ 12/12/2012 9:25:27 AM ~ Bebout Lookin at savings and otpion to come into the program anytime. Makes sense if concerned about Federal government changing the rules. He believes wise to be cautious. Wait a little bit to see how it shakes out. 1:22:46 ~ 12/12/2012 9:26:22 AM ~ Forslund Federal governmen said can come in and leave anytime you want to. In terms of cost, the costs in the early years, we are racheting them down. If delayed a year or two would still have to help them rachet down. Delay will result in smaller savings unless don't help them in the early years, especially mental health substance abuse providers. Once bring people , you can withdraw. One way to protect program place into statutue wording if Federal change 90% match take action. It would be the trigger to keep in place -- an option to consider. If don't homor the 90% longterm. The department is working with the law as is today. There is not guarantee. 1:26:21 ~ 12/12/2012 9:29:56 AM ~ Meier Currently population of childless adults not under Medicaid. What option between 133% and nothing. 1:27:08 ~ 12/12/2012 9:30:43 AM ~ Forslund a number of states interested in 100% in below. Made request for waiver. Sec. Siebilus. said HHS does not have authority to grant request. States can only provide the whole population or don't do it. Ruling came out on Monday. 1:28:20 ~ 12/12/2012 9:31:56 AM ~ Moniz Trying to get handle on offsets. How does it work? And is the insurance company picking up the tab? 1:28:48 ~ 12/12/2012 9:32:23 AM ~ Forslund the situation is that in 2014 everyone is required to have health insurance coverage. A person coming into mental health facility and have private insurance. It will be required for pay on parity for mental health coverage. They will be able to bill for services. Those below 100% poverty level will not have mental healt coverage. If state elects not to expand., the 100% and above will receive subsidy; those below are out of luck. If state does expand then those 100% and below would. If elect not to expand have to keep block grants in place for those below $100%. 1:32:31 ~ 12/12/2012 9:36:07 AM ~ Moniz trying to get handle on who is paying the bill 1:32:43 ~ 12/12/2012 9:36:19 AM ~ Forslund it is insurance companies or Medicaid. By shifting it over the states will only pay 10% of costs because of Federal paying increased FMAP. A new model of funding..private insurance or medicaid, not 100% block grant. If the state says no to the expansion, then use block grants and pay more..inability to convert services to the fee for service model. 1:34:54 ~ 12/12/2012 9:38:29 AM ~ Wallis: Sen. Bebout's discussion, option to go in and go out. Possibility of state statutorily establishing a trigger mechanism is federal govt change sthe amount i. Impact: Dependent people. If we have trigger would impact their lives dramatically 1:36:12 ~ 12/12/2012 9:39:48 AM ~ Forslund: 17 million plus have no health insurance. If you gave them coverage for a period of time and took it away, ask if the people are better off for having coverage for 3 years, losing it versus not having any. Hospitals eat costs. Is quality of life better for that time period even if taking it away impacts negatively. 1:37:37 ~ 12/12/2012 9:41:13 AM ~ wallis: As legislators, we would be under pressur to pick up that tab, state forced to provide those things. I am uninsured. I made that decision for myself. As an unemployed rancher, the cost is 3x per month what I have paid in health care. Personal finances that makes more sense. Now, the state ...it bothers me that we are assuming so much . I realize there are savings possibiliites, I feel like the fly inthe web with the spider approachings..sticky for the state with pitfalls. 1:39:26 ~ 12/12/2012 9:43:01 AM ~ Esquibel: Uncompensated child care. 200 million is that per year in the state of wyoming? 1:39:42 ~ 12/12/2012 9:43:18 AM ~ Forslund: yes, figure from two years ago according to the hospital. 