U.S. GOVERNMENT PUBLISHING OFFICE

28–525 WASHINGTON : 2018

EXAMINING THE EXTENSION OF SAFETY NET 

HEALTH PROGRAMS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

JUNE 23, 2017 

Serial No. 115–41 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

(III) 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, TEXAS

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(V) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 6 

Prepared statement .......................................................................................... 7 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 8 

WITNESSES

Michael Holmes, Chief Executive Officer, Cook Area Health Services ............... 11 

Prepared statement .......................................................................................... 13 

Answers to submitted questions ...................................................................... 111 

Jami Snyder, Associate Commissioner for Medicaid/SCHIP Services, State 

of Texas, Health and Human Services Commission ......................................... 17 

Prepared statement .......................................................................................... 19 

Answers to submitted questions ...................................................................... 126 

Cindy Mann, Partner, Manatt Health ................................................................... 24 

Prepared statement .......................................................................................... 26 

SUBMITTED MATERIAL

Statement of the Children’s Community Association, submitted by Mr. Green 

Statement of the North American Society for Pediatric Gastroenterology, 

Hepatology, and Nutrition ................................................................................... 71 

Statement of Children’s Health Groups, submitted by Mr. Luja ́n ......................

Statement of the American Academy of Dermatology Association, submitted 

by Mr. Burgess ..................................................................................................... 74 

Statement of America’s Essential Hospitals, submitted by Mr. Burgess ............ 76 

Statement of American Academy of Family Physicians, submitted by Mr. 

Burgess ................................................................................................................. 78 

Statement of America’s Health Insurance Plans, submitted by Mr. Burgess .... 83 

Statement of the Healthcare Leadership Council, submitted by Mr. Burgess ... 88 

Statement of support from Minnesota House Members, submitted by Mr. 

Burgess ................................................................................................................. 90 

Statement of support from 1,200 local state and national organizations, submitted by Mr. Burgess ......................................................................................... 92 

(1) 

EXAMINING THE EXTENSION OF SAFETY NET 

HEALTH PROGRAMS 

FRIDAY, JUNE 23, 2017 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:23 a.m., in room 

2123, Rayburn House Office Building, Hon. Michael Burgess, M.D. 

(chairman of the subcommittee) presiding. 

Present: Representatives Burgess, Guthrie, Barton, Upton, Shimkus, Murphy, Lance, Griffith, Bilirakis, Mullin, Hudson, Collins, 

Carter, Walden (ex officio), Green, Engel, Schakowsky, Butterfield, 

Matsui, Castor, Sarbanes, Luja ́n, Schrader, Kennedy, Ca ́ rdenas, 

Eshoo, DeGette, and Pallone (ex officio). 

Also Present: Representatives Costello, Dingell, and Ruiz 

Staff Present: Zachary Dareshori, Staff Assistant; Jordan Davis, 

Director of Policy and External Affairs; Paul Edattel, Chief Counsel, Health; Adam Fromm, Director of Outreach and Coalitions; 

Caleb Graff, Professional Staff Member, Health; Jay Gulshen, Legislative Clerk, Health; Peter Kielty, Deputy General Counsel; Alex 

Miller, Video Production Aide and Press Assistant; Mark Ratner, 

Policy Coordinator; Kristen Shatynski, Professional Staff Member, 

Health; Jennifer Sherman, Press Secretary; Josh Trent, Deputy 

Chief Counsel, Health; Jacquelyn Bolen, Minority Professional 

Staff Member; Jeff Carroll, Minority Staff Director; Waverly Gordon, Minority Health Counsel; Jerry Leverich, Minority Counsel; 

Rachel Pryor, Minority Health Policy Advisor; Tim Robinson, Minority Chief Counsel; Samantha Satchell, Minority Policy Analyst; 

Andrew Souvall, Minority Director of Communications, Outreach 

and Member Services; and C.J. Young, Minority Press Secretary. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. The Subcommittee on Health will now come to 

order. The chair wishes to observe that today’s hearing was originally scheduled to occur last Wednesday morning. But on that 

Wednesday morning, the Capitol Hill family and the entire country 

was shocked and horrified to learn about an awful attack that took 

place against our own. This past week has been sobering and difficult for all of us in many different ways, a number of friends, indeed. A member of this very committee is still in the hospital. They 

continue to need our prayers and best wishes as they fight to heal, 

to recover, and, in coming days, join us again. Last week’s awful 

2 

tragedy reminds us that what unites is more important than what 

divides us. We are not first Democrats or Republicans, we are 

Americans. We love our country, and we respect our colleagues. We 

are saddened, but we are strong. We are troubled, but we will unite 

around our common duty and our common service to our fellow 

countrymen that spirit of unity. 

Pause for just a brief moment of quiet reflection for those, especially the member of the committee who is not able to be here 

today. But, of course, we still have other people who are recovering 

from their injuries. 

The chair will recognize himself 5 minutes for an opening statement. 

In 2015, this committee passed the Medicare Access and CHIP 

Reauthorization Act—you are welcome—which extended funding 

for many of the Nation’s safety net programs, including the community health center funding and the State Children’s Health Insurance Program. With funding for both the community health center fund and the SCHIP program set to expire yet again at the end 

of this fiscal year, our committee has the responsibility of taking 

a critical look at how these programs operate, and setting out a 

long-term path to funding, and, perhaps, reauthorization. 

The Community Health Center Fund plays an important role in 

supplementing the services that federally qualified health centers 

are able to deliver to underserved communities by providing care 

to all Americans regardless of income, regardless of ability to pay. 

Additionally, the Community Health Center Fund provides resources for the National Health Service Corps which actually provides scholarships and loan repayment opportunities to new doctors 

willing to serve in medically underserved areas. This program has 

proven effective at placing providers, providers who are young and 

energetic and willing to work hard in some of the most medically 

unserved and challenging areas. 

The State Children’s Health Insurance Program provides 

healthcare coverage to over 8 million children across the Nation 

through flexibility capped allotments to states. The program has 

been able to successfully support children while providing states 

with opportunities to tailor their respective programs as to best 

meet the needs of their populations. However, the programs are not 

without challenges. In regards to the Community Health Center 

Fund, we are interested in seeing how federally qualified health 

centers can best maximize this investment. Succeeding in underserved areas can be difficult, and I look forward to learning more 

as to how the federally qualified health center can continue to deliver results and where improvements might be made. 

As for the State Children’s Health Insurance Program, there are 

multiple points for consideration. As is the case with other Federal 

insurance programs, there are considerable concerns regarding the 

long-term sustainability of the program. Following the passage of 

the Affordable Care Act, the program’s Federal match rate rose an 

unprecedented 23 percent, providing some states with as much as 

a 100 percent Federal match. This increase in funding has challenged the program by both shifting the nature of shared responsibility of the State Children’s Health Insurance Program to the FedVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
3 

eral Government and making states more dependent on Federal 

dollars. 

The issue is further complicated by concerns raised by the Congressional Budget Office on the efficacy of the enhanced match 

rate. According for the Congressional Budget Office, an elimination 

of the enhanced match rate would basically not impact coverage 

rates for children in the country, while a continuation of the enhanced funding would add another $7 1A1⁄2 billion to the deficit 

over the next 5 years if no other policies were undertaken to offset 

its cost. 

So today’s hearing should focus on how to best proceed with the 

Affordable Care Act’s increased funding for the State Children’s 

Health Insurance Program, the increased funding rate, and what 

a continuation of this funding would mean for taxpayers, and what 

it would mean for covered children. 

With these challenges before us, I would like to welcome our witnesses and thank them again for joining us today, thank them for 

their forbearance as the hearing got rescheduled twice. 

On the CHIP front, we have Ms. Jami Snyder who serves as the 

Associate Commissioner for Medicaid and CHIP in my home State 

of Texas, and Ms. Cindy Mann who served the administration as 

the administrator and director of the Center for Medicaid and 

CHIP services at the Center for Medicare and Medicare Services 

from 2009 to 2014. I am interested in hearing today how each of 

your experiences on both sides of this partnership has worked, and 

where you believe we can improve the ability of states to meet the 

needs of children in the program. 

And finally, Mr. Michael Holmes serves as the CEO of Cook Area 

Health Services, which I believe is in Minnesota. And as the treasurer for the National Association of Community Health Centers, 

Mr. Holmes, I look forward to your testimony today on the role that 

the Community Health Center Fund has played in supporting your 

work. There is much to discuss today. I look forward to our conversation. Both the Community Health Center Fund and the State 

Children’s Health Insurance Program provide State and local opportunities to improve access to care in the United States. 

I yield back the balance of my time, and recognize the ranking 

member of the subcommittee, Mr. Green of Texas, 5 minutes for an 

opening statement, please. 

[The prepared statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

The Subcommittee will come to order. 

The Chairman will recognize himself for an opening statement. 

In 2015, this Committee passed the Medicare Access and CHIP Reauthorization 

Act, which extended funding for many of the nation’s safety net programs, including 

the Community Health Center Fund and the State Children’s Health Insurance Program (SCHIP). With funding for both the Community Health Center Fund and the 

SCHIP program set to expire yet again at the end of the fiscal year, our Committee 

has the responsibility of taking a critical look at how these programs operate and 

setting out a long-term path to reauthorization. 

The Community Health Center Fund plays an important role in supplementing 

the services that Federally Qualified Health Centers (FQHCs) are able to deliver to 

underserved communities by providing care to all Americans, regardless of income 

or ability to pay. Additionally, the Community Health Center Fund provides resources for the National Health Service Corps, which provides scholarships and loan 

4 

repayment opportunities to new doctors willing to serve in medically underserved 

areas. This program has proven incredibly effective at placing providers, often those 

who are young, energetic and willing to work hard, in the most medically underserved areas. 

The SCHIP program provides health care coverage to over 8 million children 

across the nation. Through flexible capped allotments to the States, the program has 

been able to successfully support children while providing States with opportunities 

to tailor their respective programs as to best meet the needs of their respective populations. 

However, these programs are not without challenges. In regards to the Community Health Center Fund, we are interested in seeing how FQHCs can best maximize this investment. Succeeding in underserved areas can be difficult, and so I look 

forward to learning more as to how FQHCs can continue to deliver results and 

where improvements to the program can be made. 

As for the State Children’s Health Insurance Program, there are multiple points 

for consideration. As is the case with other federal insurance programs, there are 

considerable concerns regarding the long- term sustainability of the program. Following the passage of the Affordable Care Act, the program’s federal match rate rose 

an unprecedented 23%, providing some states with as much as a 100% federal 

match. This increase in funding has challenged the program by both shifting the 

nature of the shared responsibility of SCHIP to the federal government, and by 

making states more dependent on federal dollars. 

This issue is only further complicated by concerns raised by the Congressional 

Budget Office (CBO) on the efficacy of the enhanced match rate. According to the 

CBO, an elimination of the enhanced match rate would basically not impact coverage rates for children in the country, while a continuation of the enhanced funding 

would add an additional $7.2 billion to the deficit over the next five years if no other 

policies were adopted to offset its cost. Therefore, today’s hearing should focus on 

how best to proceed with ACA’s increased SCHIP funding rate and what a continuation of this funding would mean for taxpayers and for covered children. 

With these challenges before us, I would like to welcome our witnesses and thank 

them for joining us today as we unpack these important issues: 

On the CHIP front, we have Ms. Jami Snyder who serves as the Associate Commissioner for Medicaid and CHIP in my home state of Texas and Ms. Cindy Mann, 

who served as the Administrator and Director of the Center for Medicaid and CHIP 

Services at the Centers for Medicare and Medicaid Services (CMS) from 2009 to 

2014. I am interested in hearing today how each of your experiences on either side 

of this has partnership worked, and where you believe that we can improve the ability of States to meet the needs of children covered under the program. 

And finally, Mr. Michael Holmes serves as the CEO of Cook Area Health Services 

and as the Treasurer for the National Association of Community Health Centers. 

Mr. Holmes, I look forward to your testimony today on the role that the Community 

Health Center Fund has played in supporting your work. 

There is much to discuss today, and I look forward to our conversation on these 

programs. Both the Community Health Center Fund and the State Children’s 

Health Insurance Program provide state and local opportunities to improve access 

to care in the United States. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman. And, again, we appreciate the loss we had, the injuries you had, and particularly to our 

committee member, last week. But I am glad he is progressing very 

well. The Children’s Health Insurance Program, CHIP, and Federally Qualified Health Centers, FQHCs, are critical components of 

our healthcare safety net. Funding for both expires at the end of 

this fiscal year, and timely reauthorization is utterly critical. That 

said, we cannot talk about either without talking about Medicaid, 

and, literally, the elephant in the room. The American Health Center Act, or TrumpCare, guts Medicaid, makes structural changes 

that would inevitably lead to the rationing of care after seeing the 

House Republican’s bill to kick off 14 million enrollees on Medicaid, 

cut 834 billion from programs, the Senate plan to kick even more 

5 

kids off of Medicaid over time, and make even steeper cuts somehow managing to be more mean than even the House bill. 

In 3 years, the Senate bill will start the process of kicking millions off their Medicaid coverage. And then as if that wasn’t 

enough, starting in 2025, the plan leads to even more Medicaid 

cuts that every year becomes deeper cuts than the year before. 

CHIP is designed to sit on top of a strong Medicaid program, and 

reauthorizing it while simultaneously destroying Medicaid is simply unacceptable. 

TrumpCare jeopardizes coverage for millions of kids with Medicaid and CHIP, and the Trump budget doubles down on cuts that 

directly hurt kids. To make matters worse, the Trump administration’s budget proposals, an additional $610 billion cuts to Medicaid, 

eliminates enhanced CHIP matching for states, rolls back the requirement on states to maintain current kids’ eligibility in CHIP, 

and cuts support for CHIP kids over 250 percent of the Federal 

poverty level. 

More than 1⁄3 of all children in the U.S. and almost half the kids 

under age 6 are covered by Medicaid or CHIP. The vast majority 

of these children, more than 90 percent, are covered by Medicaid. 

I strongly support CHIP and will continue to urge my colleagues 

to fully extend the program for 5 years. And I have long championed community health centers and want to see the health center 

fund extended for the same amount of time. Without an extension 

of funding, the health center program will be decimated. Given all 

the uncertainly my colleagues are introducing in the health insurance programs, a clean extension of these two pillars of the 

healthcare safety net is of utmost importance. But again, extending 

these programs without destroying Medicaid is unacceptable. CHIP 

stands on the shoulders of a strong Medicaid program. And in fiscal year 2016, Medicaid provided more than 40 percent of the community health center’s funding. They are tied together as three legs 

on a stool that helps children get healthcare they need. No child 

should be left off worse because of Congress’s actions. 

With that, Ms. Chairman, I would like to yield 1 minute to my 

colleague from Massachusetts, Joe Kennedy. And after Congressman Kennedy, I yield the remainder of my time to Congresswoman 

DeGette. 

Mr. KENNEDY. Thank you to the ranking member. 

Ladies and gentlemen, anybody who has welcomed a child into 

this world knows that moment when you lock your eyes with your 

son or daughter the first time, the promise that you make to protect them under any circumstance. You learn quickly, sometimes 

far too quickly, that no matter how hard you try, nature will test 

the strength of that promise because children are not immune to 

an unexpected accident or a life-altering diagnosis. Facing that 

tragic reality, we as a country and as a community invest in their 

care through CHIP, through Medicaid, through a ban on lifetime 

caps into a strong community health center program. It is that recognition that our children are society’s most precious resource that 

brings us together here this morning. But TrumpCare threatens 

the fundamental guarantee of compassion for our kids. It segregates and stigmatizes children not just for their illness, but for 

6 

the fate and fortune of their family. And that is a vision that, for 

our healthcare system on our Nation, that we should never accept. 

Thank you, and I yield back. 

Ms. DEGETTE. Thank you. 

We used to all agree in this country that every child, regardless 

of his or her parents’ income, should have a chance at a healthy 

start. That is why we have been working in a bipartisan way to 

make this country get closer to that goal. I worked on the very first 

CHIP bill in 1999. And because of the bipartisan collaboration, 95 

percent of Americans children have coverage. That is an all-time 

high. So why would Congress pass this TrumpCare bill which will 

take coverage away from over 3 million children? There would be 

an unprecedented $834 billion cut in Medicare which covers more 

than 35 million kids. Half of the 9 million children in CHIP are actually in Medicaid. And so, Mr. Chairman, it is really hard for me 

to see how we can have a bipartisan reauthorization of CHIP by 

the end of September without a strong bedrock foundation of Medicaid. 

I yield back. 

Mr. BURGESS. The gentleman from Texas yields back his time. 

The chair thanks the gentleman. The chair recognizes the gentleman from Oregon, Mr. Walden, 5 minutes for an opening statement, please. 

OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON 

Mr. WALDEN. I thank the chairman. 

Today marks a really important step forward in this committee’s 

work to strength our healthcare safety net by examining the extension of two very important safety net programs. Both the Children’s Health Insurance Program, CHIP, the Community Health 

Center Program, have enjoyed strong bipartisan support for many 

years. Under current law, Congress needs to renew funding for 

these important programs, since the current funding streams will 

soon expire. We recognize that CHIP and community health centers play a significant role in the Nation’s safety net for millions 

of Americans, for millions of American children, and pregnant 

women who are generally low- to moderate-income, and millions of 

individuals who may be medically underserved or face other barriers to care. 

Individuals and families served by these programs are not just 

program enrollees: They are our neighbors. They are our friends. 

In my district alone, there are 12 federally-qualified health center 

organizations with 63 delivery sites leveraging more than $41 million in Federal money in order to serve over 240,000 patients. In 

many parts of rural eastern Oregon, a health center can serve as 

the main primary care provider in the communities that face a 

shortage of private practice doctors. And in three of my counties, 

there are no physicians, and there are no hospitals. The Student 

Loan Repayment Incentive offered through the National Health 

Service Corps also helps staff those centers and ensure patients in 

those communities can see a provider in a timely manner. So I am 

glad to be here and join my colleagues, hopefully on both sides of 

the aisle, in moving this process forward. We are united in the efVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
7 

fort to protect patients and to support innovative patient-centered 

solutions at state and local levels. 

As a result, there are strong bipartisan recognition that CHIP 

and the health center program play key roles in our Nation’s 

healthcare delivery system by providing health coverage and medical care for millions of low income Americans. 

Both programs have demonstrated successes in helping reduce 

cost for patients and families, improve health outcomes, and deliver 

cost-effective care. We view our state and local partners in these 

programs as key allies in the common cause of putting patients 

first. This is a shared responsibility. 

In my State of Oregon, our health centers partner with local providers, health systems, and the patient community through coordinated care organizations that work to provide comprehensive services focusing on prevention, chronic disease management, and locally controlled patient-centered care. 

Today, we start our funding extension discussion by hearing from 

experts who have firsthand experience running CHIP programs 

and health centers. We want to better understand if these programs face barriers to innovation. We want to hear creative strategies to deliver quality care, and we seek your guidance on what is 

working and what is not. 

As we move forward, this committee also faces important considerations regarding extending funding for these programs. There are 

decisions to be made regarding how much funding should be provided, for how long, and how Congress should pay for it so as not 

to burden the next generation with additional debt. 

Particularly, the committee will closely examine the question of 

whether the 23 percent bump for a state’s match for CHIP is appropriate to continue as we look at funding questions. I have concerns the 23 percent increase upends the traditional financial Federal-state partnership. 

As we embark on this effort, I know we all share the goals reducing cost and ensuring patients served by these programs have the 

peace of mind that they can continue to access timely, high quality 

care. And it goes without saying that this needs to be bipartisan. 

We look forward to working with our colleagues on the other side 

of the aisle. And it is important to note as well that CHIP is one 

of those programs that is actually a block grant to the states that 

seems to perform quite well when we rely on our state partners in 

this effort. 

So with that, Mr. Chair, unless others on our side seek the balance of my time, I am more than happy to yield back to get on with 

the hearing. 

[The prepared statement of Mr. Walden follows:] 

PREPARED STATEMENT OF HON. GREG WALDEN

Today marks an important step forward in this committee’s work to strengthen 

our health care safety net by examining the extension of two popular safety net programs. Both the Children’s Health Insurance Program (CHIP) and the Community 

Health Center Program have enjoyed strong bipartisan support for many years. 

However, under current law, Congress needs to provide additional funding for these 

programs since current funding streams will soon expire. 

We recognize that CHIP and community health centers play a significant role in 

our nation’s safety net for millions of Americans—children and pregnant women 

8 

who are largely low-to-moderate income, and millions of individuals who may be 

medically underserved or face other barriers to care. 

Individuals and families served by these programs are not just program enrollees—they are our neighbors, and friends. In my district alone, there are 12 federally-qualified health center organizations, with 63 delivery sites leveraging over $41 

million in federal dollars in order to serve over 240,000 patients. In many parts of 

rural Eastern Oregon, a health center can serve as the main primary care provider 

in the communities that face a shortage of private practice doctors. The student loan 

repayment incentives offered through the National Health Service Corps also help 

staff those Centers and ensure patients in those communities can see a doctor in 

a timely manner. 

So I am glad to be here and join my colleagues on both sides of the aisle in moving this process forward. We are united in the effort to protect patients and to support innovative, patient-centered solutions at the state and local levels. 

As a result, there is strong bipartisan recognition that CHIP and the Health Center Program play key roles in our nation’s health care delivery system by providing 

health coverage and medical care for millions of low-income Americans. Both programs have demonstrated successes in helping reduce costs for patients and families, improve health outcomes, and deliver cost-effective care. 

We view our state and local partners in these programs as key allies in the common cause of putting patients first. In Oregon, our health centers partner with the 

local providers, health systems, and the patient community through Coordinated 

Care Organizations that strive to provide comprehensive services focusing on prevention, chronic disease management, and locally controlled, patient-centered care. 

So we want to start our funding extension discussion by hearing from these experts 

who have first-hand experience running a CHIP program and a health center. We 

want to better understand if these programs face barriers to innovation, we want 

to hear creative strategies to deliver quality care, and we seek guidance on what’s 

working and what’s not. 

As we move forward, this committee also faces important considerations regarding 

extending funding for these programs. There are decisions to be made regarding 

how much funding should be provided, for how long, and how Congress should pay 

for it so as not to add to the burden of federal debt that Americans already face. 

Particularly, the committee should closely examine the question of whether the 

23 percent bump for a state’s match for CHIP is appropriate to continue as we look 

at a funding question. I have concerns that the 23 percent bump upends the traditional financial federal-state partnership. 

As we embark on this effort, I know we all share the goals of reducing costs and 

ensuring patients served by these important programs have the peace of mind that 

they can continue to access timely, high quality care. 

Mr. BURGESS. The chair thanks the gentlemen. The gentleman 

yields back. 

The chair would observe that there is a vote on the floor. There 

is still almost 9 minutes left. So with the committee’s permission, 

I am going to recognize the ranking member of the full committee, 

Mr. Pallone, 5 minutes for an opening statement, after which we 

will recess for votes until votes have concluded on the floor. Mr. 