198.milion, amount reported on regular basis. Uncompensated cost shifted to full paid providers. People with no insurance on medical emergency must have care provided. Cost shift by employers onto employees by increasing deductibles and co-pays. Even peoplewith coverage, can not make co-pays and deductibles so hospital eating that cost. 1:41:22 ~ 12/12/2012 9:44:58 AM ~ Wallis: Power point cost savings 47.4 million in state programs. The uncompensated part that we pay for is not reflecte in the report so potential cost savings would be higher. 1:42:00 ~ 12/12/2012 9:45:36 AM ~ Forslund: correct. Pointed out in full report. I wanted to stay away from other potential savings ...I wanted numbers under cotnrol of state government. Moving cost savings to hospitals, other providers, money into state, job growth. You can come up with all kinds of numbers to increase it, open to charge of inflating number. Not built into our analysis. 1:43:35 ~ 12/12/2012 9:47:11 AM ~ Esquibel: Tomorrow on the insurance side, the ACA requires ins companies ...85% for direct premium costs....in 2014. That would be the point when you would see cost savings... 1:44:24 ~ 12/12/2012 9:47:59 AM ~ Berger: JAC 10 minute break. 1:44:46 ~ 12/12/2012 9:48:22 AM ~ Forslund: handout page is two page summary of everything Forslund went over. 1:45:03 ~ 12/12/2012 9:48:39 AM ~ 1:45:07 ~ 12/12/2012 9:48:43 AM ~ Pause 1:45:07 ~ 12/12/2012 10:13:33 AM ~ Resume 1:45:27 ~ 12/12/2012 10:13:53 AM ~ Meeting Resumes 1:46:38 ~ 12/12/2012 10:15:04 AM ~ Nicholas: JAC needs to look on both sides of issue. Once extended, can not e withdrawn. Part of the reluctance is that it is easy to say the program is invoked and in 4 years, the program is shut off. People have had health benefits. Concern of legislators. Once the hand of aid is extended, you can not withdraw it. I struggle with what is the impact of doing nothing. How does it affect our health care providers, our insurance plans and thestate of wyoming. ..Assumption that people are not receiving health care. The yare receiving health care but are not paying for it. Hospitals are prohibited by law from turning people down for lack of payment. This is expensive health care and costs are shifted to those with health care insurance...medicaid dollars.. Some of that is cost shifted also. The price is provided to us. If the advocates for the expansion for the 1700 Wyominnites, it should almost be cost neutral. These folks are having halt care provided but it is being cost shifted. If we are putting in 50 million then should see .reduction of health care costs of 50 million because there is not longer cost shifting . Can we do an analysis of this 1700 people receiving an equivalent amount of 50 million so would expect to see 50 million reduction in other areas. 1:51:53 ~ 12/12/2012 10:20:19 AM ~ Forslund: We have stayed away from those projections. Could we make a projection? Probably. Hospitals report uncompensated care, which is critical care patients and private companies that provide coverage but have cost shifted to employees, so hospital eats those costs also. This is the uncompnesated care portion where there is no insurance and a portion of that will be covered. This is what potentially will be in the system as savings. Some people will question the validity of the numbers. 1:53:48 ~ 12/12/2012 10:22:14 AM ~ Nicholas: Community Health centers, UW family practice. If all were insured, could see 40 million of income..If there were a mechanism for us to know that we would see a savings of 50 million to other budgets so it was cost neutral if we had to take over. It makes a different proposition if we know it is cost neutral. If all we are doing, is throwing 50 million more into the system so providers income goes up, no one wants to do that. Is there a way for us to do this? ...Cost premiums of insurance include ":uncompensated costs". Insurance rates that pick up a portion of uninsured costs may have a penalty, may reimburse premium payers. Penalty for cost shifting for paying higher rates because federal govt will come. 1:58:24 ~ 12/12/2012 10:26:51 AM ~ Forslund: Issues I have been presented are the costs that are under the control of the dept of health. We can pick up costs of the expansion and the net effect will be positive, only withinthe dept of health. That is what is under our control. You move away from the dept of health and start lookin at other potential savings, we can look at it but not under our control..would be an estimate..can not guarantee it.Blue Cross Blue Shield insurance technical questions should be directed to the insurance dept. That is not part of our task.. Ins companie e. Line 28 Listing by year...... We can repurpose, reallocate funds within our budget. We can extend coverage to ..people without GF contributions by the state of Wyoming. If you only do the required, we will have a net cost of 79 million because the offsets will not be nearly as large. This is all within the Dept of Health's budget so we have compelte control of it. 2:04:04 ~ 12/12/2012 10:32:31 AM ~ Nicholas: What is the total govt received from teh fed govt for the expansion.?.page 28 of presentation handouts. 2:04:40 ~ 12/12/2012 10:33:06 AM ~ Forslund: Go back to page 19. It shows a breakdown of the cost of the federal govt, The 2nd column is the GF column. costs us shy of 100 million for 7 years. The bulk of the cost requires with the required group for the state of Wyoming. 2:05:49 ~ 12/12/2012 10:34:15 AM ~ Nicholas: The optional coverage total dollars spent are 780 million? 2:06:10 ~ 12/12/2012 10:34:37 AM ~ Forslund: The next page shows the summary. I 2:06:23 ~ 12/12/2012 10:34:49 AM ~ Nicholas: It takes ..million to get the cost savings. Cost neutral..If we put in 860 million between us and the state... 2:06:52 ~ 12/12/2012 10:35:18 AM ~ Forslund: 864 million from federal govt. state puts in .. 2:07:07 ~ 12/12/2012 10:35:34 AM ~ Nicholas: Total budget savings 2:07:16 ~ 12/12/2012 10:35:42 AM ~ Forslund: can come up with repurposing, reallocating within the department. Can come up witht he 198.5 million in offsets to cover the 151 million in costs. 2:07:47 ~ 12/12/2012 10:36:14 AM ~ Nicholas: Part of your point of annual reports of 200 million per year uncompensated costs. If people had insurance, would see benefits like reduction in cost of rooms. 2:08:24 ~ 12/12/2012 10:36:51 AM ~ Forslund: That would be benefits to the provider, including the state of wyoming. None of that is calculated in the cost. 2:08:51 ~ 12/12/2012 10:37:17 AM ~ Nicholas: Focusing on health care providers who will now save money that is presently cost shifted. If we put in 1 billion, will we see 1 billion in savings to taxpayers, people paying for insurance, etc orwill it go to drug mfc, equipment mfc, hospitals have a reserve. Have any of the states said that we will do this if we are going to see a reduction...? Can't ignore uncompensated trauma care. Fed gov may say they will adjust because t they will not allow cost shifting..I would like to know what the consequence is to not doing anything..could be dangerous, if we go to Universal Health care..rates set on premise that ....cost share is not allowed. 2:11:48 ~ 12/12/2012 10:40:14 AM ~ Forslund: I understand the question. I do not hve an answer. We have not done the analysis nor have I seen if other states have done it. 2:12:19 ~ 12/12/2012 10:40:45 AM ~ Nicholas: Should we wait and watch other states? 2:12:32 ~ 12/12/2012 10:40:58 AM ~ Forslund: The federal govt allows the state to comin into the program and leave anytime it wants. The fmap rate is 100% for the first 3 years, then goes down to 90%. The longer you delay, then the smaller the fmap rate is. Up to state when it wishes to come into the program. 2:13:25 ~ 12/12/2012 10:41:52 AM ~ Meier: Trying to balance numbers on alternative budget...budget freeze spending limits do not apply....over 2000 people over 4 years. We know 3700 people . Does number start counting at 2001 or at 1. 