Pallone, you are recognized for 5 minutes, please. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

A little over a month ago, House Republicans voted to repeal the 

Affordable Care Act and gut the Medicaid program in order to give 

tax cuts to the rich and privileged few. The result, 23 million people could lose health insurance, 3 million of them children. And 

then yesterday, Senate Republicans finally made public their bill 

where they proposed even steeper cuts to Medicaid. And now, 

today, Republicans will talk about the importance of our safety net 

programs, the Children’s Health Insurance Program, CHIP, and 

9 

the Community Health Center Fund. I agree wholeheartedly about 

the importance of extending these programs. But what our Republican colleagues seem to ignore is that our safety net is interconnected. To tear down Medicaid, which is supported by CHIP and 

community health centers, is misguided and hypocritical. Mr. 

Chairman, I believe we should judge a Nation by how it treats its 

children. CHIP covers 8.9 million kids. It stands on the shoulders 

of a strong Medicaid program that covers 37.1 million more children. Every single one of those kids deserve access to a doctor and 

access to good healthcare, yet every Republican on this committee 

voted for a bill in committee that capped health coverage for kids 

in every one of our communities. And as a result of that vote, 3 

million children would lose their health insurance, and that is simply not right. 

Today we will have a conversation about community health centers also, that providers that serve so many of our most vulnerable 

children, the Community Health Center Fund provides 70 percent 

of the funding for the health center program, which accounts for 20 

percent of revenue for community health centers. According to estimates, failure to reauthorize this funding will result in the closure 

of approximately 2,800 health centers, and 50,000 clinicians and 

other staff losing their jobs, and most importantly, 9 million patients losing access to care. 

So I strongly believe in a swift reauthorization of this funding for 

community health centers. At the same time, I will remind my Republican colleagues again that Medicaid is the largest single funding source for community health centers, providing more than 40 

percent of their revenue during fiscal year 2016. We can’t ignore 

the devastating consequences that Republican efforts to cut Medicaid by $834 billion over the next 10 years will have on community 

health centers and millions of Americans. And this includes four in 

10 children living in poverty nationwide who currently receive care 

at community health centers. 

So, Mr. Chairman, GOP efforts to repeal the ACA and jeopardize 

the Medicaid program will harm children significantly. So I urge 

my colleagues to first immediately reverse course and stop the dismantling of the Medicaid program. 

I yield the remainder of my time split between Ms. Castor and 

Mr. Luja ́n. I guess we will start with Ms. Castor. 

Ms. CASTOR. Thank you, Mr. Pallone. 

We are at a remarkable place here in America after decades of 

bipartisan work. The overwhelming number of American children 

have health coverage, 95 percent. That is something to celebrate. 

And I wanted to thank you all of the policymakers, the doctors, the 

nurses, folks back in our local communities that have worked to 

achieve a 95 percent coverage rate. This is smart policy. This 

makes America stronger. Kids are healthier, they do better in 

school, they miss fewer days of school, they are more likely to attend college, and they earn higher wages. But all of this progress 

is at risk because the GOP has produced bills—one here in the 

House, one that is even worse in the Senate that came out yesterday, that will rip coverage away from America’s kids. 

All of the progress we have made is at risk. Why? Just to give 

massive tax cuts to wealthy special interests? Those are not our 

10 

values. Our values are reflected in the fact that we work together 

in a bipartisan way to make sure kids can see a doctor and get the 

care that they need. But what the GOP bills do is the most radical 

detrimental restructuring of children’s healthcare ever proposed 

under the 50 years of Medicaid. And it must be rejected. And, in 

fact, it is wholly inconsistent for us to be talking about CHIP reauthorization, because Medicaid and CHIP are so closely interconnected. You cannot have a CHIP reauthorization without a 

strong Medicaid initiative. So let’s jettison those plans and work together to cover the remaining 5 percent of kids that don’t have 

healthcare coverage. 

And I am happy to the yield the balance to my colleague, Mr. 

Luja ́n. 

Mr. LUJA ́ N. Medicaid is the single largest health insurer for children. Because of Medicaid, the CHIP program, and ACA, 95 percent of all children now have health coverage at an all-time high. 

Sadly, Medicaid is in the crosshairs of our Republican colleagues. 

And you have heard the numbers: 37 million kids who depend on 

Medicaid nationwide, half a million in New Mexico alone; the 3 

million of the 23 million people who will lose coverage are children. 

It is simple. A strong CHIP program depends on a strong Medicaid 

program. You can’t reach out with one hand in the guise of reauthorizing CHIP while cutting $1 trillion from Medicaid with the 

other. You just can’t have it both ways. 

I yield back. 

Mr. BURGESS. The chair thanks the gentleman. Does the gentleman from New Jersey yield back? 

The gentleman from New Jersey yields back. 

The chair thanks the gentleman. Chair makes a technical observation that SCHIP is authored until the end of fiscal year 2019 as 

was accomplished in the Affordable Care Act. It was only funded 

through fiscal year 2015. This is the second funding bridge that 

has had to occur because of the fiscal cliff that was built into the 

ACA. 

We now stand in recess until immediately after the last vote. 

[Recess.] 

Mr. BURGESS. The chair would remind members pursuant to 

committee rules all Member’s opening statements will be made 

part of the record. And we do want to thank our witnesses for 

being here today taking time to testify before the subcommittee on 

this important issue. Each witness will have the opportunity to 

give an opening statement, followed then by questions from members. Again, as previously mentioned our witnesses, but today we 

will hear from Mr. Michael Holmes, Chief Executive Officer, Cook 

Area Health Services; Ms. Jamie Snyder, Associate Commissioner 

for Medicaid SCHIP Services, Health and Human Services Commission State of Texas; and Ms. Cindy Mann, partner in Manatt 

Health. We appreciate you being here today. 

Mr. Holmes, you are now recognized for 5 minutes for an opening 

statement, please. 

11 

STATEMENTS OF MICHAEL HOLMES, CHIEF EXECUTIVE OFFICER, COOK AREA HEALTH SERVICES; JAMI SNYDER, ASSOCIATE COMMISSIONER FOR MEDICAID/SCHIP SERVICES, 

STATE OF TEXAS, HEALTH AND HUMAN SERVICES COMMISSION; AND CINDY MANN, PARTNER, MANATT HEALTH 

STATEMENT OF MICHAEL HOLMES 

Mr. HOLMES. Thank you, Chairman Burgess, Ranking Member 

Green, members of the subcommittee. My name is Mike Holmes. I 

am the CEO of Cook Area Health Services, a Federally qualified 

community health center providing medical, dental, behavioral 

healthcare in nine locations to more than 12,000 patients in rural 

northern Minnesota. On behalf of the more than 1,400 community 

health center organizations nationwide, I wanted to thank the subcommittee for the longstanding bipartisan support you have consistently shown for community health centers. 

Since 1979, Cook Area Health Services has provided critical 

healthcare access to patients and communities who would otherwise go without. Our service area covers more than 8,300 square 

miles, and many of our patients travel 50 miles or more to access 

care. Each one of our sites is located in a town where the population is fewer than 600 people. 

As with many rural community health centers, we are the only 

game in town. Our health center story is just one part of a much 

larger national story. For more than 50 years America’s community 

health centers, also known as FQHCs, have served as the medical 

home for our Nation’s underserved communities and populations. 

Today, health centers represent the Nation’s largest primary care 

network, providing high quality care to more than 25 million patients. Our record of success would not be possible without the ongoing support of Congress. And I am here today to urge you to continue that support by extending your investments in the health 

center program, and specifically, the community health centers 

fund, which provides enormous value to patients, communities, the 

health system, and the taxpayer. 

Our success is reflected in the core requirements every health 

center must meet, each health center must be open to all. We must 

serve our medically underserved area of our population; we must 

offer comprehensive ranges of primary care services; and each 

health center is governed by a consumer majority board which 

works closely with health center leadership and clinicians to develop innovative responses to community needs. 

In 2010, Congress created a dedicated source of funding to sustain and grow the national investment in health centers, with an 

initial 5-year authorization, the CHC fund directed resources to 

both operational expansion and capital investment in health centers. As a result of this investment, new health center sites were 

added in more than 1,100 communities, health centers are serving 

approximately 6 million additional people, and they have expanded 

services like behavioral and dental care. 

At our health center this funding allowed us to add new access 

points in Tower, Minnesota, and helped us expand dental services 

in three other communities and to significantly expand our care coordination services. In 2015, Congress extended the Community 

12 

Health Center Fund for 2 additional years alongside CHIP and a 

number of other programs. With that extension nearing its expiration date, we strongly urge you to renew these investments and to 

do so for at least 5 years so that health centers like mine can continue to provide reliable access to our patients. 

Without action by the end of the fiscal year, health centers and 

our patients face major disruptions in care. HHS has estimated 

that should Congress not act by September 30th, it would lead to 

the closure of 2,800 health center sites, loss of over 50,000 jobs, 

and, more importantly, a loss of access to care for some 9 million 

patients. 

In conjunction with my testimony today, the Minnesota delegation has given me a letter, noting their support for health centers 

and the impact on Minnesota CHCs. In my written testimony, I 

have highlighted several other programs which fall under the subcommittee’s jurisdiction. Two key workforce programs are set to expire on the same timeline as the health centers’ fund. 

The National Health Service Corps, which provides scholarships 

and loan repayments to clinicians willing to work in underserved 

areas, is a key tool health centers use as we recruit and retain clinical staff. Fifty-four percent of National Health Service Corps clinicians practice in health centers today. Additionally, the Teaching 

Health Centers Graduate Medical Education program brings physician residency training right into community-based settings like 

FQHCs where providers are needed the most. 

And finally, I would like to note that the Medicaid program is extremely important to health centers and those we serve. And every 

State the program works hand in hand to turn the promise of coverage into the reality of care. Nearly half of all health center patients are covered by Medicaid. 

This is a time of rapid change in our health system. Health centers probably help with that change, even though as we remain 

committed to our basic founding principle, ensuring that every 

American in need has a place to go for high quality care. That purpose is made into reality every day for 25 million patients because 

of the support of Congress. And that support begins here in this 

subcommittee. I urge you to continue that support by extending 

these critical programs on a timely basis, and appreciate the opportunity to testify before you today and thank you for making health 

centers an ongoing priority. 

[The prepared statement of Mr. Holmes follows:] 

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Introduction 

Testimony of Michael Holmes 

Chief Executive Officer, Cook Area Health Services 

House Committee on Energy and Commerce, Subcommittee on Health 

Hearing on "Examining the Extension of Safety Net Health Programs" 

June 14, 2017 

Chairman Burgess, Ranking Member Green, and Members of the Subcommittee, 

My name is Mike Holmes. 1 am the CEO of Cook Area Health Services (CAHS), a Federally Qualified 

Community Health Center providing medical, dental and behavioral health care in nine locations to 

more than 12,000 patients in rural northern Minnesota. On behalf of our patients, board and staff, as 

well as the more than 1,400 community health center organizations nationwide, I want to thank the 

Subcommittee for the long-standing and bipartisan support you've consistently shown for community 

health centers. 

Since 1979, CAHS has provided critical health care access to patients and communities which would 

otherwise most certainly go without. Our service area covers more than 8,300 square miles, and many 

of our patients travel SO miles or more, often over secondary roads, to access care in our health center. 

Every one of our sites is located in a town with a population of less than 600. The large majority of our 

patients are either uninsured or publicly insured through Medicare and Medicaid. As with many rural 

community health centers, we are the only provider in most of the communities we serve. Our 

physicians are also the sole provider staff for two small critical access hospitals. We also participate in a 

federally-designated Health Center Controlled Network (HCCN) called Northern Minnesota Network, 

which drives operational efficiency and technology adoption across five member health center 

organizations. 

Our health center's story at CAHS is just one part of a much larger national story. For more than fifty 

years, America's community health centers, also known as FQHCs, have served as the primary care 

medical home for our nation's medically underserved communities and patients. Health centers are a 

cost-effective and local solution to the national challenge of providing access to primary and preventive 

care that is accessible, affordable, and ofthe highest quality. Thanks to support from bipartisan 

administrations and Congresses, the reach of health centers has grown significantly. Today FQHCs 

represent the nation's largest primary care network, serving more than 25 million patients in every state 

and territory, and are continually working to provide integrated, comprehensive care to our patients. 

Nationally, 92% of health center patients have incomes below 200% of the Federal Poverty level. Health 

centers serve nearly 8 million children. Half of health center locations are in rural communities like ours. 

Across the country, health centers employed nearly 190,000 individuals in 2015, bringing high-quality 

jobs to some of the most economically hard-hit communities in America. 

Our collective record of success would not be possible without the ongoing support of Congress. 1 am 

here today to urge you to continue that support by extending your investments in the Health Centers 

program and specifically the Community Health Centers Fund, which has proven to provide enormous 

value to patients, communities, the health care system and the taxpayer. 
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The Health Center Model of Care 

The successful community health center model is reflected in the core requirements every health center 

must meet, as defined by statute. Every health center must be open to all patients, regardless of 

insurance status or ability to pay. Health centers must operate in a medically underserved area or serve 

a medically underserved population. Health centers are governed by consumer-majority boards, who 

work closely with health center leadership and clinicians to develop innovative responses to community 

needs. And every health center must offer a comprehensive range of primary care services. In recent 

years, with support from this Subcommittee, health centers have not only added new locations, but 

have increasingly integrated behavioral health, oral health, vision care, pharmacy, substance use 

disorder treatment and other services into our comprehensive care delivery system. 

Health centers are on the front lines of nearly every major health crisis our country faces. In 2015, 

Health centers served more than 300,000 of our nation's veterans- often working with the VA to 

collaboratively address provider shortages, especially in rural communities. Health centers were a 

critical part of the response to public health threats like the Zika virus and the Flint water crisis. And as 

the opioid epidemic has grown in scope and severity, hundreds of health centers nationwide ramped up 

their capacity to provide comprehensive substance use disorder treatment in response. 

The Community Health Center Fund and Recent Investments 

In 2010, in recognition of the need for a robust primary care infrastructure to accompany changes in the 

coverage landscape, Congress created a dedicated source of funding to sustain and grow the national 

investment in Health Centers. With an initial five-year authorization, the Community Health Center 

Fund, or CHCF, directed resources toward both operational expansion and capital investment for Health 

Centers, while also boosting support for the National Health Service Corps, a critical tool for 

strengthening the clinical workforce in health centers. 

CHCF investments have been made in several areas: adding service delivery sites in new communities, 

expanding services and capacity, construction and renovation of health center facilities, technology 

adoption, and quality improvement activities. Each year, Congress has given direction to the Health 

Resources and Services Administration (HRSA), the agency which oversees the Health Centers program, 

as to how to prioritize new investments. 

As a result of these investments, new health center sites were added in more than 1,100 communities. 

Health centers are serving approximately 6 million additional people. But beyond this growth in reach, 

health centers are also providing more comprehensive care. Compared to 2010, in 2015 the number of 

behavioral health visits at health centers grew by 57% and the number of dental visits grew by 43%. At 

our health center, CHCF investments have allowed us to add a new access point in Tower, MN. They 

have also helped us expand dental services in three other communities and to significantly expand our 

care coordination services. 

In 2015, on an overwhelmingly bipartisan vote, Congress extended the Community Health Center Fund 

authorization for two additional years as one of the Health Extender provisions included in the Medicare 

Access and CHIP Reauthorization Act, or MACRA. With that extension nearing its expiration date, we 

strongly urge you to renew these investments, and to do so on a long-term basis, for at least five years, 
15 


28525.003

so that health centers like mine can truly provide a stable and reliable source of access to our patientsand recruit and retain a comprehensive health care workforce- in an ever-changing health care system. 

We are proud of the bipartisan support health centers have earned, and see it as a direct result ofthe 

high-quality care we provide to our patients and the value we provide to the health system and the 

taxpayer. Earlier this year, a letter signed by 290 Members of the House of Representatives, and led by 

two members of this Committee, Representatives Bilirakis and Green, stressed the importance of Health 

Centers and the need to keep funding for the program whole. In his FY18 budget, President Trump 

called for an extension of CHCF Funding, and Health and Human Services (HHS) Secretary Price has 

repeatedly described investing in community health centers as a top priority of the department. 

Swift action by Congress to extend these investment will not only help secure and stabilize health 

centers, it will prevent the major loss of access and disruption to the health system that would quickly 

result from a failure to act. Indeed, HHS itself has estimated that should Congress not extend the CHCF 

by September 30'", it would lead to the closure of 2,800 health center sites, loss of over 50,000 jobs, and 

most importantly, a loss of access to care for some nine million patients nationwide. 

At Cook Area Health Services, the potential impact of losing CHCF funding would be immediate and 

severe. The loss of over $2,000,000 in annual funding would leave us no choice but to close a minimum 

of two to three access points. As a result there will be no care in these communities. For many of our 

patients, medical or dental care will be 40 to 50 miles away and as with most rural communities, there is 

no public transportation. We would also have to eliminate services and reduce staff. There are no good 

options in dealing with this type of funding reduction. System-wide, this level of disruption would 

inevitably drive up costs across the health care system, as more and more patients would turn to costlier 

settings like hospital emergency rooms for routine primary and preventive care, or simply forgo that 

care. 

Importance of Coverage and Workforce Development 

While I deeply appreciate the Subcommittee's focus today on the Community Health Center Fund and 

on the Children's Health Insurance Program, I do want to very briefly highlight several other programs 

which fall under the subcommittee's jurisdiction, each of which plays a critical part in ensuring health 

centers remain able to serve underserved communities. 

In every state, Medicaid and health centers work hand-in-hand to turn the promise of coverage into the 

reality of care for low-income and vulnerable patients. Nearly half of health center patients nationally 

are covered by Medicaid, and Medicaid reimbursement represents the largest source of operating 

revenue for health centers nationwide. As I've mentioned, by statute and mission, health centers serve 

all, regardless of whether a patient who comes to us has health insurance coverage. But any health 

center can tell you the difference coverage makes especially in terms of accessing needed specialty 

care beyond our walls. We are also proud that health centers deliver value back to the larger Medicaid 

program. A recent landmark study across 13 states found that when compared to patients served in 

other settings, health center Medicaid patients had 24% lower total costs of care. In 2015, health 

centers served 16% of all Medicaid patients, while accounting for just 1.7% of total Medicaid spending. 

For nearly all health centers, especially those like CAHS in very rural areas, recruiting and retaining a 

committed and dynamic workforce is the most pressing challenge. Two key programs are an enormous 
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asset to us in addressing this challenge. The National Health Service Corps (NHSC), which provides 

scholarships and loan repayment to clinicians willing to serve in underserved areas, is a key tool health 

centers leverage as we recruit and retain clinical staff. 54% of NHSC clinicians practice in health centers 

today. Another important workforce program for Health Centers is the Teaching Health Centers 

Graduate Medical Education (THCGME) program, which brings physician residency training right into the 

community-based settings, like FQHCs, and into the underserved areas where providers are needed 

most. Data show that physicians trained in THCGME sites are much more likely to remain in those 

communities than physicians trained elsewhere. 

Conclusion 

This is a time of rapid change in our health care system. Even as health centers proudly help drive that 

change through delivery system innovation and a push toward value-based care, we remain committed 

to our basic founding purpose: ensuring that every American in need has a place to go for high-quality 

care. That purpose, that mission, is made into a reality every day for 25 million patients because of the 

support of Congress, and that support begins here in this Subcommittee. I appreciate the opportunity to 

testify before you today, and we thank you for making health centers an ongoing priority. 
17 

Mr. BURGESS. Thank you, Mr. Holmes. The committee thanks 

you for your testimony. 

Ms. Snyder, you are recognized for 5 minutes for an opening 

statement, please. 

STATEMENT OF JAMI SNYDER 

Ms. SNYDER. Good morning, Chairman Burgess, Ranking Member Green, and distinguished members of the Subcommittee on 

Health. Thank you for the opportunity to provide testimony on the 

Children’s Health Insurance Program. My name is Jami Snyder, I 

serve as the Director of the Medicaid and CHIP programs for the 

State of Texas. 

This morning, I would like to provide insight into how CHIP has 

worked for the State of Texas in response to the subcommittee’s inquiries concerning the reauthorization legislation. The Texas 

Health and Human Services Commission implemented the state’s 

CHIP program in 1998. The program currently serves approximately 380,000 children. Since implementation, the state has seen 

a notable reduction in the overall rate of uninsured children below 

200 percent of the Federal poverty level, from 18 percent in 1998 

to 6 percent in 2015. 

CHIP statute allows states the flexibility to operate CHIP as a 

Medicaid expansion program, as a separate state program, or as a 

combination of the two. Texas has historically operated CHIP as a 

separate program, which has afforded Texas the freedom to design 

a system that aligns with the state’s philosophy of ensuring accountability in the management of public funds, and increasing 

personal responsibility for program participants. 

Unlike the Medicaid program, which offers an extensive and prescriptive medical benefit for children, CHIP regulations offer states 

flexibility to tailor the CHIP benefit package to meet the unique 

needs of the populations served. This allows CHIP to function as 

a nimble program that is more easily able to respond to changes 

in the states’ fiscal outlook, emerging Federal legislation, as well 

as the evolving needs of beneficiaries. 

Since the onset of the program, Texas has delivered CHIP services through a managed care model. The state currently contracts 

with 17 managed care organizations, delivering services to CHIP 

members Statewide. The managed care delivery system offers additional advantages as MCOs are incentivized through a risk-based, 

capitated payment system to contain costs while implementing innovative service delivery and provider payment mechanisms to improve health outcomes for their members. 

Medicaid regulations make it difficult for states to implement 

cost-effective, or effective cost-sharing mechanisms for the full 

range of Medicaid beneficiaries. In contrast, CHIP offers states 

greater flexibility to design programs in which families retain a 

measure of responsibility for the cost of their child’s care. 

Most families in CHIP pay an annual enrollment fee, and all 

families in CHIP make copayments for office visits, prescription 

medications, inpatient hospital care, and nonemergent care provided in an emergency room setting. 

CHIP is a critical part of the health care safety net in Texas, offering a healthcare benefit to children who do not qualify for the 

18 

Medicaid program. Texas’ overall experience is that CHIP simply 

works. It provides reliable medical and dental benefits to the covered population at a rate of $156 per member, per month, which 

is $67 less on a per-member basis than the cost for coverage for the 

state’s Medicaid population. 

The state’s quality data also offers evidence of the efficacy of the 

program, indicating a 21 percent increase in children age 3 to 6, 

accessing well child visits, and a 90 percent increase in children receives recommended vaccines in the first 2 years of life for measurement years 2011 through 2015. 

A decision to not reauthorize the CHIP program would result in 

a loss of over $1 billion in funding annually to the State of Texas, 

and a corresponding loss of healthcare coverage for more than 

380,000 children. If funding for the program is not extended beyond 

September 2017, it is estimated the state will exhaust remaining 

resources by February 2018. As such, Texas would be faced with 

the prospect of dismantling the CHIP program. And as mandated 

by the ACA, the state would also be expected to continue adherence 

to maintenance of effort requirements at a lower Medicaid Federal 

matching rate for over 250,000 children now served under the 

state’s Medicaid program. 

Through its routine budgetary planning process, Texas has assumed continued funding for the CHIP program for fiscal years 

2018 and 2019 at the enhanced Federal matching rate. Should 

Congress elect not to move forward in reauthorizing CHIP, the 

State of Texas will no longer be able to administer this critical program, which has a proven track record of success, stemming from 

its adherence to the fundamental principles of state administrative 

flexibility, personal responsibility, and innovation aimed at enhancing outcomes for beneficiaries. 

[The prepared statement of Ms. Snyder follows:] 

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28525.005

TEXAS 

Health and Human 

Services 

Testimony Before the 

Committee on Energy and Commerce, Health Subcommittee, House of Representatives 

Hearing on "Examining the Extension of Safety Net Health Programs" 

Written Testimony by Jami Snyder, Associate Commissioner for Medicaid and CHIP Services, 

Texas Health and Human Services Commission 

June 14, 2017 

Good morning Chairman Burgess and members of the subcommittee on health. Thank you for the 

opportunity to provide testimony on the Children's Health Insurance Program (CHIP). My name is Jami 

Snyder. I serve as the director of the Medicaid and CHIP programs for the state ofTexas. This morning, 

I would like to provide the subcommittee insight into how CHIP has worked for the state of Texas, 

including its successes and challenges under current law, in response to the subcommittee's inquiries 

concerning the reauthorization legislation. 

Under the direction of the state legislature and executive leadership, the Texas Health and Human 

Services Commission implemented the state's CHIP program in 1998. The program currently serves 

approximately 380,000 children.' Since CHIP implementation, the state has seen a notable reduction in 

the overall rate of uninsured children below 200 percent of the federal poverty level, from 

approximately 18 percent in 1998 to approximately six percent in 2015.2 This reduction is attributable, 

at least in part, to the availability of CHIP as a coverage option for children under the age of 19. 

1 Texas Health and Human Services Commission, System Forecasting. June 2017. 2 CHIP Annual Report to the Centers for Medicare and Medicaid Services, Federal Fiscal Year 2016. 

1 
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The CHIP statute allows states the flexibility to operate CHIP as a Medicaid expansion program, as a 

separate state program, or as a combination of the two. Texas has historically operated CHIP as a 

separate program. Implementing and operating CHIP as a standalone program has afforded Texas 

freedom to design a system that aligns with the state's philosophy of ensuring accountability and 

stewardship in the management of public funds and increasing personal responsibility for program 

participants. 

Unlike the Medicaid program, which offers an extensive, yet prescriptive medical benefit for children, 

federal CHIP regulations afford states flexibility to tailor their CHIP benefit package to meet the unique 

needs of the population served. This flexibility in benefit package design also allows CHIP to function as 

a nimble program that is more easily able to respond to changes in the state's fiscal outlook, new 

federal legislation, as well as the evolving needs of beneficiaries. 

The CHIP benefit package in Texas aligns more closely with comparable benefit packages available 

through the commercial insurance market. Tailoring CHIP in this way has facilitated the establishment of 

a predictable program budget and the provision of CHIP services to more children, consistent with 

federal funding levels. This approach has also allowed Texas to remain within its federal funding 

allotment, in turn, preventing the need to establish a waitlist for CHIP applicants. The state's benefit 

package is cost-effective, including a basic set of health care benefits that focus on primary health care 

needs. 

In addition to basic medical benefits, other benefits offered in Texas' CHIP program include inpatient 

and outpatient behavioral health services, vision exams and corrective lenses, hearing exams and 

hearing aids, physical, occupational, and speech therapy, and durable medical equipment. All CHIP 

members may also receive up to $564 in dental benefits per enrollment period. 

2 
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28525.007

CHIP allows states to place reasonable limitations on the scope of services members may receive. For 

example, Texas imposes a $20,000 annual limit on durable medical equipment. By way of comparison, 

hard service caps are not allowable for children in the Medicaid program under federal Early and 

Periodic Screening, Diagnostic and Treatment requirements. Such limitations allow the state to more 

effectively operate the program within its federal allotment. 

Since implementation, Texas has delivered CHIP services through a managed care model, rather than a 

fee-for-service delivery system which is common to many states' Medicaid programs. Texas currently 

contracts with 17 managed care organizations (MCOs), delivering services to CHIP members statewide. 

Operating CHIP through this model facilitates administrative efficiency by alleviating the need to 

concurrently maintain and administer an operationally complex, resource intensive fee-for-service 

system. The managed care delivery system offers additional advantages, as MCOs are incentivized 

through a risk-based, capitated payment system to contain costs while implementing innovative service 

delivery and provider payment mechanisms to improve health outcomes for their members. MCOs are 

also able to offer health-related value-added services not covered under CHIP, such as sports physicals 

and car seats, at no cost to state and federal taxpayers. These services are similar to those available in 

commercial insurance plans. 

Federal Medicaid regulations make it difficult for states to implement effective cost-sharing mechanisms 

for the full range of Medicaid beneficiaries. In contrast, CHIP offers states greater flexibility to design 

programs in which families retain a measure of responsibility for the cost of their child's care. Most 

families in CHIP pay an annual enrollment fee to cover all children in the family. All CHIP families make 

co-payments for office visits, prescription medications, inpatient hospital care, and non-emergent care 

provided in an emergency room setting. CHIP annual enrollment fees and co-payments vary based on 

family income. The total amount a family is required to contribute out of pocket toward the cost of 

health care services is capped at five percent of family income. 

3 
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CHIP is a critical part of the health care safety net in Texas, offering a benefit package to children who do 

not qualify for the Medicaid program. Texas' overall experience is that CHIP simply works. It provides 

reliable medical and dental benefits to the covered population at a rate of $156 per member per month, 

which is $67 less on a per member basis than the cost of coverage for the state's Medicaid population. 

While the CHIP and Medicaid regulatory structures differ, in Texas, the MCOs responsible for delivering 

Medicaid managed care services for low-income Medicaid beneficiaries also administer the CHIP 

product. As such, the Texas CHIP program benefits from economies of scale, allowing the state to 

leverage innovations across both programs. This includes enhancing health outcomes through the 

state's Pay for Quality initiative and maintaining a robust network of providers, consistent with network 

adequacy standards established for MCOs serving both the CHIP and Medicaid populations. The state's 

quality data offers evidence of the efficacy of the program as currently structured, indicating a 21 

percent increase in children, age three to six, accessing well child visits, and a 90 percent increase in 

children receiving recommended vaccines in the first two years of life for measurement years 2011 -

2015. 

A decision to not reauthorize the CHIP program would result in a loss of over $1 billion in funding 

annually to the state of Texas and a corresponding loss of health care coverage for more than 380,000 

Texas children. If funding for the program is not extended beyond September 2017, it is estimated the 

state will exhaust remaining resources by February 2018. As such, the state would be faced with the 

prospect of dismantling the CHIP program, an endeavor that would require a minimum of seven months, 

given considerations such as the need to ensure proper member notice, the implementation of an 

enrollment freeze in advance of program termination, regulatory changes, state plan amendment 

approval, the execution of contract amendments as well as necessary system changes. As mandated by 

the Patient Protection and Affordable Care Act, the state would also be expected to continue adherence 

to maintenance of effort requirements at the lower Medicaid federal matching rate for over 253,000 

4 
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children now served under the state's Medicaid program. Through its routine budgetary planning 

process, Texas has assumed continued funding for the CHIP program for fiscal years 2018 and 2019 at 

the enhanced federal matching rate. Should Congress elect not to move forward in reauthorizing CHIP, 

the state of Texas will no longer be able to administer this critical program, which has a proven track 

record of success, stemming from its adherence to the fundamental principles of state administrative 

flexibility, personal responsibility and innovation aimed at enhancing outcomes for beneficiaries. 

5 
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Mr. BURGESS. The chair thanks the gentlelady for her testimony. 

Ms. Mann, you are recognized for 5 minutes please for an opening 

statement. 

STATEMENT OF CINDY MANN 

Ms. MANN. Good morning, Chairman Burgess and Ranking Member Green, and distinguished members of the subcommittee. I am 

pleased to be here this morning. I am Cindy Mann, a partner at 

Manatt Health, and I work on matters primarily focused on public 

coverage, and particularly the Medicaid and the Children’s Health 

Insurance Program. And as noted, prior to joining Manatt, I served 

as the Director of the Center for Medicaid and CHIP services at 

CMS responsible for Federal policy, Federal oversight of Medicaid 

and CHIP and supporting statement implementation of these programs. I am going to focus today on my testimony on the role of 

CHIP in providing affordable coverage to children, the issues facing 

Congress on the expiration of the funding. But I also do want to 

note the strong support of the comments by Mr. Holmes in terms 

of the incredibly important value and critical function of federally 

qualified health centers. 

With 20 years of experience with the CHIP program—it is hard 

to believe it is 20 years behind us—we know what has made this 

program successful, and we know what has put it in jeopardy. 

CHIP works when it has robust and stable funding, and when it 

has a strong Medicaid program with which to partner in covering 

children. 

Let’s look first at the CHIP’s history on financing. When the program was first started, the funding was ample for states that were 

just ramping up their program, but very quickly by 2002, some 

states began to see shortfalls in their funding, and we saw a mismatch between the allotments and states’ needs in terms of coverage of children. And that was not unexpected. In some respects, 

Congress didn’t know how many states would pick up the CHIP 

program, what the participation rates would be, but it gives us an 

example of what happens when you have a mismatch in funding. 

Georgia, for example, reluctantly froze enrollment from March to 

July of 2007, and only lifted a freeze after Congress passed a supplemental budget. Florida froze enrollment, it froze it for just 5 

months, and during those 5 months, 44,000 children, CHIP children, were placed on a waiting list. When CHIP was reauthorized 

in 2009, there was strong support from the Congress to avoid those 

kinds of shortfalls and enrollment freezes. CHIP has provided 

ample funding and revamped the system for distributing dollars. It 

built in new adjusters; it built in contingency funding; and a new 

system for redistributing funds across states. 

That funding formula has been maintained through the subsequent extensions. Going forward, adequate financing for CHIP 

must be assured. Beyond extending the basic program funding, 

Congress also needs to consider the issues that have been raised 

so far, the 23 percentage point increase in the match rate, and the 

maintenance of effort provision, both of which were in the Affordable Care Act. 

As my colleague from Texas noted, the enhanced funding for the 

CHIP program is very much integrated into state budgets and 

25 

helping a number of states to adopt a plan for program improvements. But we must also recognize that that enhanced funding 

goes hand in hand with the maintenance of effort provision. Without the maintenance of effort provision, millions of children will be 

at risk of losing coverage, or paying much higher costs for that coverage. 

CHIP made affordable coverage available to millions of children, 

but given the marketplace changes, the uncertainties of the futures 

of subsidies and cost-sharing reductions, indeed, even the uncertainties in the Medicaid program. It is essential to protect not just 

the funding for the program, but children’s eligibility for coverage. 

And I would suggest that it is unlikely we would continue the MOE 

requirement without also supporting state’s ability to fund that requirement and that need for stable coverage for children. 

Next, let me just circle back to my point about CHIP working, 

in large part, because of the foundation of Medicaid. Medicaid, of 

course, is the much larger program covering about 37 million children, the two programs depend on each other, kids go back and 

forth between the two programs all the time as family circumstances change. But even more fundamentally is that Medicaid 

supports CHIP by covering so many of the children with the greatest healthcare needs: lowest income children, children in poor 

health, kids in foster care, kids with disabilities. 

CHIP wasn’t designed to do that heavy lifting. It doesn’t have 

the financing structure, it doesn’t have the benefit structure to do 

that. CHIP is an incredibly critical part of that coverage continuum 

for children, but it can’t do the job alone. 

Finally, I would say that Congress has much to be proud of, 

given its long-standing support of children’s coverage. Together, 

Medicaid and CHIP have brought the uninsurance rate for children 

below 5 percent. It was over 15 percent in 1997 when CHIP was 

first enacted. It is a historic low, and it is a great achievement, but 

with sweeping changes to Medicaid now under consideration, and 

CHIP reauthorization outstanding, much is at stake for our Nation’s children. 

Thank you for your time and support. 

[The prepared statement of Ms. Mann follows:] 

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Testimony Submitted to the 

Subcommittee on Health 

Committee on Energy and Commerce 

By Cindy Mann, JD1 

Partner 

Manatt, Phelps & Phillips 

June 14, 2017 

1 Application for.admission to the District of Columbia Bar pending. Practicing under the supervision of Jill DeGraff, 

a member of the District of Columbia Bar. Admitted to practice in New York and Massachusetts. 

1050 Connecticut Avenue, N.W., Suite 600, Washingto14 District of Columbia 20036 Telephone: 202.585.6500 Fax: 202.585.6600 

Albany I Chicago I Los Angeles 1 New York i Orange County I Palo Alto I Sacramento I San Francisco 1 Washington, D.C. 
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Good morning Chairman Walden, Congressman Barton, Congressman Pallone, Subcommittee 

Chairman Burgess, Congressman Guthrie, Congressman Green, and distinguished members of 

the Subcommittee. Thank you for the invitation to participate in this hearing on examining the 

extension of safety net health programs. 

I am Cindy Mann, a partner at Manatt, Phelps & Phillips. At Manatt, I work with clients, 

including states, health care providers and provider organizations, foundations, and consumer 

organizations, on matters relating to health care coverage, delivery system reform, and 

financing, focusing primarily on publicly financed coverage and particularly, Medicaid and the 

Children's Health Insurance Program (CHIP). I also currently serve as an advisor to the 

Bipartisan Policy Center on the future of health care. Prior to joining Manatt, from June 2009 

through January 2015, I served as Deputy Administrator for the Centers for Medicare & 

Medicaid Services (CMS) and as Director of the Center for Medicaid and CHIP Services. In that 

capacity, I was responsible for federal policy and oversight of Medicaid and CHIP and for 

supporting state implementation of those programs. Previously, I was a research professor at 

Georgetown University's Health Policy Institute and founded the Center for Children and 

Families, a research and policy organization focused on children's coverage. I also served as the 

Director of the Family and Children's Health Programs Group at the Health Care Financing 

Administration (now CMS), where I directed federal implementation of CHIP and Medicaid with 

respect to children, families and pregnant women from 1999 to 2001, the early years of CHIP 

implementation. I have over 30 years of experience in these matters both at the federal level 

and in states. 

My testimony today will focus on the role of CHIP in providing affordable, comprehensive 

health coverage to low-income children and the key issues facing Congress given the expiration 

of federal funding for CHIP on September 30, 2017. I will highlight CHIP's success and bipartisan 

support, as well as its role in the children's coverage continuum, recognizing that CHIP's future 

and its ability to continue to perform well for children across the nation is closely tied to the 

future of Medicaid, which today covers more than 37 million low-income children nationwide. 2 

The foundation of Medicaid makes it possible for CHIP to do its part. 

Examining CHIP's 20-Year Success as a Safety Net Program 

CHIP covers 8.9 million children nationwide, including children covered through the Medicaid 

program for whom states claim CHIP enhanced funding, as well as children enrolled in separate 

CHIP programs. As you know, states have a choice to use their CHIP funding to either expand 

Medicaid to children, serve children through a separate program or employ a combination of 

these two strategies. Of those enrolled under any of these options, 97% have household 

income at or below 250% of the federal poverty level (FPL). 3 Together-Medicaid and CHIPhave been primarily responsible for a historic decline in the children's uninsurance rate. 

2 https://www.medicaid.govlchipldownloadslfY-20 16-childrens-enrollment-report.pdf 3 https:llwww.macpac.gov/wp-content/uploads/2017/03ffhe-Future-of-CHIP-and-Childrens-Coverage.pdf 

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Between 1997 and 2012, the uninsurance rate for children was cut in half4 and has continued 

to decline, reaching 4.8% in Fiscal Year (FY) 2015, an all-time low. 5 

CHIP's success is the result of a number of factors: 

• First, from the program's inception in 1997, there has been a strong, bipartisan 

commitment to children's coverage at the federal, state and community levels. While it 

was not initially clear how states would react to the new federal funding opportunity 

provided by CHIP, by 2000, this commitment to children's coverage-boosted by CHIP's 

enhanced federal funding-had translated to all 50 states and the District of Columbia 

implementing CHIP. The focus on children's coverage also prompted states and 

communities to promote enrollment of eligible children by simplifying the application 

process for both Medicaid and CHIP and undertaking targeted outreach efforts; as a 

result, participation rates-that is, the proportion of eligible children actually enrolled 

and covered by Medicaid and CHIP-have increased steadily over the years. 

• Second, Congress' longstanding commitment to ensure an adequate federal financing 

stream for CHIP has been critical to the program's success. Established as a block grant 

administered through capped state allotments, federal CHIP funding proved too little to 

meet many states' needs during the program's first decade, resulting in states freezing 

enrollment and encountering other significant operational and budgetary challenges. 

However, beginning with the Children's Health Insurance Program Reauthorization Act 

(CHIPRA) in 2009 and continuing through CHIP's most recent reauthorization in 2015, 

Congress' commitment to the future of CHIP has been demonstrated by the 

authorization of sufficient financing and incorporation of financing features that have 

supported coverage in the years since. CHIP's past experience-first with shortfalls and 

enrollment freezes and then with adequate and timely funding-demonstrates why it is 

so important for Congress to act now to fully finance the program. 

• Finally, CHIP's success also is based on its close connection to Medicaid; the majority of 

the 8.9 million children whose coverage is financed through CHIP are enrolled in 

Medicaid and others move between Medicaid and CHIP as family income or children's 

health needs change. In many ways, CHIP works well because of the foundation of 

coverage provided by and financed through the Medicaid program, which covers the 

nation's lowest-income children and plays a unique role for children with complex 

medical needs. 

4 https:llkaiserfam ilyfoundation.fi les. wordpress.com/20 14107/8615·the-impact-of-the-children s-health-insuranceprogram-chip-what-does-the-research-tell-us.pdf - 5 Georgetown Center for Children and Families analysis of the American 

Community Survey, https://ccf.georgetown.edu/wp-contentluploads/20 !61!1/Kids-ACS-update-11-02-l.pdf 

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Key Issues for CHIP 

Ensuring Adequacy of Federal Funding for CHIP 

Ample funding has propelled CHIP's success and ensured stability in coverage for children in 

recent years and is a critical factor to safeguard the program's continued ability to serve the 

nation's low- and moderate-income children. History shows a direct correlation between 

adequate financing and states' abilities to operate without shortfalls and to cover eligible 

children. From FY 1998-2001, as states ramped up their CHIP initiatives, the federal CHIP 

allotment was sufficient to meet federal CHIP expenditures, but between FY 2002-2008, those 

allotments proved inadequate. As a result, many states stopped enrolling eligible children by 

adopting enrollment caps or freezes. 6 For example, facing a $124 million shortfall, Georgia froze 

its CHIP program from March 11-July 1, 2007. 7 The impact on children was swift: when Florida 

instituted a freeze on July 1, 2003, more than 44,000 CHIP-eligible children were placed on a 

waiting list by mid-November 2003. 8 Research by the Kaiser Family Foundation shows that 

while most states' freezes lasted less than year, their impacts endured even after the freeze 

was lifted. 9 Moreover, shortfalls contributed to significant uncertainty for states, families, and 

health care providers, and on multiple occasions, prompted Congress to adopt short term, stopgap measures to shore up funding to states facing shortfalls. 10 

These early experiences contributed to a strong resolve across party lines to ensure the 

adequacy of future CHIP allotments during subsequent CHIP reauthorizations. Under CHIPRA, 

Congress not only significantly increased federal CHIP allotments for an additional five years (FY 

2009-13) but also revamped CHIP's financing structure to provide new cushioning under CHIP's 

capped funding model. Beginning in FY 2009, the federal CHIP allotment more than doubled 

from the average federal CHIP allotment during the program's first decade ($10.6 billion in FY 

2009 compared to an average of $4.0 billion per year from FY 1998-2008).11 By FY 2013, the 

annual federal CHIP allotment was $17.4 billion. Beyond authorizing federal CHIP allotments 

that the Congressional Budget Office (CBO) correctly projected would exceed federal CHIP 

outlays, 12 Congress included a number of additional measures to make the capped funding 

model more responsive and sustainable. CHIPRA revamped the state allotment formula 

(including allowing adjustments for population, health care inflation and changes in eligibility 

6 http :/lccf.georgetown.edulwp-content/uploads/20 12103/Federal%20medicaid%20pol icy_ CJIIP-not-a-model-forblock-grant.pdf 

7 http://dch. georgia.govlsitesl dch.georgia.gov/files/i mported/vgn/images/portall cit_l21 0/3 7 /II /86098649PRPeachCare _Enrollment_ Freeze_ Lift. pdf 8 http:// ccf.georgetown.edu/wp-content/uploads/20 12/03/F ederal%20medicaid%20policy _CHIP-not -a-model-forblock-grant.pdf 

9 https:llkaiserfami lyfoundation. fi lcs. wordpress.com/2002112/408 1-north-carolina-health-choice. pdf 10 http :1/ccf.georgetown .edu/wp-content/up loads/20 12103/F ederal%20medicaid%20policy _CHIP-not -a-model-forblock-grant.pdf 

11 This docs not account for the shortfall funding or CHIP bonus fund; https://www.gpo.gov/fdsys/pkg/GPOMACPAC-MACBasics-CHIP-20 11-09/pdf/GPO-MACP AC-MACBasics-CHIP-20 11-09.pdf 12 https://www.cbo.gov I sites/defau lt/fi les/recurringdata/51296-2009-03-chip. pdf 

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and benefits), developed a contingency fund, and established a new redistribution plan for 

allocating unspent allotments to states facing shortfalls. Congress reaffirmed its commitment to 

robust federal funding for CHIP in the Affordable Care Act {ACA) and when it passed the 

Medicare Access & CHIP Reauthorization Act {MACRA) of 2015. In reflecting upon CHIP's 

success, it is clear that adequate funding-evidenced by appropriations that have exceeded 

expenditures for nearly the past decade-has enabled CHIP to provide coverage for a growing 

number of children and to maintain program stability. 

The Future of the Enhanced FMAP and the Maintenance of Effort Provision 

Beyond the overall level of funding, Congress also must consider whether and how it will 

address the 23 percentage point increase in the federal CHIP match rate and the maintenance 

of effort {MOE) provision adopted in the ACA. From CHIP's inception, states have received an 

enhanced federal medical assistance percentage {eFMAP) for CHIP {historically a 30% reduction 

in the state share under the regular FMAP rate), and since October 1, 2015, they have received 

an additional 23 percentage point increase to the match rate, boosting the federal share of 

CHIP funding to between 88 and 100%. 

This enhanced federal funding has helped make it possible for states to maintain coverage for 

children {as required by the MOE provision), and in some instances, adopt discrete program 

improvements. A recent survey conducted by the National Academy for State Health Policy 

(NASHP) indicated that nine states used or planned to use the federal funding increase to 

enhance their CHIP benefits, invest in outreach and marketing to improve coverage rates, 

pursue health services initiatives or expand coverage to new populations. 13 

These enhanced federal funds are now fully integrated into states' budgets and a key source of 

funding for sustaining CHIP. Both the Medicaid and CHIP Payment and Access Commission 

(MACPAC) 14 and the National Governors Association {NGA) 15 recommend extending the 

enhanced CHIP match for five years through FY 2022. 