2:14:16 ~ 12/12/2012 10:42:42 AM ~ Forslund: Assumption due to a slowing economy, not due to medicaid expansion. 2:14:32 ~ 12/12/2012 10:42:58 AM ~ Meier: Whre does the count start at? supposition of slowing economy.. 2:14:59 ~ 12/12/2012 10:43:25 AM ~ Forslund: starts at 28,000 plus 1..idea that if the economy started tanking and unemployment rate went up significantly, we set arbitrary number, we could absorb sign. ...could ask for additional funding. 2:15:55 ~ 12/12/2012 10:44:22 AM ~ Stubson: Numbers on optonal coverage, and broadening perspective tto taxpayer. Your numbers do not talk about federal tax savings. If you throw in throw in federal, we have to spend 3/4 billion to get...Have you looked at anticipated savings on the federal side. Does it make sense to spend that to get 47 million savings. 2:17:23 ~ 12/12/2012 10:45:49 AM ~ Forslund: Two perspectives: If you do not expand there is a net cost of 12 or 14 million per year because of the required population coming on board. If you do expand, can reallocte funds within the dept without expanding the budget of the WDH. Fed govt is paying aproximately 1/2 of costs. If we do expand, they pay 100% of cost ...800 million of federal funds..Elected not to provide coverage and paying 14 million a year or provide coverage and reallocate existing funds within dept to do it. Fed govt will pay match for req group or the required and the optional group. 2:19:42 ~ 12/12/2012 10:48:09 AM ~ Stubson: Looking at all tax dollars spent, it will take an extra expenditure of 730 million to get to the state savings. Is that an accurate way to look at it? 2:20:25 ~ 12/12/2012 10:48:51 AM ~ Forslund: 738 million is federal share of that expansion group. If you look at dollars and cents, taxpayers can save 738 million not to expand. Would cost the state of wyoming 100 million, will not hve to spend 150 million in match. but pay for 190 million worht of program costs that we can not divert over. ... 2:22:07 ~ 12/12/2012 10:50:33 AM ~ Bebout: Offsets, 4 primary categories, being creative to get 198 million to buy in to coverage. Do they require waivers? Fed govt ...total dollarrs. If we do this, do we know for sure we will get the offsets, the waivers? 2:23:22 ~ 12/12/2012 10:51:48 AM ~ Forslund: There are more than 4 programs..60+% is coming from menatl health and substance abuse. Almost all programs are state general funds. Dept has no say over that. State of Wyoming is unique in that the state has been generous with its GF's to pay for these services. Other states have not provided services or put it as part of medicaid. Wyoming elected not to do that. In short term it cost state more money. In long term, it cost. We do not need permission to repurposed funds. Fed govt anticipates offsets. 2:25:31 ~ 12/12/2012 10:53:58 AM ~ nicholas: Assume Cheyenne medical center, 50% of appendectomy uninsured so room rate is 300 per night and physician at 10,000 per procedure. Assume colorado comes in, everybody pays so room rates reduced and appendectomy's cost less so cost shifting. What is impact on Cheyenne medical center when they still charge 300 per room and 10,000 when you can go to Poudre and get it for less because they took the money. 2:27:32 ~ 12/12/2012 10:55:58 AM ~ Forslund: Point made yesterday. ..controls, employers paying sigificant portion. report out republicly. If you are a ..contractor, competing with companies that are out of stae with less expensive health ins because those states have done expansion and wyo has not. Does this put them at a competive disadvantage as employers? 2:29:44 ~ 12/12/2012 10:58:10 AM ~ Meier: Everyone mandated to have insurance whether we pass this or not? 2:30:23 ~ 12/12/2012 10:58:49 AM ~ Forslund: Yes except for people under 100% of federal poverty level. 133 - 138% will get a subsidy. People under 100% do not get subsidy or entered into the program. 