In addition, the boost in the matching rate goes hand in hand with the requirement that states 

maintain children's coverage levels, a provision that extends, under current law, through FY 

2019. Stability of the current CHIP and Medicaid eligibility levels is particularly critical given the 

uncertain future of the individual and small group markets and Marketplace subsidies-which 

many of the CHIP children would seek to use if CHIP coverage was curtailed. Even if these 

children were able to secure coverage in the individual market, relative to CHIP, they would 

face reduced benefits and their families would experience higher costs. Thus, it is important for 

Congress to retain and extend both the MOE and the enhanced financing provisions. Putting 

CHIP coverage at-risk in these uncertain times is both unnecessary and ill-advised. MAC PAC 

13 http://www.nashp.org/wp-contcnt/uploads/20 17/02/20 17-CHIP-Survey-Results.pdf 14 https ://www. macpac.gov/wp-content/uploads/20 1710 I /Recommendations-for-the-Future-of-CHIP-and-Chi ldrensCoverage.pdf 

15 https:l/www.nga.org/cmslnga-letters/chip-reauthorization 

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proposes extending both the current match rate and the MOE for five years. At the very least, 

withdrawing the enhanced match ahead of the slated FY 2019 expiration date (and the 

expiration of the MOE provision) would be particularly problematic for states and disruptive to 

children's coverage. 

Maintaining Medicaid as a Strong Foundation of Coverage for Low-Income Children 

CHIP was established in 1997 to provide coverage for children in families with too much income 

to qualify for Medicaid but too little income to afford private insurance. At that time, 10 million 

children nationwide-nearly 15% of all children16-did not have health insurance. 17 The 

program emerged as way of enabling states to expand children's coverage beyond the Medicaid 

eligibility levels in effect at the time, while permitting considerable operational flexibility. As 

noted, states have flexibility in designing their program as either a Medicaid-expansion, 

separate CHIP or combination approach, and they also have flexibility in benefit design, though 

they must meet certain minimum standards. In partnership with Medicaid, CHIP has been able 

to have an outsized impact given its relative program size. Without the steady presence of 

Medicaid to cover the country's poorest, most vulnerable children, CHIP's impact would have 

been significantly more limited. 

The record-low levels of uninsurance among children achieved in recent years is due to both 

CHIP and Medicaid. This is true not only because Medicaid is a far larger program, but also 

because the combined presence of Medicaid and CHIP offer families continuity of coverage as 

family incomes and circumstances fluctuate. The Congressionally-mandated CHIPRA evaluation 

found that one in four children enrolled in a separate CHIP program and half of all children 

enrolled in a CHIP-funded Medicaid expansion were covered at some point in the year in 

"regular" Medicaid. Over a three-year period, children moved between the two programs at 

even higher rates. 18 Without a stable Medicaid program to turn to, millions of CHIP children 

could lose coverage over a relatively short period of time. 

CHIP's success is also due in part to the availability of more robust coverage through Medicaid. 

CHIP's benefit design, while pediatric-focused, is not as broad as Medicaid's, although some 

states have applied the Medicaid benefit standard in their separate CHIP programs. According 

to MACPAC, Medicaid finances 40 times as much care as CHIP overall, due both to the relative 

sizes of the programs and to Medicaid's role in the lives of children with significant health care 

needs. 19 Partly as a result of the lower incomes of the children served and partly as a result of 

eligibility design, 20 Medicaid is responsible for a greater share of children in poor health and 

16 http://www. urban.org/research/publication/uninsurance-among-children-1997 -20 15 -long-term-trends-and-recentpatterns 

17 https://www.macpac.gov/subtopiclhistory-and-impact-of-chip/ 18 https://aspe.hhs.gov/system/files/pdf/77046/rpt_ CHIPevaluation.pdf 19 Manatt analysis ofMACPAC spending data (FY 2015); Medicaid: $556 B; CHIP: $13.7 B 20 Medicaid covers I 00% of children in foster care nationwide, as well as children with higher income levels through 

states' disability pathway and medically-needy options. 

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those with the most complex medical needs such as cancer, cerebral palsy, and autism, among 

other special health care needs. 21•

22 The Kaiser Family Foundation estimates that for more than 

4 million children with special health care needs nationwide, public insurance, including 

Medicaid and CHIP, represent their sole source of health coverage. 23 Notably, more than one 

fifth (22%) of these children live in families with income below the FPL, while another 22% are 

in families with household income between 100-199% FPL. 24 Without Medicaid as the bedrock 

of public coverage for poor children and those with complex health care needs, either CHIP 

would face greater costs as states tried to fill the gap left behind by Medicaid or many children 

would face impediments accessing needed care. For CHIP's success to be assured in the future, 

Medicaid's future also must be secure. 

likewise, CHIP also has bolstered Medicaid's success, Most notably, CHIP offers coverage to 

children whose family income brings them over their state's Medicaid eligibility level and for 

whom affordable employer-based coverage is unavailable. But, the impact goes beyond 

coverage. The advent of CHIP prompted many states to examine their enrollment processes, 

not only for CHIP but also for Medicaid, leading to significant simplifications that helped boost 

participation in both programs. In addition, as states adopted CHIP outreach efforts, many 

families learned that their children were Medicaid-eligible, helping to drive down the overall 

uninsurance rate among low-income children (i.e., the "welcome mat" effect). CHIPRA also 

provided states with a new option to streamline the eligibility and renewal processes for both 

Medicaid- and CHIP-eligible children using Express lane Eligibility (HE), 25 A recent study 

conducted by the Office of the Inspector General found that all 14 states that initially adopted 

ELE reported benefits, including reduced costs and administrative burden. 26 Finally, through 

CHIP, federal and state policymakers have launched quality of care initiatives to improve 

children's coverage across public programs (influencing private insurance as well). These gains 

further highlight not only CHIP's contributions to children's coverage but also its critical 

partnership with Medicaid. 

The Need for Timely Congressional Action 

With federal funding for CHIP set to expire on September 30, 2017, Congressional action is 

needed as soon as possible to ensure program continuity, budget certainty for states, and, most 

importantly, stable coverage for children. According to MACPAC, unless federal CHIP funding is 

extended, four states and D.C. are projected to exhaust their federal funding allotments by 

21 https://www .macpac.gov/wp-content/uploads/20 15/03/State-Children%E2%80%99s-Health-1 nsuranceProgram_ CHIP-Fact-Sheet.pdf 22 http://khn.org/news/chip-offers-families-with-seriously-ill-kids-more-financial-protection-than-aca-plans/ 23 http://www.kff.orgimedicaid/issue-brief/medicaid-and-children-with-special-health-care-needs/ 24 http://www .kfforgimedicaid/iss ue-brief/medicaid-and-children-with-special-health-care-needs/ 25 https://www.medicaid.gov/medicaid/outreach-and-enrollment/express-lane/index.html 26 https://oig.hhs.gov/oei/reports/oei-06-15-0041 O.pdf 

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December 31, 2017, and all but one state are expected to exhaust their federal funding by June 

30, 2018Y 

Without an assurance from Congress on the extension of CHIP funding, many states will be left 

scrambling as early as this summer. Though the ACA's MOE provision requires states to 

maintain 2010 Medicaid and CHIP eligibility levels for children through FY 2019, separate CHIP 

states are not required to maintain coverage in the absence of federal funding. Thus, unless a 

state with a separate CHIP can replace federal funds with state dollars, these states will be 

forced to cap enrollment or terminate their CHIP programs. Doing so would require some states 

to begin making operational decisions this summer and then (or soon thereafter), noticing CHIP 

enrollees and terminating provider contracts. 

This would have consequences for millions of children and families. Approximately 3.7 million 

children are enrolled in a separate CHIP program. While MACPAC estimates that approximately 

2.6 million of these children would enroll either in subsidized Marketplace coverage or a 

parent's employer-sponsored insurance (ESI), the remaining 1.1 million of these children are 

projected to become uninsured if states terminate their CHIP programs. 28 Even for families that 

manage to secure an alternative source of coverage, they can expect to see their out-of-pockets 

costs rise substantially compared to out-of-pocket spending under CHIP. While the impact 

would vary by family, MAC PAC projects that by adding a child to a parent's ESI, families could 

face an average of nearly $3,800 more in out-of-pocket costs annually; for some families, the 

additional out-of-pocket costs could reach almost $9,000 more than with CHIP, greater than 

20% of a family's income. 29 Though not nearly as steep, MACPAC estimates that children 

moving from CHIP to subsidized Marketplace coverage also would face higher cost-sharing, 

mainly in the form of higher deductibles and co payments but also premium costs for some 

children 30 

Children with special health care needs may be the most impacted during this transition. An 

analysis conducted by The Wakely Group in 2016 found that in some states, these children 

could go from having no cost-sharing in CHIP to over $10,000 in out-of-pocket costs annually in 

the MarketplaceY Compounding these substantial cost increases and concerns around benefit 

design is the uncertainty surrounding states' Marketplaces and the availability of sufficient 

subsidies in the American Health Care Act of 2017. These findings reinforce the need for 

Congress to act quickly to secure the future of CHIP. 

27 https://www.macpac .gov/wp-content/uploads/20 17/03/F ederai-CJ liP-Funding-When-Will-States-ExhaustAllotments. pdf 28 https://www. macpac .gov/wp-content/uploads/20 17/0 !/Recommendations-for-the-Future-of-CHIP-and-ChildrensCoverage.pdf 

29 https://www.macpac.gov/wp-content/uploads/2015/03/Sources-of-Coverage-for-Children-lf-CHIP-Funding-lsExhausted.pdf 

30 https://www.macpac.gov/wp-content/uploads/2015/03/Sources-of-Coverage-for-Children-If-CHIP-Funding-lsExhausted.pdf 

31 http://www. wakely .com/wp-content!uploads/20 17/03/CHIP-vs-QHP -Cost-Sharing-and-Benefits-ComparisonFirst-Focus-Oct-20 16.pdf 

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Recommendations 

Several nonpartisan and bipartisan entities, including MAC PAC, 32 NGA, 33 the National 

Association of Medicaid Directors (NAM D), 34 the Bipartisan Policy Center, 35 and the American 

Academy of Pediatrics (AAP), 36 among others, have issued recommendations on the future of 

CHIP. Their recommendations are based on ensuring that children continue to have access to 

affordable health coverage and that states have budget and program certainty in the years 

ahead. 

Notably, these entities all support extending CHIP funding. MACPAC, NGA and the AAP 

recommend extending federal CHIP funding (including the enhanced matching rate) for five 

years (through FY 2022), and MACPAC and the AAP also recommends extending the MOE for 

the same time period. Similarly, the Bipartisan Policy Center recommends extending both 

federal CHIP funding and the MOE through FY 2021. In addition, during their respective 

confirmation hearings earlier this year, Health and Human Services Secretary Tom Price voiced 

his support for extending CHIP and suggested that an eight-year extension of CHIP would be 

better than a five-year extension; 37 similarly, CMS Administrator Seema Verma voiced her 

support for reauthorizing CHIP for "as long as possible." 38 Taken together, these actions would 

help ensure continuity of coverage for children, particularly given the current uncertainty 

surrounding other sources of health coverage in the U.S. 

While the President's budget proposes to extend federal funding CHIP, the proposed two-year 

extension should be strengthened, in line with the five years proposed by MACPAC and NGA, 

along with an extension of the other key provisions discussed. A two-year extension, while 

valuable, provides little stability given state budgeting cycles and leaves states less able to plan, 

modify and improve their programs, a point confirmed by state CHIP directors in their 

communications with NASHP. 39 1n its recommendation to Congress on the future of CHIP, 

NAMD echoed the importance of a timely extension of CHIP funding to assure states of 

budgetary and operational certainty. 40 There is little disagreement that CHIP has been a 

resounding success and little reason to put its future into question. Stability is even more 

important now given the questions associated with the future of states' Marketplaces and the 

critical importance of enabling states to continue providing affordable, pediatric-specific 

32 https :1/www. macpac .gov/wp-content/uploads/20 1 710 1 /Recommendations-for-the-Futurc-of-CHIP-and-ChildrensCoverage.pdf 

33 https:l/www.nga.org/cmslnga-lettcrs/chip-reauthorization 34 http://medicaiddirectors.org/wp-content/uploads/20 17/03/NAMD-Letter-CHIP -and-D-SNP-rcauth-FINAL. pdf 35 https://cd n.bipartisanpolicy .org/wp-content/uploads/20 17/02/B PC-Health-CHIP. pdf 36 American Academy of Pediatrics letter to Orrin Hatch (May 23, 2017). 37 https://www.c-span.org/video/?422427-1/hhs-nominee-representative-tom-price-testifies-confirmation-hearing 38 https ://www .c-span.org/video/?4 23 823-1/cms-administrator -nominee-seema-verma-testifies-confirmation-hearing 39 http://www.nashp.org/wp-content/uploads/20 17/02/20 17-CHIP-Survey-Results.pdf 40 http:/ /medicaiddirectors.org/wp-content/uploads/20 17/03/NAMD-Letter-CHIP -and -D-SNP-reauth-FINAL. pdf 

9 
35 


28525.019

manatt 

manatt I phelps I phillips 

coverage that serves as a much needed complement to Medicaid for millions of low-income 

children nationwide. 

CHIP, in partnership with Medicaid, has been a remarkably successful program. Its bipartisan 

support over the past 20 years and its contribution to driving down the uninsured rate among 

children nationwide are just two of the many indications of its success. While Congress is in the 

midst of considering changes to the nation's health care system, it is imperative to heed the 

lessons from this program, whose inception and continuing success have their roots on both 

sides of the aisle. In the face of ongoing uncertainty in the health care system, there has never 

been a more important time to act with quick resolve to secure the future of children's health 

coverage. 

10 
36 

Mr. BURGESS. The chair thanks all of our witnesses for their testimony today, and appreciate your being here and your being flexible with us as this hearing was rescheduled a couple of times. 

I now want to go to vice chairman of the committee, Mr. Guthrie, 

5 minutes for his questions, please. 

Mr. GUTHRIE. Thank you very much. Before I get into my questions, I know we have had some comments from some of my colleagues, and the others on Medicaid and the way the AHCA dealt 

with Medicaid. As we know, Medicaid is a program that is growing 

rapidly and could implode. So what we decided to do, and we very 

carefully sat down and walked through the AHCA, was how are we 

going to move forward? And the principled way of moving forward, 

I know there is a block grant option in the bill, but the principle 

way we decided to move forward was on an approach to Medicaid, 

that in the 1990s, was bipartisan. As a matter of fact, every sitting 

Member of the Senate who was in the Senate in the 1990s on the 

Democratic side signed a letter to President Clinton supporting an 

option of going to per capita allotments, some being key ranking 

members and then leadership on the other side. 

Medicaid, over the next 10 years, under our proposal, will grow, 

not cut, will grow by 20 percent, so I just want to make sure the 

record reflects more than some of the rhetoric we have heard. 

First, Ms. Snyder, in addition to basic medical benefits, Texas’ 

CHIP program include behavioral health services; vision exams 

and corrective lenses; hearing exams and hearing aids; physical, occupational and speech therapy; and durable medical equipment. 

There is also limited dental benefit. In your testimony, you seem 

to contrast this with Medicaid extensive, yet prescriptive medical 

benefit for children. I believe every member of this committee 

wants to ensure low-income children have adequate access to 

healthcare, whether in Medicaid or CHIP. But it sounded like you 

might have some ideas on the way Medicaid could better serve children. Do you have any ideas you would like to share with us? 

Ms. SNYDER. Thank you, vice chairman. Absolutely, we are a fundamental believer in Texas in both the Medicaid and CHIP programs. I think, as is evidenced by my testimony, we enjoy the flexibility that the CHIP program offers to states in designing a benefit 

that actually is responsive to the population that served under the 

CHIP program, which is a population of children that don’t qualify 

for Medicaid. Certainly, we always in Texas are, and like many 

other states, looking at opportunities to infuse elements of personal 

responsibility into programs such as Medicaid, and clearly, we already have done so with CHIP. But we do realize that the populations that are served under those programs are distinctly different, and so want to be cognizant of those differences in terms 

of the populations as we consider cost-sharing opportunities, benefit limitations, and so forth. 

Mr. GUTHRIE. Thank you. Mr. Holmes, also, the reliance community health centers is very important in our health safety net. And 

in 2015, we extended the community health center fund for 2 additional years. In your testimony, you call on us to do a longer-term 

basis for at least 5 years. Maybe some of the reason for that is selfevident, but would you like to describe what is better for you in a 

37 

longer extension over a 2-year extension, the things you can do differently, or maybe more efficiently? 

Mr. HOLMES. Thank you, Mr. Vice Chairman. Two years is a 

short period of time for safety net providers to go into the workforce and recruit new providers. One of the more difficult conversations any safety net provider has when they are trying to bring in 

new physicians, new dentists, is to have that discussion about, if 

the lead time to recruit these providers is 1 to 2 years, to say, we 

hope to have a job for you in 2 years. It really limits our ability 

to have realistic conversations with new providers that we need to 

help serve our patients. Two years is a short planning cycle for any 

small business to try and address changes in the environment, and 

certainly, in a healthcare environment that is changing rapidly. 

And a longer planning cycle just would make us more effective in 

how we deliver care to our patients. 

Mr. GUTHRIE. Thank you. Also, every health center must meet 

statutory-defined criteria to receive in HRSA, section 330 grant. 

One of the conditions that must be made in order for health centers 

to receive one of these grants, and how does an applicant demonstrate to HRSA the need for health services? And I have a 30- 

second time left. 

Mr. HOLMES. There are 19 basic requirements to fund to be eligible to receive health care center funding. Each one of those areas 

must be defined and documented in a competitive grant application 

which occurs every 3 years at the current time. 

Mr. GUTHRIE. And what you do is critical, so we really appreciate 

your efforts. We appreciate it. 

I yield back. 

Mr. HOLMES. It is critical for us to show Congress that we do 

what we say we are doing, and that we are who we say we are. 

And without that, we want to have a process that is transparent 

for all organizations to say, this is what we do, this is who we 

serve, and this is how we can care for our patients. 

Mr. GUTHRIE. Thank you. I yield back. 

Mr. BURGESS. I thank the gentleman. The gentleman yields back. 

The chair recognizes the gentleman Mr. Green for 5 minutes of 

questions please. 

Mr. GREEN. Thank you, Mr. Chairman. I would like to ask unanimous consent to place in the record letters from both a number of 

associations encouraging a 5-year extension on funding for the 

Children’s Health Care Program. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. GREEN. One thing I think is really important and I highlight 

that Medicaid and CHIP are linked together, and many of our 

CHIP kids receive Medicaid benefits. In fact, two-thirds of the 

CHIP kids actually receive the more comprehensive Medicaid benefit package, because states have recognized how important coverage is for children. That is why I am disturbed by what the 

House has done passing TrumpCare, and what the Senate looks 

like they are poised to do next week. 

The conversation about children’s coverage is something that this 

committee should have before passing legislation, capping, and 

blocking, granting coverage for 37 million children. This morning, 

38 

I read that 3 million children will lose coverage under the House 

bill, and Senate cuts to Medicaid are even deeper over time. Even 

one child losing coverage in our country is unacceptable. We can do 

better for our children. 

Ms. Mann, can you start off with some of the important contexts 

we should have as we consider the reauthorization in CHIP, which 

I want to be clear, I strongly support and believe Congress must 

immediately do. What do people mean when they say CHIP stands 

on the shoulders of Medicaid? And can you discuss the history of 

CHIP and how it worked with Medicaid programs to bring us to 

the highest rate of coverage for children in our history? 

Ms. MANN. Thank you. I would be glad to address that question. 

CHIP was established to extend coverage to children who otherwise 

weren’t going to be eligible for Medicaid, and states could cover 

those children, either in Medicaid or in separate CHIP programs. 

So the idea that CHIP sits on top of Medicaid is, in fact, exactly 

how it is designed by Congress, and how it is operated in the program. And why CHIP needs that support is that Medicaid really 

does, as I noted, much of the heavy lifting. Both in terms of numbers, Medicaid covers about 37 million children, CHIP covers over 

8 million children. Medicaid covers the children who are often in 

the poorest health, foster care kids, kids with disabilities. Any 

child, when they get a disability, when they get a chronic illness, 

they often have to turn to Medicaid, even if they are eligible for the 

CHIP program. It is not necessarily designed to be that robust a 

benefit package. They work hand in hand. 

And at the same time, what CHIP has done is really helped modernize the Medicaid program over the years. When CHIP was started, it really got a lot of energy around children’s coverage, and people started to look at not just how to design the new CHIP program, but what should we do to improve the Medicaid program? So 

simplified applications made it easier for families to enroll. That 

had a lot to do with the success and the uninsured rate that we 

have seen. So the two really are side by side and complement each 

other, and are needed for the continuum of coverage for children. 

Mr. GREEN. Following up on my colleague from Kentucky, do you 

have anything to say about the flexibility of Medicaid between different states with different Medicaid programs? 

Ms. MANN. There is a great deal of flexibility in Medicaid. In 

fact, often you hear from Members of Congress and others, oh my 

God, it is such a complex program, in part, because there are 56 

jurisdictions that administer it, and there is quite a bit of distinction and differences among them because of the flexibility accorded 

to states in the program. 

States have a lot of flexibility to design their delivery system as 

a managed care, is it fee for service? Accountable care organizations? They design their payment system; they design their care 

management system. The area where Medicaid is clear, however, 

is on the benefit protection for children. It is actually 50 years, almost to the day, where Congress adopted the early periodic screening and diagnostic treatment program to make sure that all kids 

in Medicaid get screened for vision, hearing, developmental delays, 

other problems. And if they have a medical problem, the benefit requirement in Medicaid is that they get treated. 

39 

Mr. GREEN. I am almost out of time. Texas receives a 1115 waiver that, I think, bipartisan, we supported. There is flexibility in 

states. Although, before I was elected to Congress, served 20 years 

in the state legislature, and I watched how we were funding Medicaid back then. And my concern is that the flexibility—we also 

vote this Federal money, in Texas, our match is two-thirds Fed, 

one-third state, of course, Louisiana gets a little better than that. 

Someday maybe we will get to that level. But we also need to have 

guidelines for what we know that funding will go through. 

Ms. MANN. Absolutely. 

Mr. GREEN. So I want flexibility, but I also make sure it is spent 

on the healthcare for poor people, including children. 

Ms. MANN. Absolutely. 

Mr. GREEN. Thank you, Mr. Chairman. 

Mr. BURGESS. The gentleman yields back. 

The chair thanks the gentleman. The chair recognizes the chairman of the full committee, Mr. Walden. The gentleman from Oregon, for 5 minutes, please. 

Mr. WALDEN. I thank the chairman. And I want to thank our 

witnesses for your testimony. We appreciate what you do in our 

states, and communities, and what those you represent here today 

do. 

Mr. Holmes, in your testimony, you say that many of your patients travel over 50 miles off and over secondary roads to access 

care in your health center, and that oftentimes, you are the only 

provider in the communities you serve. In addition to isolation and 

distance, what other challenges exist that we should know about 

in care and delivery that are unique to rural areas? And I would 

just preface that by saying my district would extend from the Atlantic Ocean to Ohio. And so it is bigger than nearly every state 

east of the Mississippi River. So I am used to pretty remote, rural, 

extreme remote, whatever the furthest-out remote nomenclature is, 

we got it in my district. But can you speak to some of those issues 

and the reimbursement issues? 

Mr. HOLMES. Delivery of care in a service area that is almost the 

size of New Jersey is challenging. It is challenging because we are 

in small communities. Two of our health center sites are attached 

to critical access hospitals. And the critical access hospitals are 

small. They are 14 beds, and 16 beds, they have attached long-term 

care units. We have to be able to recruit providers to see these patients. We are in a frontier area, and it is long distances between 

sites. If we are not there, no one else is there. The next level of 

care for our system, or our health delivery system, is 40 to 50 miles 

away to an entry point. 

When we look at rural areas, it is where we have our agriculture; 

it is where we have our forest products; it is where we have our 

mining; and we can’t relocate those jobs to urban areas. We have 

to deliver care to the people that are working in those industries, 

and it presents challenges of distance, and time, and access. Payment reimbursement methodologies that come to FQHCs help on a 

per-visit basis to subsidize or offset some of the infrastructure 

costs. I could be much more economically efficient if I had all of my 

patients and all my providers in a single site, but I can’t, because 

I can’t have patients traveling 60, 70, 80 miles in. 

40 

Mr. WALDEN. Let me ask, I am thinking about the clinic I have 

in Fossil, Oregon, it is 92.2 miles to The Dalles, Oregon, where 

Mid-Columbia Medical Center is. That would be most likely the 

nearest hospital, so more than 90 miles away. This is one of three 

counties where we have physician assistants, but beyond that, no 

other access and no hospital in this three-county region. 

Talk to me about telemedicine and what role it can play and 

what you encounter. I understand the recruitment issue, and some 

of that goes back to the states because they want to do their board 

certification. So I have had various health centers and providers 

say, we can wait 6 months to a year to get through the process 

from the State of Oregon to get approval to get somebody here, and 

meanwhile, they go somewhere else, perhaps. We are not as bad as 

some, not as good as others. Can you talk about telemedicine? 

And then, I had an amendment before it became law and then 

it expired on sort of bonus payment for home healthcare, because 

it is more expensive to go out and back 90 miles each way to take 

care of somebody in a remote area. Perhaps you could address 

those things? 

Mr. HOLMES. We have a common electronic medical record platform across all of our sites. We have some clinics that are mid-level 

provider sites only. They are staffed by nurse practitioners or physician’s assistants. If they have issues or questions about care of a 

patient, they can route that chart to one of our physicians in one 

of our other sites for assistance in care delivery. 

We have some telemedicine capabilities. We have telemental 

health services with the University of Minnesota, Duluth, where 

we can have patient’s access, some psychiatric and psychology care. 

And we do have some telederm setups. But part of the problem we 

have with telemedicine is that in the rural areas, there is not a significant infrastructure for high speed internet. 

Mr. WALDEN. Right. 

Mr. HOLMES. So we can’t do home monitoring, because in many 

places, there is not even a cell service, cell phone signal. And so 

we end up having patients coming into our sites, which is the closest access point they can. And we will work with the patient there, 

whether it is with direct hands-on care, or through some telemedicine. 

Mr. WALDEN. That is helpful. We also have jurisdiction over 

spectrum and broadband buildout. It is a big bipartisan effort on 

our committee to get access. We just had a hearing this week, as 

a matter of fact, on getting access to unserved areas first with the 

Federal support, and then underserved after that, and how we 

mapped that and really figure out where those areas are. So thank 

you all for the work you do and for your testimony today. 

I yield back. 

Mr. BURGESS. The gentleman yields back the chair. The chair 

recognizes the gentleman from New Jersey, the ranking member of 

the full committee, Mr. Pallone, 5 minutes for questions, please. 

Mr. PALLONE. Thank you, Mr. Chairman. 

I believe deeply in the CHIP program. I want to see a full 5-year 

extension of current CHIP policy. However, I also believe deeply in 

the Medicaid program. And I know that a lot of our success with 

the CHIP program is due, in part, because it bills so seamlessly on 

41 

top of the Medicaid program in its current form. And as virtually 

every stakeholder agrees, the TrumpCare bill passed by the House 

would decimate coverage for 23 million people, 3 million of them 

children. What is worse is that the Senate’s own TrumpCare bill 

doubles down against kids. And it is a fact that these proposals are 

bad for kids. 

So with that in mind, Ms. Mann, I wanted to ask you some questions. First, why is the current full 5-year extension of the CHIP 

program with the maintenance of effort in the so-called 23 percent 

bump in payments for states so critical now more than ever? 

Ms. MANN. Thank you. MACPAC, the pediatricians, and NGA 

have all recommended a 5-year extension. MACPAC with 23 percentage points and the maintenance of effort, and I think for good 

reason. And I think it goes back to the points that Mr. Holmes 

made about health center funding. These 2-year cycles are just not 

sufficient for states to be able to really do the kind of planning and 

improvements that make sense for kids. And I also think the other 

side of that is to look at what is going on broadly in the healthcare 

marketplace right now. If CHIP were to end more abruptly, then 

children will be at risk of not having coverage, or if they find coverage, they will have significantly higher out-of-pocket costs. 

This is really a time of great uncertainty in our healthcare marketplace, small ‘‘m’’, and it is really a time, given the bipartisan 

support for children’s coverage, to give CHIP 5 years to be stable 

and to do the job it needs to do for children. 

Mr. PALLONE. Well, I obviously agree with you and the importance of an immediate and full extension, but I also share the same 

belief about reauthorizing the community health center fund. I 

think we need to do it immediately. But again, when you talk 

about the health center program, a lot of success due, in part to 

the Medicaid program, which provides more than 40 percent of 

community health center revenue each year. And unfortunately, all 

that success, I think, is jeopardized with TrumpCare. And yet my 

colleagues argue that a cap on the Medicaid program is not a cut 

at all. In fact, the administration was up here testifying on the 

budget of the Ways and Means chair arguing that TrumpCare was 

not a cut to Medicaid at all. So I would like to hear from someone 

who knows a lot about Medicaid and CHIP, many have likened the 

capping of the Medicaid program to be just like managed care, 

which, in Medicaid, is quite widespread. Is the cap in Medicaid like 

managed care? 

Ms. MANN. Well, I will jump in and answer that. And I am sure 

Ms. Snyder also has a view on that. It is very unlike managed care. 

States use managed care largely for CHIP programs and for their 

Medicaid programs. They set rates, they set rates at a regular period of time. They adjust rates based on the acuity and the needs 

of the population that are served. They take into account policy 

changes, healthcare cost changes, and they are constantly reexamining their rates. 

In the cap in the bill, it is set based on spending from years back, 

moved forward, adjusted by a national trend rate that is not related to the actual needs and cost of serving people in that state. 

And it doesn’t adjust based on acuity of the needs; it doesn’t adjust 

based on the healthcare costs in that community. 

42 

Mr. PALLONE. So what is going to happen to benefits and provider revenue with a capped or block granted Medicaid program? 

Ms. MANN. Well, states have three major levers to do significant 

reductions of spending in the Medicaid program: enrollment, provider payment rates, and benefits. I think likely, with the kinds of 

changes that are proposed, all three will be relied on by states. But 

if you think about going to provider rates, which is maybe the first 

place states will turn, we worry a lot about access for kids. Access 

is in good shape for kids right now in our Medicaid program, but 

if we thin out the payment rates for providers, if we lower our payment rates for managed care organizations, we are going to have 

access issue and problems of serving children, as well as seeing 

some children who are on optional kinds of programs, kids with 

brain injuries and other types of HCBS services, Home and Community Based Services may be losing their coverage and services 

all together. 

Mr. PALLONE. Are there any winners for this policy, regardless 

of what states are carved out? And is it going to matter? 

Ms. MANN. Well, no states are carved out, and I think it is just 

a fact of math that when there is a Federal and state partnership 

to share all costs and the Federal Government is saying, I am pulling out of that partnership, and I am setting my limits at a certain 

amount, and the state is responsible for everything above that, 

every state becomes a loser in that formula. 

Mr. PALLONE. All right. Thank you. Thank you, Mr. Chairman. 

Mr. GUTHRIE [presiding]. Thank you. The gentleman from New 

Jersey yields back. The gentleman from New Jersey is recognized. 

Mr. LANCE. Thank you, and good morning to the distinguished 

panel. 

Is it the view of the panel that the current formula for Medicaid, 

which is open ended, as I understand it, should continue as it exists permanently without any analysis of a potential modification? 

I ask the question legitimately and I was one of 20 Republicans not 

to vote for the healthcare plan on the floor of the House of Representatives. Ms. Mann, I will start with you. 

Ms. MANN. I think the shared commitment, the shared partnership around underlining financing of the program is critical and 

needs to be retained. I think there are always areas of improvement. There has been years of complaints about how the FMAP 

itself, how that share is actually the formula for that. That could 

be looked at, though it is a quagmire of political complications 

when one does. 

Mr. LANCE. I think that is the understatement of the day. As I 

understand it, the costs have increased relatively significantly in 

the last decade. Is that accurate? 

Ms. MANN. The costs per enrollee, actually, in the Medicaid program, have grown much more slowly than either commercial insurance or Medicare. Medicaid costs have grown, but that is because 

it is covering many more people. 

Mr. LANCE. Others on the panel who would like to address the 

issue? 

Ms. SNYDER. I would be happy to respond to the question. 

Very similar to Ms. Mann, I think we can all agree that there 

is always opportunity for improvement when we look at the fundVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
43 

ing formula for Medicaid as it currently stands. As a state, I can 

tell you Texas is looking very closely at the implications of the 

ACA, as well as the proposal that has been advanced by the Senate, specifically for the implications for the State of Texas and how 

the proposed funding formulas would play out for the program, 

versus the funding formula that we are now working with. 

Mr. LANCE. Yes. 

Mr. HOLMES. From a rural standpoint and a small safety net provider standpoint, I think it is important to recognize that not all 

Medicaid patients are evenly distributed across all payer types and 

across all providers. In the rural areas, there is a higher level of 

Medicaid population and where nursing home care paid by Medicaid may be 64 percent nationally. In the nursing homes that I am 

familiar with, their Medicaid population is 90 percent. And so there 

is a disproportionate percentage in some of our communities that 

rely on Medicaid. And so any time we have a change in that system, I worry about unintended consequences and how the rural 

providers, and rural safety net providers, and all safety net providers adapt to those changes. 

Mr. LANCE. Regarding rural America, is this particularly important as it relates to those in nursing homes, as opposed to children 

and other populations served by Medicaid? 

Mr. HOLMES. In the rural areas, we still have a significant nursing home population, a long-term care population, but we have a 

disabled population, and we have a population of moms and kids. 

Mr. LANCE. Well, that is true across the country, obviously. Is 

there a disproportionate percentage in rural America in one of the 

cohorts you have just mentioned? 

Mr. HOLMES. I believe that there is a disproportionate share in 

the rural areas for long-term care, because we have an aging in 

rural parts of the country. A lot of the younger people have moved 

out of the rural areas to urban areas where the jobs are. And so 

we have a graying of the population in these rural communities. 

Along with that graying of the population, I think there is a greater reliance on some of the programs to help provide care. 

Mr. LANCE. Thank you. I think that this is an issue that deserves 

a great deal of attention, and I am not one who wants to make this 

a partisan issue. I think that it is a very difficult issue, and we 

have to examine it, in my judgment, based upon the facts that we 

want to cover as many Americans as possible. We also have a responsibility to the tax-paying public with a rising Federal debt. 

And I hope that we can examine these very difficult issues in a bipartisan capacity moving forward, because I do not think that this 

is an issue that should be politicized. 

I yield back 17 seconds. 

Mr. GUTHRIE. The gentleman yields back his 17 seconds. The 

lady, Ms. Matsui from California, is recognized. 

Ms. MATSUI. Thank you very much, Mr. Chairman. 

CHIP and the Community Health Centers’ Fund are critically 

important programs for serving children and families in our communities. And I do look forward to working with my colleagues to 

continue their funding in the future, and hopefully far into the future. However, we all know we can’t have a conversation about 

safety net that CHIP and community health centers provide withVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00049 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
44 

out including Medicaid as their foundation, because Medicaid is the 

foundation of our Nation’s safety nets. 

Forty-one percent of children in California are on Medicaid and 

CHIP. That is about two in every five kids. I say 41 percent on 

Medicaid and CHIP because you can’t separate the two. CHIP eligible children in California, in fact, receive services through the 

Medi-Cal program. The CHIP and community health centers programs and the children and families they serve, will be devastated 

by the Medicaid cuts proposed by the TrumpCare bill. 

Ms. Mann, I am going to ask you this, because the way it looks 

now, if the TrumpCare bill goes through, billions of dollars will be 

cut from Medicaid. Would states be able to continue to cover the 

same number of people? Would they be able to cover the same type 

of services? Where might they cut? And are there examples of difficult choices states have had to make when budgets were 

squeezed? 

Ms. MANN. Sure. The Medicaid program, I think, certainly as CBO has projected, the reductions in Medicaid funding $834 billion 

over 10 years would result in about 14 million people in the Medicaid program losing coverage. That will grow over time due to the 

impact of the caps, and how the caps get tighter and tighter over 

time just because of the way the math works. So, we will see necessarily, I think, lots of impacts to the program, both on that coverage number, but also in terms of whether we see limitations on 

the kinds of benefits to people are able to access. states will have 

to look, for the first time, I think, really closely at so-called outlier 

cost people: elderly people, children who are in special waiver programs, for example, whose expenditures are so much higher than 

the cap would be. Every time they enroll somebody in that situation, the state will lose a lot of money under the way the caps are 

designed. 

We also see big concerns about access, whether lower payments 

to providers, lower payments to health plans will narrow networks, 

children won’t be able to get access to specialty care, and the kind 

of services that they need in a timely way. 

Ms. MATSUI. So it seems to me you will be rationing care here. 

It seems to me they would have to make very difficult decisions as 

to what population will get the care that they need. 

Ms. MANN. What you will have even more than you have now, 

there are always issues at the state level about funding the Medicaid program. It is a big expenditure. States do not just spend 

their money without a lot of examination. But under a capped environment, you will have both cuts and a limit. And that will increase the competition between populations and between providers 

inside the state. 

Ms. MATSUI. OK. Thank you. 

I would ask you also about in California, children receive full 

EPSDT, which is Early and Periodic Screening, Diagnostic and 

Treatment services through Medi-Cal. Can you talk about the impact of access to these services on children and families? And can 

you talk about the differences in the benefits and resulting health 

outcomes? 

Ms. MANN. EPSDT was really designed initially because of concern about low-birth weight babies, about children growing up, 

45 

even children going into the Armed Forces, and as young adults 

and not being in healthy shape. It is really a very sensible benefit 

package that says there should be screening, diagnostic testing. 

And then it simply says that when a child needs treatment, as recommended by their doctor, they get the treatment that they need. 

That is an incredibly important service that is available to children, and, I think, the kind of standard we all want for our children. With reductions in spending, that might be a hollow promise; 

you might have the promise even for EPSDT if it is still there, but 

can a child find a provider, can a child get to a dentist, can that 

child get to the specialist that they might need for a particular 

kind of circumstance. 

Ms. MATSUI. I see I am out of time and I would like to submit 

my questions for the record. 

Thank you. I yield back. 

Mr. GUTHRIE. The gentlelady yields back. The gentleman from 

Virginia, Mr. Griffin, is recognized for 5 minutes. 

Mr. GRIFFITH. Thank you, Mr. Chairman. I appreciate it very 

much. 

Mr. Holmes, you have been talking about some of the rural 

issues, and I appreciate that, because my district is larger than the 

State of New Jersey. And you indicated that the territory that you 

cover is about the size of New Jersey, or a little bit less than that. 

And one of the things that has been rattling around in my head 

is that—the telemedicine issue that you touched on earlier is that 

we ought to be able to figure out a way to save money longterm, 

maybe not initially but longterm, by using telemedicine and not 

only save some money but increase the effectiveness of the care in 

the rural areas or at least make it more accessible. For example, 

I have a bill in that deals with making sure that folks, by telemedicine, talking to the appropriate neurologist, et cetera, can get a 

quicker response on getting the tPA, in the case of a stroke. Because, obviously, if you are in a rural area, sometimes you can’t get 

to the hospital where the right doctor has to look at you currently 

to give that medication. But we can speed it up. 

You mentioned that you all are providing some services for mental health. I think that is extremely important, because if we can 

catch that, just like with the stroke, instead of having somebody in 

long-term care, which we have talked about and how expensive 

that is, tPA can stop a lot of that. Likewise, with mental health, 

if we catch it early in a regular clinic and we are doing that a little 

bit in my district now. What we found is that people are much 

more likely to go to the clinic, the community center, if they can 

just step into the other room and get the mental health, even if it 

is by telemedicine, because we don’t have the ability to have population to have psychologists or psychiatrists in every one of those 

communities. But there is still a certain stigma. Maybe that is not 

the way it is supposed to be, but there is, particularly in rural 

areas, to getting mental health services. If they can just step into 

another room in the clinic, nobody knows whether they are getting 

their foot looked at for toe fungus or whether they are getting a 

mental health evaluation. 

So just some comments on that, and do you believe that there 

might actually be some savings there longterm, particularly in 

46 

rural settings, because we prevent folks from having more serious 

maladies. 

Mr. HOLMES. I believe there are opportunities for cost savings by 

integrating behavior health into primary care, along with medical 

services. We have a couple of rooms set up in some of our clinics 

that have the telemedicine capabilities, the hookups for behavioral 

healthcare. Those patients are scheduled routinely. There is no indication that it is a specialty behavioral health visit for that patient when they are in the waiting room. 

And some of the other things we do is that we do have some behavioral health specialists that come in from some of the local mental health agencies to our clinics. And they have office space and 

exam room space embedded right into other space. So we try and 

care for the patients in the best way that we can within the local 

situation, within the local facilities. 

There still are reimbursement challenges with telemedicine. The 

originating facility is not usually a part of the reimbursement 

methodology. So you have to build the infrastructure without having payment for that infrastructure. You have to maintain it. You 

have to have enough bandwidth to have interactive television in 

those interactive conversations. 

Mr. GRIFFITH. All right. Let me springboard off of that. And I believe I have got my names right. Sometimes I get them wrong. But 

the Stark Act, currently, if I understand correctly, prevents us from 

using some of our facilities in conjunction with a hospital that 

might be willing to pay for some of that infrastructure, because at 

one time, they were worried about collusion and raising the bills. 

Today, I have got underserved areas. I could use some space in a 

nursing home, long-term care facility, and put in some telehealth 

stuff, even if it was in conjunction with the hospital, because, in 

all fairness, I only got one hospital that’s really in competition if 

you are talking about somebody having a heart attack. But my 

folks have to travel about 45 minutes to get there. 

So do you think we need to also look at maybe relaxing some of 

that, particularly when we can get into underserved areas? 

Mr. HOLMES. Antitrust issues are certainly an issue for medical 

delivery, especially now when we are seeing the development of 

large systems of care and yet we have small providers that are trying to deliver services in a cost-effective way. Small areas don’t 

have the depth of resources to have competitive services. We have 

to find the best way to deliver that care to our populations. But we 

have to be, at this point, careful of antitrust issues. And it is always something that is in the back of our minds. 

Mr. GRIFFITH. So what you are saying is we have to try to figure 

out the balance. We would prefer to have competition, but where 

there is no competition, maybe we need to take a look at giving 

some flexibility on the antitrust issues to make sure that we are 

getting services there. 

Mr. HOLMES. Yes, sir, I agree. 

Mr. GRIFFITH. All right. I yield back, Mr. Chairman. Thank you. 

Mr. BURGESS. Thank you. The gentleman’s time has expired. 

And now recognize Mr. Luja ́n from New Mexico. 

Mr. LUJA ́ N. Thank you. 

Mr. BURGESS. Five minutes. 

47 

Mr. LUJA ́ N. Thank you, Mr. Chairman. 

Ms. Mann, I keep hearing on the news that TrumpCare doesn’t 

cut Medicaid, yet the CBO said that is just not true. And I am 

looking at these quotes from different stakeholders. The American 

Academy of Pediatrics says, ‘‘The U.S. and its healthcare legislation fails to meet children’s needs.’’ There is too much at stake for 

those of us who care for children to be silent. Pediatricians will 

continue to speak out for what children need until we see legislation that reflects it. The Children’s Hospital Association are unified 

in calling on the Senate to reject the bill. They say, at its core, the 

bill is a major step backwards for children and their health. And 

the American Academy of Family Physicians say that this legislation would have a profoundly negative impact on Americans. 

So, Ms. Mann, can you set the record straight? Is TrumpCare a 

cut for children, families, and for everyone in the Medicaid program? 

Ms. MANN. Yes. 

Mr. LUJA ́ N. That is a pretty straightforward answer. Just so that 

I am clear, you respond to that question with a resounding yes. 

Ms. MANN. With a resounding yes. There is $834 billion taken 

out of the program. There is 14 million people, by CBO standards, 

losing coverage. There is countless other changes that states will 

have to make if those cuts are imposed. And children will suffer 

both from the caps, from their parents losing coverage, from the 

loss of the expansion. There is enormous ramifications to the Medicaid program. Negative ramifications. 

Mr. LUJA ́ N. I appreciate that clarification, Ms. Mann. When I 

asked that question during our 27-hour markup in this committee, 

I was responded to several times that Medicaid was not cut. I appreciate the clarification of the reduction, the cut of $834 billion 

from the Medicaid program. 

Ms. Mann, as we have heard today, the Children’s Health Insurance Program is an important provider of health insurance coverage for nearly 9 million American children. However, the Medicaid program is a primary source of coverage for low-income children covering four times as many kids as CHIP. In New Mexico, 

for example, there is over 414,000 kids that rely on Medicaid and 

15,000 kids that rely on CHIP. 

Can you please describe the role that Medicaid plays in children’s coverage? 

Ms. MANN. Sure. And that ratio that you have in New Mexico is 

pretty much what the national average looks like. It is, first of all, 

a much larger program, as you noted from your New Mexico figures. Medicaid just covers so many more children. And it covers infants. It covers newborns. It covers kids at school age. It covers 

adolescents. It covers 100 percent of a state’s foster care kids, for 

example. Any child who has been determined disabled under the 

Social Security definitions, they go into the Medicaid program. 

They don’t go into the CHIP program. Covers early intervention 

services for very young children. Covers school-based healthcare 

services. It is a program with lots of different functions and lots of 

different ways in which it serves the child population. 

Mr. LUJA ́ N. And I think you addressed the next question I had, 

which was what would the concern be associated if the Senate 

48 

passed their bill or the House-passed Republican repeal bill, otherwise called as TrumpCare, would pass and how it would affect 

CHIP. I think you eloquently described that. 

Our Nation’s leading children’s health providers advocates, including the American Academy of Pediatrics, Children’s Defense 

Fund, Family Voices, First Focus, March of Dimes have all spoken 

out against the Republican repeal bill. And in a March 22 statement, they wrote: In addition to the bill’s initial proposal to fund 

Medicaid through per capita caps, the Republican bill would allow 

states to choose a block grant model, which would eviscerate existing protections afforded to children and pregnant women in the 

Medicaid program. Comprehensive EPSDT benefits would no 

longer be required for children, allowing states to ration limited 

dollars by drastically cutting back pediatric services. 