2:31:07 ~ 12/12/2012 10:59:33 AM ~ Meier: Savings in behavioral halth would accrue to dept of health whether we take expansion or not? 2:31:30 ~ 12/12/2012 10:59:57 AM ~ Forslund: No..those providers will be all over you...provide service but have cut funding. 2:32:01 ~ 12/12/2012 11:00:28 AM ~ Meier: people mandated to buy insurance, more people will have it. All ins. policies must provide mental health insurance in every policy bought. If a person goes to mental health facility, it will be covered by their insurance. Folks at mental health and substance abuse centers will have inc. revenues from ins. proceeds because of the mandated ins. coverage Correct/ 2:33:33 ~ 12/12/2012 11:01:59 AM ~ Forslund: Correct. People from 100% poverty level and above will have coverage..mental health parity..Debate you will experience..still need just as much money as those people under 100%. 2:35:09 ~ 12/12/2012 11:03:35 AM ~ Meier: proporionalize it...how many under 100% less than 17,000. correct where you are haed. 2:35:50 ~ 12/12/2012 11:04:16 AM ~ ForslundL You are correct. I will not be able to provide the data 2:36:15 ~ 12/12/2012 11:04:41 AM ~ Meier: ? Forslund: Decision will be made by the legislature. 2:36:32 ~ 12/12/2012 11:04:59 AM ~ Meier: decision on offsets directly related to passage of ACA and passage of optional expansion, numbers are lumped together. 2:37:00 ~ 12/12/2012 11:05:26 AM ~ Nicholas: Can you make a reasonable allocation? One assumption is that everyone will have insurance. Some people will take the tax penalty. Assumption that if we all do this, then insurance rates will drop. Take a tax penalty and don't pay taxes. .. 2:38:26 ~ 12/12/2012 11:06:53 AM ~ Meier: Should be a way without too much problem to determine current insured now and apply the mental health parity bandaid. We know how many are insured, we know how many need mental health services. If we pass expansion or not, how much money would flow back into mental health system without passage of expansion. not whole picture but a number for that offset. 2:39:57 ~ 12/12/2012 11:08:24 AM ~ Meier: Do you know what he is asking for and what is your assessment of reasonable staff time. 2:40:13 ~ 12/12/2012 11:08:40 AM ~ Forslund: We can do an elementary analysis. At the end of the day, it is a policy call. Mental health association will question validity of the simplicity of the formula, anaylsis. At end of the day, it is a policy call that we will do it. 2:41:47 ~ 12/12/2012 11:10:13 AM ~ Nicholas: Pls provide us a rudimentary and state JAC asked for it, state the assumptions. Health care providers can come in and add their assumptions if they want to. Put in all the caveats. If you find out the anaylsis will take 100 hours of labor, we will release youf rom the request. 2:43:00 ~ 12/12/2012 11:11:26 AM ~ Meier: Determine the offset above the 120 million. .. 2:43:36 ~ 12/12/2012 11:12:02 AM ~ Nicholas: How many peopkle and how many policies? How many policies not currently covering it will have to cove rit? If the ins. commission has that info, then it is okay. I doubt they have that info about what policies have mental health coverage. 2:44:42 ~ 12/12/2012 11:13:09 AM ~ Meier; 7% number will go up. To understand if we expand or not, have to determine the offsets. 2:45:16 ~ 12/12/2012 11:13:43 AM ~ Nicholas: My concern is not asking for the info, it is tasking the dept, you keep introducing elements they don't have. too many unknowns. 2:45:43 ~ 12/12/2012 11:14:10 AM ~ Meire: I will work with WDH and the ins commission 2:46:12 ~ 12/12/2012 11:14:38 AM ~ Nicholas: Assign an employee, be honest if itwill take too much time. 2:46:48 ~ 12/12/2012 11:15:14 AM ~ Forslund: Get with Jesse Springer, he will be assigned this project. 2:47:24 ~ 12/12/2012 11:15:50 AM ~ Nicholas: Jesse, let him know how much time it will take to get info. 2:47:42 ~ 12/12/2012 11:16:09 AM ~ Esquibel: What if's, can they be adressed by using the Massachusetts implementation of the ACA,? Info is probably there, Possible ways to address concerns. 