And, Mr. Chairman, I would like to ask for unanimous consent 

to submit their statement for the record. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. LUJA ́ N. And just as I close, Mr. Chairman, I appreciate the 

conversation about the concerns, Mr. Holmes, with the impact in 

rural communities. I represent a district that takes about 8 1A1⁄2

hours to drive across. This is critically important. When we talk 

about the concerns to these rural healthcare facilities, the conversations that were taking place about the importance of mental 

and behavioral health programs in these small clinics, if these bills 

become law that would eliminate the Affordable Care Act, we 

would see those programs get eliminated, if not disappear. 

And when it comes to getting broadband access across America, 

I certainly agree. I have said it once, I will say it again: If there 

is a debate taking place with TSA about being able to have a phone 

conversation on an airplane once you board in Los Angeles, California, and you can stay on that phone till you get to New York, 

then we should be able to have broadband coverage all across rural 

America in every part of our beautiful country. We once electrified 

rural America. Now let’s make sure that we connect rural America 

with affordable, fast Internet. Everyone should have it. We can get 

it done. And I am glad to hear it being talked about today. 

Thank you, Mr. Chairman. 

Mr. BURGESS. The chair thanks the gentleman. 

The chair can see a downside to you being on the telephone between Albuquerque and New York. But nevertheless, your comments are appreciated. 

The chair recognizes the gentleman from Georgia, Mr. Carter, 5 

minutes for questions, please. 

Mr. CARTER. Thank you, Mr. Chairman. And thank all of you for 

being here. This is a very important program, certainly very important in my state. In the State of Georgia, SCHIP is the PeachCare 

program. We are very proud of it. It has been a very good program 

that has benefited many, many recipients. 

I want to ask you, I will start with you, Ms. Snyder, and then, 

Mr. Holmes, I will also want you to address this, but I know that, 

in my district alone, we have got six federally funded health centers, and they serve over 55,000 patients. Very, very important. 

One of the things that we require, the Federal statute requires, is 

49 

that states reimburse these federally qualified health centers and 

rural health centers using prospective payment system. And there 

have been groups who said this could be done better. And let me 

quote real quick. The National Association of Medicaid Directors 

has said: This distinct reimbursement system limits Medicaid’s 

ability to use the full range of value-based purchasing strategies in 

this care delivery setting, including models that incorporate financial risk. It also prevents many states from comprehensively transforming the healthcare system across all providers. The directors 

have said states need to be allowed to align value-based purchasing 

approaches. 

How do you feel about that? Ms. Snyder, what do you think? 

Ms. SNYDER. Congressman Carter, I am happy to answer question to the degree that I can. 

What I can tell you is that the State in Texas is well aware of 

the requirement around a prospective payment system and very 

committed to working with all of our managed care and provider 

partners in the advancement of value-based purchasing initiatives. 

Unfortunately, I cannot answer specific questions in regard to 

FQHC reimbursement at this time, because the state is in the 

midst of active litigation on the matter. 

Mr. CARTER. Oh, do tell about that. 

Ms. SNYDER. I wish I could, but I can’t. 

Mr. CARTER. OK. We will give you a pass. 

Mr. Holmes? 

Mr. HOLMES. Over the years, payment methodologies have 

changed across all provider types, whether it has been a cost-based 

payment, whether it is a discounted fee-for-service payment, or 

whether it is prospective payment system payment. FQHCs are 

currently reimbursed under an FQHC prospective payment methodology for both Medicare and Medicaid. 

A couple of years ago, Medicare updated their payment methodology. And I think it is important to note that Medicare, in that 

payment methodology update, retained the payment-per-visit methodology where a bundled set of services is reimbursed under that 

methodology. 

We are looking at a change to value-based purchasing for all provider types. I think the question that comes in with value-based 

purchasing is how do you determine value? We have seen, in Minnesota, for instance, we have clinical outcome disclosures for outcomes of care for all medical groups. And the medical groups will 

range from Mayo Clinic down to the smallest safety net provider. 

And there are different ratings for optimum care and for diabetic 

care or optimum cardiovascular care. 

But what concerns me about value-based payments is whether or 

not that value truly reflects the skill and the care of the provider 

or if it reflects the patient population that provider served. If I was 

going to a value-based system, I would wonder whether or not the 

best value is perceived in the suburban areas where there are high 

levels of income, there are high levels of poverty—or low levels of 

poverty and high education. I think we have to be careful that 

value does not reflect our patient populations but more accurately 

reflects the care that is delivered by the provider. 

50 

Mr. CARTER. OK. All right. Very quickly. I have just a few seconds left. But I want to ask you, Mr. Holmes, if you have experienced the 340B program? Do you all use that at all and what has 

been the impact on your systems there? 

Mr. HOLMES. We use the 340B program. We have some savings 

under 340B. In turn, we use those savings to pay for some of our 

care coordinators and some of our patient assisters where we can 

align our patients into the pharmaceutical manufacturers patient 

assistance programs, because free is better than discounted. 

Mr. CARTER. OK. Ms. Snyder, you all use 340B? 

Ms. SNYDER. We do. 

Mr. CARTER. And the impact? 

Ms. SNYDER. I think it is a very valuable tool, in terms of influencing reimbursement in regard to pharmaceuticals. 

Mr. CARTER. OK. And what do you use the savings for? Can you 

identify it specifically? 

Ms. SNYDER. Yes. I would be unable to identify it specifically. 

But certainly, I think we are always looking at opportunities to 

maximize savings that we are seeing in our system through various 

means, including—— 

Mr. CARTER. OK. Well, we are looking at that closely on this 

committee—— 

Ms. SNYDER. OK. 

Mr. CARTER [continuing]. And on the O&I Committee. So be prepared on that. OK? 

Ms. SNYDER. Absolutely. 

Mr. CARTER. All right. Thank you. 

Mr. Chairman, I yield back. 

Mr. BURGESS. The gentleman’s time has expired. The chair 

thanks the gentleman. 

The chair recognizes the gentlelady from Florida, Ms. Castor, 5 

minutes for questions, please. 

Ms. CASTOR. Thank you very much, Mr. Chairman. And thank 

you to our witnesses and the role that you all have played with 

your organizations and hitting this historic mark of 95 percent of 

America’s kids with health coverage now. And it certainly isn’t the 

time to go backwards. We need your expertise in how we maintain 

that level. And anyone who cares about making sure kids are on 

a pathway to success in life really need to focus on this devastating 

TrumpCare bill and the most radical change to health services for 

kids under Medicaid in the 50-year history. 

At the same time, we do need to reauthorize the Children’s 

Health Insurance Program. And there are a few portions of it that 

I think are vital to maintaining that 95 percent an upwards coverage rate. One of them is the enhanced 23 percent bump. I have 

heard some people say that the 23 percent bump in the match did 

nothing to improve children’s coverage. Well, I can tell you, coming 

from the State of Florida, and this happened in many other states 

last year, we were able to eliminate the 5-year Medicaid CHIP 

waiting period for children by using that bump up. It has been a 

major win for children and families. 

In Florida, approximately 17,000 children were now able to come 

onto the rolls. I know in Arizona they were able to lift their enrollVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00056 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
51 

ment freeze in CHIP, in KidCare, allowing 30,000 kids to receive 

healthcare coverage. 

Ms. Mann, how important is it, as part of the reauthorization, to 

maintain the 23 percent match, or bump up? 

Ms. MANN. I think, as you note, it really has triggered in a number of states. And the National Academy of State Health Policy did 

a report talking to CHIP directors about the impact. But also, as 

Ms. Snyder said, it really is integrated into state budgets. And a 

new Kaiser survey of state budgets done by Health Management 

shows that 26 states are experiencing budget cuts. So I think if we 

pull those dollars out from the CHIP program, we will definitely 

see repercussions. And as I noted before, I think it is very much 

tied to the maintenance of effort—— 

Ms. CASTOR. Exactly. That was my next question, because I have 

heard folks say that that maintenance of effort that has been in 

place for 7 or so years and then was extended, in a bipartisan way, 

in the MACRA, some folks say that has limited state flexibility and 

innovation, and it should be allowed to expire. But, boy, that maintenance of effort has been vital to the continuity of care. 

So is that as it is important? Do the 23 percent go hand-in-hand? 

Ms. MANN. They go hand-in-hand. You could have a maintenance 

of effort requirement continuing to protect children’s coverage and 

pull the money out from states, but I think there would be a lot 

of unhappy states with that arrangement. They really do go hand 

in hand. And I think even more now than 2 years ago, in terms 

of the stability of coverage is just critically important for children. 

Ms. CASTOR. So if we didn’t do that as part of the reauthorization, do you think we would see the return of waiting lists and lost 

coverage for kids? 

Ms. MANN. I think we would. We definitely would see a pullback. 

Ms. CASTOR. One of my great fears, and I know it has been intimated that, way back in the 1990s, Bill Clinton and the Democrats 

fooled around with block grants. And I can tell you, right now, this 

is very dangerous to the ability of our kids to be successful in life 

when you move this direction. And I am particularly frightened for 

my home State of Florida, because Florida spends about $1,880 per 

child Medicaid enrollee. It is the lowest rate in the country, Ms. 

Mann. If we went to Medicaid caps, it appears that that would lock 

in Florida’s low spending rate. But we are a high growth state, and 

our needs change over time. 

What would happen to our state’s ability to take care of kids and 

the elderly and people with disabilities? 

Ms. MANN. I think Florida is a good example of many states’ experience where they would be what is referred to as a relatively 

low spending state. They would be locked into those dollars, modified only by a small trend rate over time. And if they chose to add 

benefits, if they chose to put different care management in to help 

kids with asthma, kids with diabetes, they would either have to do 

that at state dollars or by cutting something else in the program. 

Ms. CASTOR. Like education or—— 

Ms. MANN. As you know, in Florida there is not a lot of give—— 

Ms. CASTOR. I mean, where would we go? Would it be folks in 

nursing homes? They are very expensive. Or would it be special 

needs kids or children’s hospitals? 

52 

Ms. MANN. Absolutely. And nationwide, we spend about a third 

of our dollars on long-term services and supports for the elderly, for 

people with disabilities. Populations will be vying for those limited 

dollars just to be able to keep steady, never mind lose ground. 

Ms. CASTOR. Thank you for helping to explain what is at stake. 

Thank you very much. 

I yield back. 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady 

yields back. 

The chair recognizes the gentleman from Oregon, Dr. Schrader, 

5 minutes for questions, please. 

Mr. SCHRADER. Thank you very much, Mr. Chairman. I appreciate it. 

Mr. Holmes, I would love to get into a discussion with you on 

value based. You may have some good points if it was still a silobased delivery system in modern medicine. But I point out, in the 

ACA, there were some risk adjustments to take some of that issue 

away. And in Oregon, most of our physicians, nurse practitioners 

in Medicaid/CHIP arena now use coordinated care organizations. 

We get bundled payments so that it is not just the doctor being responsible for the outcome. But you had a social worker, a dentist, 

mental health provider. And, frankly, they take it upon themselves 

to make sure they have ultimate success. But I won’t belabor that 

point. That is another discussion. 

What percentage of your community health centers’ budget 

comes from Medicaid? 

Mr. HOLMES. Nationally, it is just under 50 percent. 

Mr. SCHRADER. OK. So that is a pretty big number. The plans 

we have heard from our Republican colleagues would pretty much 

devastate the funding for community health centers, because it 

would be tough to make up that 50 percent. 

What would happen to your expansion if the Republican plans 

went into effective and you were cut significantly, and particularly 

if you have any rural areas? 

Mr. HOLMES. Certainly, if we have an immediate reduction, it 

places us in a difficult position. We have 10 different medical and 

dental delivery sites in nine different communities. There is no way 

for us to be able to sustain all of those sites with a significant reduction in resources. That means we are faced with which sites do 

we close, which staff do we lay off, how do we reconfigure our providers. And it all affects access to care for our patients. 

Mr. SCHRADER. All right. Thank you. 

Ms. Mann, I guess I will preface my comment. I am like a lot 

of my Republican colleagues, I have got huge swaths of rural Oregon in my district. And so I am a little surprised, because 25 percent—well, no, actually, half of the kids in rural Oregon get their 

healthcare through Medicaid. It is so critical to the success and 

health of these communities. It is a key portion. The rural hospitals are a key component and portion of our economic growth in 

employment in these communities. 

So I am very concerned about how these reductions in Medicaid 

reimbursement, certainly over the long haul, will affect them. Can 

you talk a little bit more about what might happen in rural areas 

if the Medicaid expansions roll back like we are talking about? 

53 

Ms. MANN. I think one of the things we have been talking about 

so far in this hearing about ways to modernize our system of delivering care, ways to integrate behavioral health and physical health, 

ways to bring in telehealth, changing care practices, expanding our 

electronic health records, those all require investments. And so the 

first thing that will go will be any of those investments. And states 

will be scrambling to bring their spending down below the caps 

that are set by the Federal Government if the bill passes just because any dollar spent over that cap will be wholly state dollars, 

and any Federal dollars brought down over the cap will be clawed 

back the next year and really harm the state. 

So we will not see investments for sure, but we will likely see 

reductions in funding for community providers and other specialty 

providers that allow that fragile fabric of access in rural areas to 

be able to work. 

Mr. SCHRADER. All right. Thank you. 

Ms. Snyder, you talk about the reduction in uninsured rate for 

kids, I think 16 to 6 in Texas and stuff. What will happen to that 

uninsured rate in Texas if some of the Republican healthcare plans 

go through as currently envisioned? Will it go up or down? 

Ms. SNYDER. So what I can tell you is the CHIP program, clearly, 

in Texas precedes the advent of the ACA, the AHCA, or the Senate 

proposal that was advanced yesterday. The CHIP program in Texas 

is highly successful. As I mentioned, it has resulted in a reduction 

in the percentage of—— 

Mr. SCHRADER. What about the Medicaid piece? If the Medicaid 

reimbursement for Texas is cut as proposed, is your children’s uninsured rate going to go up or down? 

Ms. SNYDER. So we are, right now, looking at the implications of 

the legislation that has been proposed on the House side, as well 

as the proposal that was advanced yesterday, to determine how 

that is going to impact the state. What I will tell you, as a 

state—— 

Mr. SCHRADER. You are not sure quite yet? 

Ms. SNYDER. We are still looking into that, yes. 

Mr. SCHRADER. All right. Well, I appreciate that, and that is a 

good answer, given where you all are coming from. And I feel sorry 

for a lot of your providers. I know rural hospitals in your state, in 

many states, that did not do the expansion are facing some pretty 

tough times. 

I think there is some middle ground here, to be quite honest with 

you. I too am in favor of making sure that Medicaid is put on a 

budget, but a budget that is realistic and doesn’t result in tons of 

uninsured children, children that we should not be balancing the 

budget of this country on. I worry about that. But I look forward 

to work with my Republican colleagues to fix this system overall. 

And I yield back. 

Mr. BURGESS. The gentleman yields back. The chair thanks the 

gentleman. 

The chair recognizes the gentlelady from California, Ms. Eshoo, 

5 minutes for questions, please. 

Ms. ESHOO. Thank you, Mr. Chairman. And thank you to the 

witnesses. 

54 

I just want to start out by speaking about what is racing through 

me throughout this hearing, and that is that I have lived my life 

for my children. And I think everyone here has as well. We are 

talking about something that couldn’t be more sacred: our children, 

my children, your children, the children of our Nation. 

And I really am overwhelmingly sad by what is happening. I 

can’t believe that this is taking place in our country. There is some 

sort of conflation that is going on here today. It is important for 

us, obviously, to reauthorize the CHIP program and the other, and 

with all of everything that should be a part of it. But to have the 

evisceration of Medicaid as the top issue, top line headline of today 

that is going on in the Congress, what are we doing? 

Children need patriots in the Congress. I don’t know what has 

happened to the Republican party. I don’t recognize it. Republicans 

that are in my district don’t support any of this. And a strong 

CHIP program depends on a strong Medicaid program. So there is 

like a pretend thing going on here. CHIP this, CHIP that. CHIP, 

CHIP, CHIP. What about the chipping away at or the destruction 

of Medicaid? Does anyone here think that we are going to be able 

to care for, provide what our children need in our country if we rip 

away $834 billion out of Medicaid for tax cuts that were taking 

care of them? 

There are myths that are swimming around. The myth that 23 

percent bump in the ACA did nothing to improve children’s coverage. Since the enactment of the enhanced 23 percent bump and 

the matching payments for CHIP, the states have used those additional dollars to improve the care and expand coverage for kids in 

our country. There is a myth that CHIP is the primary insurer of 

low-income children in the United States. Medicaid is the primary 

insurer of low-income children in the United States. 

So, yes, CHIP is important, but let’s not let all these myths creep 

in around it. This is a shameful thing that is taking place in our 

country. It really is a shameful thing, and it is hurtful. What is 

going to happen to children that are disabled? Anyone examined 

their conscience on that? 

So I would like to go to Ms. Mann and ask you to expand on the 

issue of disabled children. It is one thing for children to get the 

basic care that we all provided for our children. I think these families that have disabled children are among the most courageous 

people in our country in what they need to deal with. They get up 

earlier in the morning because they have a lot of things to do for 

that child. It costs more money, more doctors, more complications 

in their lives, more complexities. And they try to balance their affections too, because the other little ones may end up feeling that 

this one other child is getting more attention from the parents. 

This is what takes place in people’s lives every single day across 

our country. 

And we are sitting here in some insulated, air-conditioned, greenpainted room as if this one thing that we are going to reauthorize, 

and we should, is just going to take care of everything, and that 

anyone that is involved in it and votes for it has absolution. They 

don’t, in my view. 

So, Ms. Mann, would you just say a few words about disabled 

children and these programs that are knitted together. 

55 

Ms. MANN. Yes. Certainly. Thank you for your comments. So 

Medicaid has many different eligibility pathways, and there are 

many different definitions of what is a disabled child. There is a 

category in the Medicaid program that if you have been determined 

disabled by the Social Security Administration of the state, then 

you automatically get Medicaid. In that circumstance, there are 

about 1.9 million children around the country who fit in that category. And based on that medical necessity standard that we 

talked about before, they get the care that they need, and they get 

the kind of care that really is not otherwise available in the commercial market. And some of them get special waiver service. They 

will get respite care for that caregiver who, as you say, is going 20 

hours a day in terms of taking care of their child. They will get a 

wheelchair refitted as they age and as they grow. So it is a very 

important program. 

And then there are other kids within the other categories of the 

Medicaid program. They may be foster care kids, they may be just 

low-income kids. They might not have a disability that meets that 

level of disability, that gets them into the category of disabled, but 

they are kids with very significant healthcare needs. And they too 

have their needs met very strongly by the Medicaid program, which 

is, I think, why you see those statements from organizations like 

Family Voices, Parents of Kids with Special Healthcare Needs. 

Ms. ESHOO. Thank you so much. 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady’s 

time has expired. 

The chair recognizes the gentleman from Texas, vice chairman of 

the full committee, Mr. Barton, 5 minutes for questions, please. 

Mr. BARTON. Thank you, Mr. Chairman. I apologize. I, after 

votes, took a group of Members and staffers out to the hospital to 

see Matt Mika, one of the individuals that was shot in the incident 

last week at the congressional Republican baseball practice. So I 

am a little bit late getting back. 

I think it is obvious—— 

Ms. DEGETTE. How is he doing? Give us a report. 

Mr. BARTON. He is up and—— 

Mr. BURGESS. Do not violate HIPAA, come on. This is a Federal—yes. 

Mr. BARTON. He is doing very well, Diane. I can’t go into details, 

apparently. But he is excited, and hopefully he is going to be out 

of the hospital within a week. 

Mr. GREEN. Did the chairman invoke HIPAA? 

Mr. BARTON. Yes, I am not a doctor. I can just tell you what I 

saw. OK? I saw a breathing, happy young man who is wearing the 

cap of his employer, which I am not going to publicize. But they 

sell a lot of chicken and they are headquartered near Arkansas. 

Now, to the purpose of this hearing, Mr. Chairman, we want to 

talk about CHIP reauthorization and community health centers. 

And I think the last CHIP reauthorization I was one of the chief 

cosponsors of. So we are obviously for CHIP and the community 

health centers. My family foundation has bought a building in my 

hometown and donated it to the Hope Clinic, which is a community 

health center for Ellis County, and the Nel Barton annex is providing services for low-income citizens in Ennis, Texas, and is 

56 

doing very, very well. And so we are strong supporters of the community health centers and SCHIP. 

I have two questions that I have been asked to ask our distinguished panel. This one is for Ms. Snyder and Mr. Holmes. This 

committee earlier this year passed a bill to charge millionaires, 

people who have won the lottery, a little bit more if, in fact, they 

have come into some extra money. To put it in perspective, this policy change would mean millionaire Medicaid beneficiaries would 

only pay approximately $70 more each month. That would save apparently several billion dollars. 

Would you two support making millionaires on Medicare to pay 

their fair share to help pay to extend the SCHIP and the health 

center funds? That was supposed to have been asked by Mr. Walden, but he is not here to ask it. 

Ms. Snyder. 

Ms. SNYDER. Congressman Barton, I am happy to answer the 

question. As I have mentioned in my testimony earlier and in some 

of my responses over the course of the hearing, in Texas, we are 

very much in support of personal responsibility and infusing a level 

of personal responsibility into the programs that we administer. 

Certainly, this, I think, is a good example of an opportunity to infuse that personal responsibility into one of our programs in a way 

that is commensurate. Ultimately, we hope, with the earnings, that 

each of those individuals is lucky enough to be a beneficiary of lottery winnings is able to draw down as income. 

So we would support a measure such as that and would support 

that it ultimately reflect the earnings in a way that holds individuals accountable. 

Mr. BARTON. Mr. Holmes. 

Mr. HOLMES. Certainly, the expenditures of the Federal Government are important to its people. It is also important to where 

those expenditures are directed. We have common things that we 

need to do as far as defense, but we also need to look at the care 

of our most vulnerable populations. And in order to do that, we 

need money. That money is coming from the taxpayers. And we 

have to make sure that it is a fair system and that it is a system 

that has good return. 

I will say, from a health center perspective, we are concerned 

about the return on investment that the taxpayer is making in 

health centers and that we use those dollars wisely to lessen the 

burden on the taxpayer, and that we show a return for those dollars in the savings and the Medicaid programs and the Medicare 

programs and throughout all of our patient population. 

Mr. BARTON. My time has expired, Mr. Chairman. I will submit 

the other question for the record. 

I do want to say that we are working on a bipartisan basis. We 

have a bill called the ACE Kids Act. And we had it in the last Congress with over 200 cosponsors. Ms. Castor, who just left, Mr. 

Green, I think everybody in the room right now who is a Member 

was a cosponsor in the last Congress and hopefully will be in this 

Congress. We are going to reintroduce that very quickly. 

But it is a bill for these special needs children that have complex 

medical conditions to create a medical home so that their care can 

be coordinated with Medicaid across state lines. And it is a volVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00062 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
57 

untary optional program for the states to participate in. But if they 

choose to participate, it apparently is a piece of legislation that will 

make the care much better and also save money for the taxpayers. 

And we hope to reintroduce that bill in the very, very near future. 

And we have a commitment to have a hearing on it. And hopefully, 

we are going to have a commitment to move that bill. 

With that, I yield back. 

Mr. BURGESS. The gentleman yields back. The chair thanks the 

gentleman. 

The chair recognizes the gentlelady from Colorado, Ms. DeGette, 

5 minutes for questions, please. 

Ms. DEGETTE. Thank you very much, Mr. Chairman. 

We have been talking a lot today about—at least on this side of 

the aisle—our concerns about what this TrumpCare bill would do 

to Medicaid and how it would interface with the CHIP program, because CHIP is something that we have all agreed is important for 

the children of this country, but it really does ride on the foundation of Medicaid. I want to talk a little bit about that. 

The $840 billion cut to Medicaid and converse of the program 

into a per-capita cut, under TrumpCare, it would then be combined 

with President Trump’s budget, which cuts CHIP funding by $3.4 

billion by eliminating this so-called 23-point bump. So Medicaid 

covers 37 million children, and nearly 9 million additional are covered under CHIP. I am trying to figure out what would happen if 

both the TrumpCare cuts to Medicaid and the budget cuts to CHIP 

went through. 

Ms. Mann, can you discuss, from your knowledge, how these proposed Medicaid cuts and the CHIP proposal under the Trump 

budget would affect children in the states? 

Ms. MANN. Certainly. Thank you for your question. The House 

provision around setting caps for the program would fundamentally 

change the commitment that the Federal Government makes to the 

children, to people with disabilities, to parents, to pregnant women, 

to people, elderly, who are served by that Medicaid program. And 

they would force states to have to significantly reduce their spending in order to stay within the caps, unless they were going to 

spend only their state-only dollars. 

And so the kinds of things that states would end up doing, no 

doubt reluctantly, would be things that would reduce access to 

care, things that would potentially look at some of these specialized 

programs for kids with brain injury and special healthcare needs, 

pull out funding around children’s school-based services and early 

intervention care. A number of different ramifications we think 

that that would have. 

In addition, it would pull out the funding for the expansion population. And this often talks about the so-called childless adults in 

the expansion population—I say so-called, because I would be a 

childless adult. My children are grown. I am not a childless adult. 

But many of those individuals covered under the expansion are 

parents. 

Ms. DEGETTE. Right. 

Ms. MANN. And children do better when their parents are 

healthy. So between those cuts and the budget cuts, I think we 

would see a really devastating change for children’s coverage. 

58 

Ms. DEGETTE. Let me follow up and ask you, do you think of the 

children who would lose their insurance or lose some of those specialized benefits under the cuts, could they be covered by CHIP? 

Ms. MANN. CHIP is not designed, both in its financing and in its 

benefit structure, to pick up those children. 

Ms. DEGETTE. To pick up those kids. That is right. 

Ms. MANN. And if you are pulling the 23 percentage points away 

from CHIP, we are going to see a ratcheting down of CHIP. 

Ms. DEGETTE. But CHIP is really designed to be in addition to 

Medicaid. 

Ms. MANN. That is right. 

Ms. DEGETTE. It is not as a substitute. 

Ms. MANN. It needs the foundation of Medicaid in order to operate well. 

Ms. DEGETTE. Now, the administration has said they might 

allow states to lower the bar on Medicaid benefits, cost sharing, 

and other attributes. And I think you alluded to this, but if those 

programmatic changes go into effect, then how is that going to impact kids in light of the proposed cuts? 

Ms. MANN. Well, there are many ways in which whether it is increased cost sharing and premiums for children and families at 

very low incomes, we talked about lottery winners, but most of the 

children on Medicaid have incomes below the poverty line. For a 

family of three, that is about $1,700 a month to support three people every month for rent, food, utilities, all that they need. So those 

kinds of responsibilities may be hard for families to bear. 

In addition, if there are reductions in the benefits. If there are 

waivers to EPSDT and kids can’t get dental services or kids can’t 

get transportation. We have talked about some of the problems 

that children face in rural areas. They need help getting transportation to medical care. So those are all of the kinds of ways besides 

just absolutely cutting a group of children who are high-needs children off the program that states may have to turn to under caps 

and further budget cuts. 

Ms. DEGETTE. And states have their own set of budget issues too. 

In my state, we have a constitutional prohibition against raising 

taxes without a vote. So it is not like states have huge pools of 

money they are going to pour into this. 

Thank you so much, and I yield back. 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady 

yields back. 

The chair recognizes the gentleman from Illinois, Mr. Shimkus, 

5 minutes for your questions, please. 

Mr. SHIMKUS. Thank you, Mr. Chairman. I’m sorry I wasn’t here. 

I was with Coach Barton as we went up to the hospital. So I 

haven’t been able to follow all the activities that have been going 

on in the hearing. 

And I think it is safe to say, bipartisanwise, that we support the 

Medicaid program and we support CHIP. So the real debate, from 

what I am gathering, is, you know, tied into whatever the Senate 

is doing, whatever we did. So let me just ask a question. Does anyone at the panel know our national debt? 

Mr. Holmes, do you know how much our national debt is? 

Mr. HOLMES. I believe that it is close to $20 trillion. 

59 

Mr. SHIMKUS. Ms. Snyder? 

Ms. SNYDER. That is my understanding as well. 

Mr. SHIMKUS. Ms. Mann? 

Ms. MANN. Nineteen point six, I think. And a little over 13 is 

public. 

Mr. SHIMKUS. And what is debt? When we say that, what is that? 

Is it safe to say it is our promises to pay future services either— 

because we know what drives our national debt. It is the mandatory spending programs. People don’t like to say this, but it is just 

true. It is Medicare, Medicaid, Social Security, and our interest 

payments. 

I will point everybody up to the pie chart, which has been—I use 

this a gazillion times. So that is 2015 spending. And when we find 

on our budget, we are fighting that blue area, which is the discretionary. And we are going to be going through that. Does anyone 

reject that pie chart as being an accurate depiction of our Federal 

spending? 

No. OK. I am seeing everybody believing that what we put up 

there is accurate. 

So in the red, we have automatic spending and Social Security, 

Medicare, Medicaid, which means we are not engaged in determining those costs. They are automatic, other mandatory interest 

payment. And the blue is what we call discretionary spending. 

So go to the next chart. So this is what has happened in our Nation since 1965. As you see that the mandatory spending continues 

to grow, squeezing out the discretionary budget, which are things 

like defense, education, HHS, Department of Energy, roads, 

bridges, infrastructure, and the like. And so if left unchecked, in 

2026, we continue to start having big problems. And that is why 

we discuss it. 

We don’t discuss the debate on mandatory spending out of a desire to be mean, vindictive. We actually discuss this to save our 

country. Admiral Mullen said in testimony before the Armed Services Committee, our debt is our national threat. The threat to our 

country relies in that depiction there. 

So what we did in our healthcare bill—and I am not sure what 

my colleagues on the other side ended up saying, but the fact is we 

have Medicaid spending and we have a percentage of growth, per 

capita growth. So as much as they want to say it is a cut, over the 

years, it has increased Medicaid spending at a slower rate than 

what would happen if you left it automatic. That is the reality of 

the state. 

So if someone is something you are cutting Medicaid, in real dollars, they are not telling the truth. It is an inaccurate depiction of 

what we have done. And my guess is that is what has been going 

on today in the hearing. Where we are trying to get control of the 

threat to our Nation, which is our national debt, and we are trying 

to provide to our providers a stable funding stream that grows and 

let them, through the Medicaid program in the state, manage how 

best to provide for their citizens in the states. Empowering governors, who are actually closer, so it just impels me to raise that. 

And my time is almost over. But I would just end on this. This 

is from a report, and I can provide it to the minority. I am not asking for it to be submitted into the record. But current projections 

60 

bear no resemblance to a picture in which people historically dependent on Medicaid would lose their benefits. To the contrary, 

CMS estimates that Medicaid enrollment would stay roughly constant at current levels under the AHCA, while still be being substantially higher than projected before the Affordable Care Act was 

passed. Indeed, CMS finds that many states would still cover some 

of the ACA expansion population, even if lawmakers do away with 

the AC’s inflated Federal matching payment rate. This would mean 

expanded coverage relative to pre-AC levels, while also being equitable for the ACA. 

And my time has expired, and I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman’s 

time has expired. The gentleman yields back. 

The chair recognizes the gentleman from California, Mr. 

Ca ́ rdenas, 5 minutes for questions, please. 

Mr. CA ́ RDENAS. Thank you, Mr. Chairman. I appreciate the opportunity to hear from the witnesses and also the opinions of our 

colleagues. 

Unfortunately, my colleague, Mr. Shimkus, his time was expired, 

but I would like at least one of the witnesses to take an opportunity to respond to the narrative that we just heard for the last 

5-plus minutes. 

Ms. Mann, would you like to maybe enlighten us a little bit 

about the juxtaposition between the argument that was just made 

on expenditures versus healthcare? 

Ms. MANN. Sure. I will take a stab at that. Thank you. 

Let me say a couple of things. One is that the Medicaid reductions in spending in the bill largely are not being used to reduce 

the deficit. They are largely being used to finance new tax cuts in 

the bill. So the connection there is not as strong as it might otherwise seem. 

But I think the bigger issue in terms of the healthcare debate is 

there is no dispute, I think, among anyone, healthcare policy experts, hospital administrators, consumers, state Medicaid agencies, 

that we need to do what we can to bring down healthcare costs. 

And that has been, I think, what people have been engaged in, particularly in the last 4 or 5 years, the integration of behavioral 

health, the physical health, the care management, the telehealth. 

Those are all mechanisms to deliver better care and to do that in 

a way that lowers cost. 

And what won’t work is if you simply take one part of the 

healthcare system, the largest source of coverage for the lowest income people, and just say, on that program, we are going to put 

a cap, because that doesn’t change the cost. That doesn’t change 

the healthcare needs. It is a tougher job to do that. 

Mr. CA ́ RDENAS. In the long run, what you just described, if you 

just take away dollars and reduce benefits of being able to see a 

doctor or getting healthcare, in the long run, doesn’t that set us on 

a trajectory to increase cost and reduce the health level of Americans? 

Ms. MANN. I think that is absolutely right. When people don’t get 

care at the right time at the right place, they go to emergency 

rooms, they have more inpatient admissions. 

61 

Mr. CA ́ RDENAS. That is preventative care, which, ‘‘A stitch in 

time saves nine.’’ I love that. When I was a kid, I hated hearing 

that, but now that I am adult, gosh, makes a lot of sense, especially 

as a policymaker. 

Ms. Snyder, taking a swath of money, like $1 trillion away from 

our American healthcare system, and then—I don’t know if you 

agree with me, but having less people having direct access to care, 

doesn’t that create—in the long run, we put ourselves on charting 

the course of, oops, now per person long term we are probably 

spending more for healthcare and maybe not even having better 

care, just more emergency care, more last-minute care. 

Ms. SNYDER. So what I would say is I think the CHIP program 

actually provides us with a great opportunity to look at a program 

that does infuse some of those critical concepts into the program 

framework that can help to drive down costs. Those include state 

administrative flexibility, the inclusion of personal responsibility—— 

Mr. CA ́ RDENAS. Yes, but with all due respect, state flexibility is 

something that is thrown around a lot. But if you have more flexibility and a heck of a lot less money or resources to provide care 

for your state constituents, your people who live in your state, can 

that contribute to, oops, we are now setting ourself on a course 

where less care in time early on, less preventative care means that, 

oops, we are now snowballing for different reasons and having 

more expenditure need on care in the long run? 

Ms. SNYDER. So I think that is a great question, and I think—— 

Mr. CA ́ RDENAS. Well, what is the answer? Is that an accurate 

narrative or I am just not seeing it right? 

Ms. SNYDER. What I would say is it is incumbent upon states, 

and it is going to be more crucial than ever that states—— 

Mr. CA ́ RDENAS. I used to be a state legislator. I used to be the 

budget chairman. So I know what it is like to make those tough 

decisions, saying we have all the things that we love to do but just 

not enough money to do it. And then when the Feds go around saying we are going to block grant you, and all of a sudden we went 

from taking off a 0 of how much money the Feds give us, then we 

say, oh, my gosh, that didn’t reduce the need to provide for our constituents. All it meant is we have less money to do it with. 

Ms. SNYDER. And I believe that is the case. And so what it is 

going to really call on us to do is to critically evaluate the data that 

we have on hand and ensuring that we are making informed and 

smart decisions—— 

Mr. CA ́ RDENAS. Sure. But with all due respect, if I were a single 

mother with two children and people are telling me, reevaluate 

your family situation, and I have no healthcare coverage for my 

children, that analysis ain’t going to do my diddly when my son 

gets really sick and gets a fever, and I don’t have a clinic to go to, 

and I don’t have coverage, and I am not part of CHIP anymore because I am on a waiting list, or I don’t have Medicaid anymore because I am on a waiting list for my state. 

And then all of a sudden, guess what I am going to do as that 

single mom? I am going to end up in the emergency room. And, 

gosh, darn it, I think it is going to cost the state more. It is going 

62 

to cost that hospital more. It is going to tax them. It is not going 

to help my challenge. 

For Heaven’s sakes, if my child has a fever because he has a 

more serious condition, and if I would have taken him to a doctor 

2 years ago, they would have found it early, and all of a sudden 

now my child has fourth stage something else. Oh, believe me, we 

are going in the wrong direction. 

And I appreciate your generosity, Mr. Chairman, for allowing 

some of us to go over our time on both sides of the aisle. Thank 

you. I am out of time. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. 

The chair recognizes the gentleman from New York, Mr. Engel, 

5 minutes for questions, please. 

Mr. ENGEL. Thank you very much, Mr. Chairman. 

I want to make a statement and then I have a couple of questions for Ms. Mann. 

Let me say at the outset that I strongly support CHIP, the Children’s Health Insurance Program, and our Nation’s community 

health centers. I was very proud to support the Medicare Access 

and CHIP Reauthorization Act back in 2015, and it most recently 

extended those two vital programs. 

I would like to point out, though, that those reauthorizations 

passed the House in March of 2015 and was signed into law by 

mid-April, and yet here we are at the end of June without a plan 

to fund programs set to expire in September. It is certainly not 

right. 

And in reality, our timeline is even tighter than that. Months before their funds are depleted, some states must start the process 

of shutting their CHIP programs down. And that means that if 

Congress doesn’t act fast, it is entirely possible that children will 

see their coverage disrupted, and I think Mr. Ca ́ rdenas pointed 

that out. 

So why hasn’t Congress acted yet? Why didn’t we vote to extend 

funding for CHIP and community health centers in March as we 

did in 2015? And the answer is that TrumpCare monopolized the 

House’s time and prevented us from doing all these important 

things. 

And that is not the only thing that TrumpCare has endangered. 

TrumpCare will cut and cap care for the 37.1 million children on 

Medicaid. And on top of that, TrumpCare’s radical restructuring of 

Medicaid has dangerous implications for the CHIP program. A 

strong CHIP program depends on a strong Medicaid program. They 

work in concert to afford children comprehensive coverage. 

How? First of all, more than half of children with CHIP are actually enrolled in expanding Medicaid coverage that is financed by 

CHIP. These programs also work together to meet the needs of different populations of kids since Medicaid covers benefits that other 

insurers do not. 

CHIP reauthorization is vitally important for America’s kids. I 

don’t dispute it. My Democratic colleagues don’t dispute it. But in 

a discussion on this topic—a discussion on this topic can occur in 

a vacuum. If TrumpCare becomes law and Republicans therefore 

63 

succeed decimating Medicaid, there is no way to go around it. Children will be much worse off. 

I want to talk about President Trump’s budget, which unfortunately exacerbates the problems that TrumpCare creates for kids. 

While we should enact a full, long-term extension of CHIP, this 

budget proposes harmful changes to the program. 

What does it do? It will abolish the enhanced Federal funding 

match that states get now. It will overturn the requirement that 

states maintain children’s current eligibility levels, turning back 

the clock on historic coverage improvements, and cut off support for 

CHIP kids above 250 percent of the Federal poverty level. 

I want to talk more about this last point, because right now, 24 

states have income eligibility for Medicaid and CHIP and are greater than 250 percent of the Federal poverty level. This includes my 

State of New York. We are a high cost-of-living state. So what you 

buy in New York, you buy a lot less for the same money than you 

do in other states. It is ridiculous to penalize states like mine. The 

administration wants to cut off Federal dollars, give nearly half of 

all states the flexibility to cover children above 250 percent of the 

Federal poverty level. 

We hear a lot about states’ rights, and yet we want to take away 

the flexibility that states have, the programs that states deem are 

important for them. We want to tell them, the Federal Government, what they can and cannot do. So much for states’ rights. 

If this cut takes effect, I have to imagine that states will have 

no choice but to restrict eligibility for the CHIP program, thus cutting off care for children who have CHIP coverage today. So it is 

bad enough that we won’t be helping children who need this coverage; it will be throwing children off who have it today. 

So let me ask you, Ms. Mann, since this provision would affect 

my district, where one-third of children are covered by Medicaid or 

CHIP, I am extremely concerned about its potential effects. Can 

you tell us what we can expect to happen if Federal support for 

CHIP kids above 250 percent of the Federal poverty level is cut off? 

Ms. MANN. Thank you for the question. You are absolutely right. 

We have about 24 states that cover children at some income levels 

above 250 percent of the poverty line. 

Most of the children actually in the program, 97 percent, have 

incomes below 250 percent of the poverty line. But those states 

that have increased their eligibility levels have made a determination, have exercised their safe flexibility because of cost in that 

state, because of market conditions in the state, for various reasons 

of concern for the kids in their states have decided that having 

CHIP as an option for those children is really important. 

And I should say, New York, like every other state that covers 

children at higher income levels, requires the families to pay a portion for their care, so there is premiums and the premiums slide 

in accordance with the income. 

If in a state like New York with high healthcare costs and high 

premiums for other kinds of coverage have to end their coverage, 

go down to 250 percent of poverty, those children will be scrambling for other kinds of care. They will pay higher cost. Their benefits won’t be as pediatric focused as they are in the New York 

CHIP program. And many of them, because of what is called the 

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family glitch, won’t be able to qualify for subsidies in the marketplace. 

Mr. ENGEL. Well, I had a couple of more questions, but you have 

really answered them about how this in turn would effect coverage 

levels—— 

Mr. BURGESS. That is good, because your time has expired. So 

the gentleman yields back, and the chair thanks the gentleman for 

his participation. 

I want to recognize myself for questions. The chair would point 

out that the chair did delay his questions until the end to allow all 

other members to ask their questions and then accommodate their 

travel plans, if they had them. I may not use the entire 5 minutes, 

because this has been a very robust and insightful discussion. 

We do have a task ahead of us, which is the funding for the State 

Children’s Health Insurance Program, which concludes on September 30 of this year, the end of the fiscal year. That, of course, 

was a fiscal cliff that was set in motion under the Affordable Care 

Act, when the Affordable Care Act passed and was signed into law 

in 2010, as CHIP was reauthorized to the end of fiscal year 2019, 

funded only until the end of fiscal year 2015. Your chairman, as 

part of the SGR Repeal, managed to get 2 years of funding until 

fiscal year 2017, and that is the task that is ahead of us at this 

time. 

So, Ms. Snyder, I need to ask you what is just a very practical 

and Texas-focused question, but since the majority of the dais 

members now are from Texas, it will be appropriate. You said in 

your testimony, what you provided us in your testimony, that 

Texas has just concluded its legislative session. Is that correct? 

Ms. SNYDER. Exactly. 

Mr. BURGESS. And Texas, the legislative session is every 2 years. 

So your budget is now set until the next legislative session in 2019. 

Is that correct? 

Ms. SNYDER. That is correct. 

Mr. BURGESS. And there were some assumptions made by the finance committees that are there in the Texas House and Texas 

Senate, the budget committees in the House and Senate, there 

were some assumptions made that the funding for State Children’s 

Health Insurance Program would, in fact, continue until 2019. Is 

that correct? 

Ms. SNYDER. Yes, with the 23 percent additional bump in—— 

Mr. BURGESS. So changes that we make now come after the fact 

for what your state Senators and state representatives assume to 

be what was going to be available for them to include in their 

budget, and any changes we make now would have a significant effect on the state budget that has already been passed and I believe 

signed into law. Is that correct? 

Ms. SNYDER. Exactly, an $800 million impact over the biennium. 

Mr. BURGESS. So I understand the importance of getting this 

done. And let me just also say that under current law, under the 

Affordable Care Act, under current law, something happens to disproportionate share funding in Texas. Doesn’t it? 

Ms. SNYDER. Yes. 

Mr. BURGESS. What is that that happens to disproportionate 

share funding? They have funds that go to hospitals that see a disVerDate Nov 24 2008 15:59 May 29, 2018 Jkt 037690 PO 00000 Frm 00070 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-41 CHRIS
65 

proportionate share of Medicaid, low income, and uninsured. What 

happens to those funds in Texas? 

Ms. SNYDER. Can I ask you to clarify the question? 

Mr. BURGESS. What happens under current law, under the Affordable Care Act, so-called DSH funds, the disproportionate share 

funds, those additional funds paid to hospitals, paid to institutions 

to see a disproportionate share of Medicaid low-income and uninsured, what happens to those funds at the end of this fiscal year? 

Ms. SNYDER. And I am sorry, I don’t know the answer to the 

question. 

Mr. BURGESS. Well, I know the answer. 

Ms. SNYDER. And I apologize. 

Mr. SHIMKUS. I know the answer too. 

Mr. BURGESS. And I will be glad to share it with the committee. 

Those funds, under current law, under the Affordable Care Act— 

of course, everyone is going to be lying down the allegiant fields of 

ObamaCare. There is going to be no need to provide additional 

funding to those hospitals because everybody has got this wonderful health insurance that was provided under the ACA. 

But under current law, Texas is going to lose those funds in October of this year, and that was an effort—we did try to correct 

that in the bill that passed through this committee in a 28-hour 

markup and passed on the floor of the House the first part of May. 

And I know my state counterparts were very interested that we 

take care of that discrepancy, and I think that we have. 

Let me just ask you, because I have run a little bit long with 

that, we all want our dollars to be spent appropriately. And Medicaid has a history. Sometimes dollars aren’t always spent appropriately. But over and above the dollars being spent appropriately, 

if a patient is eligible for Medicaid, but they also have a commercial insurance, another third party that is supposed to be liable for 

their medical care, sometimes the path of least resistance is just 

to bill the Medicaid system, and that seems to be a quicker way 

of collecting the money. 

But one of the things that we have been working on is to enhance the ability to collect the third-party liability, if there is coverage that is actually owed by another payer, a commercial insurer. 

So what has your experience been in managing potential overpayments within the state related to third-party liability? 

Ms. SNYDER. So we are very committed in the State of Texas to 

ensuring, when there is another payer source, that we are capitalizing on that payer source and that Medicaid remains the payer of 

last resort. 

We have efforts underway, both within the Medicaid program 

and in conjunction with our inspector general, to ensure that we 

are systemically drawing on the funding that is available from 

those other payer sources. It is one of our priority projects every 

year, understanding that that Medicaid impact is the payer last resort. 

Mr. BURGESS. Very good. Well, we will have legislation coming 

on that, and I appreciate your input on that. 

Mr. Holmes, let me just ask you. I certainly appreciate what you 

do and what other people involved in community health centers 

and federally qualified health centers provide. When a patient sees 

66 

a physician or a nurse practitioner at a federally qualified health 

center who is covered by Medicaid, is the rate reimbursed by Medicaid the same as it would be by a physician practicing in private 

practice in the same town? 