2:48:48 ~ 12/12/2012 11:17:14 AM ~ Nicholas: Info available fomr our own staff and organizations that we are part of. primarily they are to serve the labor committee. Making them our research group, you have to be careful.. LSO analyst...Here is my concern. I expect with JAC that we are given all info. available, be judicious with information asked for..don, check with the labor committee. 2:51:39 ~ 12/12/2012 11:20:05 AM ~ Bebout: 10,600 required, assumping no opt in on the expansion, will we be able to go to medicaid and request 50% match? Is that a sizeable number? 2:52:28 ~ 12/12/2012 11:20:55 AM ~ Forslund: AT people above.. 2:52:42 ~ 12/12/2012 11:21:08 AM ~ Bebout: 100% state funds for mental health and substance abuse..get the money from medicaid that we have not in the past. 2:53:12 ~ 12/12/2012 11:21:38 AM ~ Forslund: No we will not be able to do that. Mental health parity required. Mental health providers will bill to private insurance, We provide a block grant to those organizations. We will be double paying for a portion of their population assuming they will be billing. Some are billing medicaid even though they are receiving the block grant. Those below 100% will not hve insurance ormedicaid. for them to receive services, they will need to continue to receive block grants from the state. ..If you do not do the expansion and you strip the block grant money, you put those mental health organizations in a precarious situation. They deny coverage to those without ins or suck up the costs some way. it is not a formula. It is a policy call. 2:56:19 ~ 12/12/2012 11:24:45 AM ~ Bebout: We can not today do the 50% medicaid match today that we are now paying block grant for? That is what you are saying. 2:56:42 ~ 12/12/2012 11:25:09 AM ~ Forslund: People above 100% will hve ins. No we will not be bringing in medicaid. 2:57:19 ~ 12/12/2012 11:25:45 AM ~ Steward: markup...how will it be done? 2:58:04 ~ 12/12/2012 11:26:30 AM ~ Nicholas: Budget request from dept for medicaid expansion. The governor has denied it. The motion will be the gov's rec. Members may make a motion to reject the govs rec and go with the dept. If that passes, the staff will make an amendment, either within the dept or by a section 300. The lbor committee may be doing a bill. This committee looks at the issues a little different than labor. This may take debate. People voting need to hve thought about all the issues. 2:59:50 ~ 12/12/2012 11:28:16 AM ~ Perkins: How can we see overall ...Your dept monitors certain programs like colo rectal,. Would your dept know as it sees bills for theose screenings if the rates hve changed. Is that info available? I am looking for methods we can see corresponding reductions in growth or in costs.. 3:01:56 ~ 12/12/2012 11:30:22 AM ~ Forslund: We hve that data. If there were handful of procedures we could put together a 5 or 10 year history. Part of medicaid options report, is to look at medicaid growth on a global basis. We can provide that. 3:03:12 ~ 12/12/2012 11:31:38 AM ~ Perkins; Antedotal ...If you look at that evidence, is it valuble to extrapopulate that.... 3:04:05 ~ 12/12/2012 11:32:31 AM ~ Forslund: Excellent point. We can put together a dash board relatively easy to put certain indicators of costs. If we elect ot expand, we can put a pre, post to see if market is responding. . 3:06:02 ~ 12/12/2012 11:34:29 AM ~ Nicholas: Have not gone through budget. At 2:00 we have mgt council and training. Biggest gaency..no point in rushing this. Scheduled to see A and I today. My recommendation is to have A and I come in tomorrow morning at 8. Tell auditor, treasurer and state lands that they will be brought back in during the session. 3:07:38 ~ 12/12/2012 11:36:05 AM ~ Richards: That will work. I think we can do workforce services and A and I. 3:07:56 ~ 12/12/2012 11:36:23 AM ~ Nicholas: What color tab? 3:08:02 ~ 12/12/2012 11:36:29 AM ~ Jones: White tab 3:08:10 ~ 12/12/2012 11:36:36 AM ~ Nicholas: auditor, treasurer, state lands on call for tomorrow, will call them at noon. Start at A and I, then move to retirement. Other 4 entities have an hour notice. They will go at the end of the day. keep flexibility. go through the budget from 1 to 2. I would like to talk about health care exchanges. 3:11:52 ~ 12/12/2012 11:40:19 AM ~ harshman; Question presented: If we decided to opt in, we could make it conditional on the study of indicators. we c ould make it conditional to get out if the 90% changed. Any comment 3:12:32 ~ 12/12/2012 11:40:58 AM ~ Forslund: The director can not guarnatee the 90% or any other federal match rate. All I can do is preseent the data bsed onteh law today. The federal govt put into place an automatic trigger that action takes place unless US congress takes action tostop it from happening. the state legislature in Wyoming can do the same thing. If the federal govt does not live up to guarantee or match, a trigger can be put in place that the the optional portion of the program ends. Harder to shut down a program than votes to not allow it to shutdown. More difficul to sop it than to do it. Only protection Ican think of. People's health better for whatever time they hve coverage. Working poor..younger age, service industries employees with multiple jobs not earning enough to get above poverty level, part-time, not geting coverage. Betting many will not be long-term stays as opposed to elderly or people with disabilites. 3:16:56 ~ 12/12/2012 11:45:23 AM ~ harshamn: Savings on page 16 could be savings to the GF . 3:17:12 ~ 12/12/2012 11:45:38 AM ~ Forslund: .....Mental health providers bill for services. Getting block grants, not dependent on insurance. Say they can transfer their business model. Will lose block grant but make it up by billing for services. I see no reason for state of Wyoming to give providers block grants and then allow them to bill for services, being paid double. do not shut off over night. Give a few years for transition. 3:18:53 ~ 12/12/2012 11:47:20 AM ~ Hastert: My concern is that there are fiscal consequences of not doing this as well as quality of life consequences. No one knows. ...options...better leaders than that. 3:21:19 ~ 12/12/2012 11:49:45 AM ~ Nicholas: Debated at markup. We are here with 20 people who provide info. This is time to provide info., not debate. Question difficult for every member because they feel that a hand once extended may not be taken away. use this time for a question. 3:22:26 ~ 12/12/2012 11:50:53 AM ~ Esquibel: In the governor's budget, in your dept, in bullets on budget reduction. "reimbursements as much as possible..In governor's message to the legislature. Examples of higher expenses that we pay to out of state providers. 3:23:55 ~ 12/12/2012 11:52:22 AM ~ Forslund: children's hospital. WDH medicare program reimbursed at 90% of billed charges. Compare out rates to regional rates, we are sign. higher. in terms of what the state of wyoming is paying. Suggestion to bring our payments in line with other states in the region. Example of how we would adjust reimbursements. 3:25:15 ~ 12/12/2012 11:53:42 AM ~ Nicholas: Assign Jesse and Dawn or one of the analysts, figure out what material has been collected by labor, put on our dirve. Create a health care drive..Then if dept looks at documents on the list, make a recommended reading schedule. 3:27:11 ~ 12/12/2012 11:55:37 AM ~ Forslund: have generated 5 or 6 reports for joint labor and JAC. Info on medicaid program, potentioal reform, suggestions on budget changes. That is available. We can try to point out areas that will be useful for you. 3:28:26 ~ 12/12/2012 11:56:53 AM ~ Nicholas: Co-chairs may decide to do a call back with Dept of Health . Status of healt care exchange.. 3:29:09 ~ 12/12/2012 11:57:36 AM ~ Forslund..brief discussion on alternate budget proposal. 3:29:23 ~ 12/12/2012 11:57:50 AM ~ Nicholas: We will do that. 45 minute lunch. Return at 12>45 3:29:55 ~ 12/12/2012 11:58:21 AM ~ 3:29:59 ~ 12/12/2012 11:58:26 AM ~ Stop Recording