Mr. HOLMES. It is not, in most cases. Health centers are paid 

under a PPS system, and it is a bundled set of services for the 

Medicaid patient. And it is based on payment methodology that 

was passed through Congress many years ago. And that is different 

than a discounted fee for service payment arrangement that currently exists with a number of other Medicaid providers. 

Mr. BURGESS. And that would be the provider out in private 

practice? 

Mr. HOLMES. That is correct, unless those providers are in a 

capitation system or in some type of ACO. 

Mr. BURGESS. Be careful. We have heard that ‘‘capitation’’ is a 

bad word this morning. 

Mr. HOLMES. It is a method of payment where you are paid on 

a per-member per-month basis. And for that per-member permonth basis, you are delivering the scope of care within that agreement. 

Mr. BURGESS. And another aspect of the difference between a 

doctor in private practice and a doctor working in a federally qualified health center is the liability question. Is that not correct? 

Mr. HOLMES. That is correct. 

Mr. BURGESS. So a doctor in private practice has to carry medical 

liability insurance, which, as you know, in some areas, can be quite 

expensive. But in a federally qualified health center that cost is 

ameliorated by participation in the Federal Tort Claims Act. Is that 

correct? 

Mr. HOLMES. That is correct. And it was under Congress’ direction to include health center physicians and providers in FTCA, because they felt it was a method to save healthcare dollars. 

Mr. BURGESS. And I don’t disagree with that. In fact, probably 

when Gene Green was in the State House in the early 1990s, our 

state legislature provided doctors who did a certain percentage of 

Medicaid in their practice the first $100,000 in liability coverage. 

That didn’t last, and I don’t know why. It was probably too expensive as a state program. 

But if we want to encourage the number of providers to see patients who are covered by Medicaid, that seemed to me to be a very 

forward-leaning aspect of what they did back in the early 1990s. 

So I want to thank my colleague from Texas. I am sure he was the 

main driver of that liability assistance when it occurred. 

Well, I want to thank all of our witnesses. Seeing no other members wishing to ask questions, I do want to thank the witnesses for 

being here. 

We received outside feedback from a number of organizations on 

these bills, so I would like to submit statements from the following 

for the record: the American Academy of Dermatology Association; 

America’s Essential Hospitals; American Academy of Family Physicians; AHIP; the Healthcare Leadership Council; our House colleagues from Minnesota; a CHIP letter from 1,200 local state and 

national organizations. So without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

67 

Mr. GREEN. Mr. Chairman, I won’t ask for the 4 minutes extra 

you have on your 5 minutes, but—— 

Mr. BURGESS. No, sir, I accrued all of the extra minutes I gave 

on your side and utilized them for our side, because I knew my 

questions would be most important. 

Mr. GREEN. Well, I appreciate your activity, but that was taken 

at the end. All I want to do is—give me 1 minute. 

Mr. BURGESS. The gentleman is recognized. 

Mr. GREEN. First of all, I was in the legislature in 1991, and I 

am not sure but—after that I ran for Congress. But the State of 

Texas is going to be in special session. Is that not correct? 

Ms. SNYDER. That is correct. 

Mr. GREEN. In the next few weeks. Having been there and done 

that, nobody likes special sessions in summer. 

But the other issue is, Texas did not expand Medicaid. Is that 

correct? 

Ms. SNYDER. That is correct. 

Mr. GREEN. OK. And the other issue is third-party coverage. 

That is not unusual, because if you have an auto accident, the hospital has—in Texas, I assume everywhere else—has a right to put 

a hospital lien on that, whatever you win from your lawsuits. So 

I don’t have any problem with Texas doing that under Medicaid, 

so that is pretty common. 

But that is not going to solve our problem with Medicaid in our 

terrible program we have in Texas. And even there, when Democrats were in the majority, Texas has always have been very conservative. Our Medicaid program is nothing compared to some others. 

And, in fact, I will give one example. After Katrina, the Houston 

area received a quarter of a million people. We brought them in 

under our Medicaid system, although the state legislature was out 

of session. We were able to get Federal money to do the state 

match for those folks, and over a period of time, they either went 

back to Louisiana or they became Texan. And that is when I found 

out that Louisiana actually gets 75 percent Federal reimbursement, and Texas receives 67 percent. And I would hope maybe our 

subcommittee could look at that and see why is it more expensive 

than Louisiana. 

Mr. BURGESS. Will the gentleman yield? 

Mr. GREEN. I would be glad to. 

Mr. BURGESS. I do not know all of the intricacies of the formula 

that CMS uses to calculate, but it is based on the average state income as well and probably reflects that average state income in 

Texas is somewhat greater than the average state income in the 

State of Louisiana. And that is probably a fiscal fact for which we 

should both be extremely grateful and thank our lucky stars that 

we live in Texas. 

Mr. SHIMKUS. Would the gentleman yield? 

Illinois is a 50/50 state, so I just want you to put that on the 

record. 

Mr. GREEN. Thank you, Mr. Chairman. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. 

68 

Let me just continue on the unanimous consent requests that I 

was doing. I also want to ask unanimous consent to submit for the 

record copies of the Congressional Record volume 141, issue 207, 

Friday, December 22, 1965, where Senator Patty Murray introduced to the record over in the Senate a letter to President Clinton 

asking for the participation in a per-capita cap arrangement. 

Mr. GREEN. 1995. 

Mr. BURGESS. Did I say 1995? 

Mr. GREEN. You said 1965. 

Mr. BURGESS. 1965. 1995. Time flies. 

I also want to submit for the record a New York Times editorial 

from 1997, February of 1997, called ‘‘Making the Budget Bearable,’’ 

where they point out that the President offers an important reform 

of Medicaid proposing to control future spending by placing a cap 

on the amount of Federal spending per enrollee and allowing states 

to place enrollees in managed care without going through the frustrating process of begging for Washington’s approval. 

Without objection, so ordered. Those things will be entered into 

the record. 

Mr. BURGESS. Pursuant to committee rules, I remind members 

they have 10 business days to submit additional questions for the 

record. I ask that witnesses submit their responses within 10 business days upon a receipt of those questions. 

Without objection, the subcommittee is adjourned. 

Mr. GREEN. Mr. Chairman, we could be here all day, but I also 

wanted to remind you, in 1995, I think the Senate Republicans 

wanted an individual mandate. 

Mr. BURGESS. That was actually in response to a request for a 

block grant. 

The subcommittee stands adjourned. 

[Whereupon, at 1:14 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

69 


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,.r • 

1f r 

FIRST FOCUS march \:~:i) of dimes· f',":!uHn y A FIGHTING CHANCE FOR EVERY BABY~ 

EQ~diatric~ ,SSOCIATIONO~ Nurse 

Practitioners· 

CHILDREN'S 

HOSPITAL 

ASSOCIATION 

American Academy 

of Pediatrics 

Children's Defense Fund 

DEDICATED TO THE HEALTH OP ALL CHILDREN'" 

children's 

dental health 

June 14, 2017 

Statement of the Children's Community Urging Congress to Act Quickly on a Strong, 

Five-Year Extension of Funding for the Children's Health Insurance Program 

As advocates for children and pregnant women, today we call on Congress to take immediate 

action to stabilize CHIP in its current form and enact a five-year extension of CHIP funding. 

Congress should protect the gains in children's health coverage that have resulted in more than 

95 percent of all children in America being enrolled in some form of insurance coverage. 

Together, Medicaid and the Children's Health Insurance Program (CHIP) are an integral part of 

this success and we urge Congress to ensure that coverage for children and pregnant women 

provided through Medicaid and CHIP is protected and not disrupted in any upcoming 

legislation. 

Our organizations are deeply distressed about the devastating consequences for children and 

pregnant women that would result from drastic cuts to Medicaid or restructuring Medicaid into 

a per capita cap or block grant. Today, 37 million children get health coverage, including 

important health services in schools, through Medicaid. Medicaid covers roughly half of all 

births in this country, including the majority of care provided for preterm and low birthweight 

infants. Any proposal that imposes deep cuts to Medicaid or turns Medicaid into a per capita 

cap or block grant would have a significant impact on the health and well-being of half of our 

nation's children and pregnant women. Congress should abide by a "do no harm" principle 

when it comes to coverage for children and pregnant women. 

As the House Energy and Commerce Subcommittee on Health meets today for a hearing "to 

Examine Extending Funding for Health Programs Strengthening the Safety Net," our 

organizations are focused on the future of CHIP. We call on Congress in the strongest possible 

terms to take immediate action to fully extend CHIP in its current form for five years. 

CHIP is a 20-year old bipartisan health coverage program for children in working families that 

enjoys near-universal support in Congress and in statehouses across the nation. Senators, 
70 


28525.021

representatives, and governors all recognize the importance of CHIP in providing affordable, 

pediatric-specific coverage to almost 9 million children in low-income working families who 

cannot afford private coverage or lack access to employer-based coverage. CHIP also provides 

quality, affordable care to pregnant women in 19 states, allowing them to obtain the care they 

need to have healthy pregnancies and give birth to healthy infants. 

Despite its enormous success, CHIP's funding is set to expire on September 30, 2017 and states 

are just weeks away from setting in motion processes to establish waiting lists and send out 

disenrollment notices to families. Once undertaken, these actions will have an immediate 

effect, creating chaos in program administration and confusion for families. This is a fiscally 

irresponsible and eminently avoidable problem. 

Extending CHIP is particularly important in light of the ongoing debate on and uncertainty 

regarding the future of the Affordable Care Act (ACA), Medicaid, and the stability of the 

individual insurance markets. With state budgets already set for the coming year, states are 

counting on CHIP to continue in its current form. Changes to CHIP's structure- including 

changes to the Maintenance of Effort or the enhanced CHIP matching rate- would cause 

significant disruption in children's coverage and leave states with critical shortfalls in their 

budgets. Given CHIP's track record of success, now is not the time to make changes to CHIP that 

would cause harm to children. 

CHIP was a smart, bipartisan solution to a real problem facing American families when it was 

adopted in 1997 and its importance and impact in securing a healthy future for children in lowincome families has only increased. Today, we stand united in urging Congress to ensure that 

their actions match their words in protecting and preserving the health and well-being of all of 

America's children and pregnant women. As Congress works to reform our nation's health care 

systems, a primary goal should be to improve health coverage for children, but at a minimum, 

no child should be left worse off. To this end, a long-term extension of federal funding to 

sustain existing CHIP programs is a necessary first step. 

Contact: Ari Goldberg, VP Communications, First Focus, 240-678-9102, 

agoldberg@firstfocus.org 

#KeepKidsCovered 

#Do NoH arm 

2 
71 


28525.022

Statement for the Record 

House Energy and Commerce Subcommittee on Health 

Examining the Extension of Safety Net Health Programs 

June 23, 2017 

Presented by 

North American Society for Pediatric 

Gastroenterology, Hepatology and Nutrition 

On behalf of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition 

(NASPGHAN), we urge Congress to enact a long-term funding extension of the Children's Health 

Insurance Program (CHIP) as quickly as possible. CHIP funding is currently set to expire on September 

30,2017. Swift action on a CHIP funding extension bill would provide much-needed certainty to states 

and families and ensure that health coverage for the 8.9 million children who rely on CHIP will not be 

disrupted. 

NASPGHAN is an organization comprised of 1,800 members who have specialized training and 

expertise in caring for children with disorders of the digestive system, liver and nutrition. As we have 

experienced first-hand, CHIP plans provide critical access to child-specific pediatric subspecialists. 

Unlike many private insurance plans, which are based on the health needs of adults, CHIP offers 

insurance with age-appropriate benefits that is affordable for middle-income families. 

CHIP has strong bipartisan roots and was developed as a state-federal partnership that gives governors 

broad flexibility to design programs targeting the needs of their pediatric population. The Society feels 

that an uncertain future of the CHIP program is a significant problem for states as they are already 

developing their budgets and negotiating contracts with insurers and providers. 

For states to continue their CHIP programs without interruption, they must know that that federal 

support for CHIP will exist beyond September. If funding is not stabilized, states will have no choice but 

to begin planning for the impending fUnding shortfall, which could lead to drastic program cuts through 

enrollment caps, benefit reductions, reductions in eligibility, or provider payment cuts. 

At a time when children's coverage rates have hit record highs -with more than 95 percent of our 

children enrolled in some type of health coverage it would be devastating if states begin to dismantle 

their CHIP programs. Given the uncertainty in the insurance market and as Congress continues to look 

at broader health system reforms, it is important that CHIP remains a stable source of coverage for 

children. 

Coverage provided through CHIP and Medicaid must be protected. As a Society that is dedicated to the 

health and well-being of children, we arc hopeful that our nation's leaders can work together to continue 

the current CHIP policy that is working well for states and families. NASPGHAN members urge 

Congress to make swift action on a long-tcrrn CHIP funding extension an immediate priority. 
72 


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6/2312017 Leading Children's Health Groups to House ofRepresentathes: Keep Medicaid Strong 

Leading Children's Health Groups to House of 

Representatives: Keep Medicaid Strong 3/22/2017 American Health Care Act would jeopardize care for children and families 

Washington, DC-The American Academy of Pediatrics, Children's Defense Fund, Children's Dental Health Project, Family 

Voices, First Focus Campaign for Children, March of Dimes and National Association of Pediatric Nurse Practitioners issue 

the following joint statement opposing the American Health Care Act's (AHCA) drastic changes to Medicaid and their 

detrimental impact on children and families: 

"Our organizations represent children, pregnant women, families, children's health care providers and advocates across the 

country, and we speak with one \Oice today to urge the U.S. House of Representatives to keep Medicaid strong for children 

and vote 'no' on the AHCA. This bill ends the Medicaid program as we know it, jeopardizing cowrage for the 72 million 

vulnerable Americans -primarily children, pregnant women, seniors and people 'Nith disabilities -who rely on Medicaid for 

their health care. 

Children make up the single largest group of people who rely on Medicaid; nearly 36 million children receive Medicaid 

coverage, including children with special health care needs and those from low~lncome families. Medicaid also provides 

comprehensi\e prenatal care to pregnant women, allowing millions of pregnant women to have healthy pregnancies and 

helping millions of children get a healthy start. Unlike many pri\18te health insurance plans, Medicaid guarantees specific 

benefits designed especially for children. Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSOT) 

benefits are the definitiw standard of pediatric care, cowring an array of services like developmental, dental, vision and 

hearing screenings, and allowing health problems to be diagnosed and treated appropriately and as earty as possible. Simply 

put: Medicaid works. In fact, children in Medicaid are more likely to get check-ups, miss less school, graduate and enter the 

workforce than their uninsured peers. 

Medicaid is able to provide affordable, comprehensive care for awry child because of the strength of Medicaid's statewfederal 

partnership. The program already provides flexibility to states and allows each state to meet the needs of its Medicaid 

population when a natural disaster, public health crisis like the current opioid epidemic, or economic recession increases the 

number of people enrolled and the cost of providing services. 

The AHCA includes harmful proposals to restructure Medicaid, and the changes to AHCA unveiled on Monday evening go 

from bad to worse, allowing e'.ien more damaging changes to the program. In addition to the bill's initial proposal to fund 

Medicaid through per capita caps, the amendments would allow states to choose a block grant model, which would 

eviscerate existing protections afforded to children and pregnant women in the Medicaid program. Comprehensi\e EPSDT 

benefits would no longer be required for children, allowing states to ration limited dollars by drastically cutting back pediatric 

services. 

Block grants and per capita caps haw a singular purpose, to reduce federal funding to states. In a bill that is supposed to be 

improving care for Americans, block grants and per capita caps shift costs from the federal go~vemment to the states, putting 

pressure on states to come up with the resources to cowr their Medicaid patients when federal funds run out and costs 

inevitably rise. These drastic changes would place politicians, rather than health care pr0\4ders, in charge of health care for 

children, pregnant women and families. Whether a tife-sa\1ng childhood vaccination, a wheelchair or a hearing aid, politicians 

should not be the ones determining who gets what coverage, which providers offer those ser..-;ces, and what families must 

pay. 

The AHCA does not make co~.-Srage more affordable for families. In fact, it makes it harder for families to afford premiums in 

the individual market and phases out the option for states to expand Medicaid to cover more low-income adults, which has 

httpsJ!vwm.aap.org/en-us/about-the-aaplaap..press-room'Pages/ChildrensCoa!itionAHCAOpposition.aspx 215 
73 


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612312017 Lead!ng Children's Health Groups to House of Representatiws: Keep Medicaid Strong 

led to tremendous cost sa\.1ngs for states and better health outcomes for families across the country. Having healthy parents 

means children are healthier, too. Stopping Medicaid expansion, restructuring Medicaid financing, and opening the door to 

harsh new requirements for Medicaid enrollees, as the AHCA proposes, are not only bad for state budgets, they are harmful 

to child health. 

The AHCA's pro\oision allowing states to deny Medicaid cowrage unless mothers and fathers are working is especially 

onerous. This provision would mean that a married mother of an infant could be required to retum to work 60 days aftergiiJing 

birth in order to keep her Medicaid coverage. Maintaining health coverage for mothers after birth is essential for infants' 

healthy development. Among adults with Medicaid coverage, about 80% are in working families; this proposal is not only 

short-sighted and dangerous, it offers a solution to a problem that does not exist. 

In short, our organizations are united in opposition to any threat to Medicaid that would jeopardize the gains we've made in 

children's coverage and dismantle a pillar program that millions of families rely on. More children are insured today than at 

any time in American history; the AHCA will rewrse that progress. We urge Congress to oppose the AHCA and to instead 

pursue policies that prioritize children and keep Medicaid strong." 

Earlier today, many of our organizations joined a letter with more than 400 organizations dedicated to imprm1ng the well-being 

of children from all 50 states and the District of Columbia to urge Congress to keep the unique needs of children and their 

parents front and center as they consider any changes to the nation's health care system. 

About the American Academy of Pediatrics 

- The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical 

subspecialists and pediatric surgical specialists dedicated to the health, safety and JAe!l-being of infants, children, 

adolescents and young adults. For more information, visit \-Wvw.aap.org and fo!Jowus on TWtter @AmerAcadPeds. 

About the Children's Defense Fund 

The Children's Defense Fund Leave No Child Behind® mission Is to ensure every child a Healthy Start, a Head Start, a Fair 

Start, a Safe Start and a Moral Start in life and successful passage to adulthood v.ith the help of cering families and 

communities. 

About the Children's Dental Health Project 

The Children's Dental Health Project (CDHP) is an independent nonprofit that creates and advances innovative poficy 

solutions so that no child suffers from tooth decay. Based in Washington, D. C., CDHP is driven by the vision of all children 

ach;eving optimal oral health in order to reach their full potential. We use data measurement and analysis to advance models 

that incentivize oral health, not just pf!yment for treating the symptoms of dental disease. CDHP seeks to lead the way 

toiN8rd a health care system that is truly inclusive of oral health, from payment to care delivery. Leam more about CDHP at 

>W!4V cdhp. org. 

About Family Voices 

Family Voices is a national, nonprofit, family-led organization promoting quality health care for ail children and youth, 

particularly those Wth special health care needs< Working Wth family leaders and professional partners at the local, state, 

regional, and national levels since 1992, Family Voices has brought a respected family perspective to improving health care 

programs and polfcies and ensuring that health care systems include, listen to, and honor the voices of families. 

https:/fwml.aap.org/en"us/aboul·the-aap/aap.press.room'Pages/ChildrensCoa!itionAHCAOppositiortaspx 3/5 
74 


28525.025

American Academy of Dermatology Association 

Statement for the Record 

House Committee on Energy and Commerce 

Subcommittee on Health 

Hearing: "Examining the Extension of Safety Net Health Programs" 

June 14, 2017 

Chairman Burgess and Ranking Member Green, on behalf of the American 

Academy of Dermatology Association (Academy), which represents more than 

13,500 dermatologists nationwide, thank you for your leadership in convening 

the hearing entitled "Examining the Extension of Safety Net Health Programs." 

The Academy is pleased to submit the following statement for your 

consideration. 

The Academy appreciates your leadership in holding this hearing to examine 

the extension of several important health care safety net programs, including 

the Children's Health Insurance Program (CHIP), Federally Qualified Health 

Centers (FQHCs) and the Community Health Center Fund (CHCF). 

Dermatologists are the only residency-trained physicians fully educated in the 

science of cutaneous medicine and surgery, including more than 3,000 unique 

skin disorders ranging in complexity and commonality. At any given time, 1 in 

3 Americans suffers from a skin disease, including non-melanoma skin cancer, 

melanoma, and psoriasis. Preserving and improving access to the quality care 

provided by dermatologists for all Americans is important in managing these 

conditions. 

In light of the Subcommittee's hearing, the Academy would like to highlight the 

important role that the Community Health Center Fund (CHCF) has played in 

improving access to care for patients through community health centers 

(CHCs). CHCs provide access to much needed health care services for low 

income patients, serving over 25 million patients, including 7.5 million children 

and 1.2 million homeless patients, each year. 1 CHCs also provide significant 

savings to our health care system by providing preventive services and by 

helping patients manage chronic disease. Without an extension of the CHCF 

this year, CHCs would face a destabilizing 70% reduction in funding. Without 

this funding, several thousand centers would be forced to close, leaving an 

estimated 9 million patients without access to necessary care. 

The Academy is committed to ensuring that every patient has access to safe 

and effective dermatologic care. To that end, dermatologists provide in-person 

and consulting services to CHC patients through in-person treatment; through 

telemedicine and teledermatology services, including store-and-forward 

technologies; and through clinics and patient referrals under the Extension for 

Community Healthcare Outcomes (ECHO) program. In these ways, CHCs 

help provide patients in underserved areas with access to important specialty 

1 American Health Centers 2017 Fact Sheet 

Sulanne M. Olbricht, MD 

Barbara M, M<:1thes, MD 

lin"'"•'' 

M.srtn Van Beek, MD, MPH 

Elaine Weiss 

,.,;rf(! 
75 


28525.026

American Academy of Dermatology Association 

Statement for the Record 

June 14, 2017 

Page 2 of2 

care, such as dermatology. Currently, only select CHCs offer telemedicine and 

teledermatology services for patients; but with additional funding, these services could be 

expanded, further building on the mission of CHCs and increasing access to care for 

patients who might otherwise wait much longer to access the care they need. In addition, 

expanding access to such services could help reduce wait times and unnecessary 

referrals for in-person visits. For example, the previously mentioned ECHO program, 

which several dermatologists engage in today, allows for dermatologists to use live video 

conferencing to train primary care providers, including those at CHCs, to identify skin 

diseases. Furthermore, by connecting primary care physicians and specialists, the ECHO 

program has been shown to reduce costs through further educating primary care 

providers about specialty care and treatment which results in a reduction of unnecessary 

referrals. 

Increased funding has the potential to build on past successes such as these and improve 

access to care. Furthermore, without continued funding for CHCs, low income patients 

would lose access to not only primary care but to essential specialty services, including 

care for serious skin diseases, which will ultimately result in increased costs to the entire 

health care system. 

Again, the Academy appreciates the Subcommittee's effort to address the extension of 

funding for these vital safety net programs. Please feel contact Christine O'Connor, the 

Academy's Associate Director of Congressional Policy, at coconnor@aad.org or (202) 

609-6330 if you have any questions or if we can provide additional information. 
76 


28525.027

AMERICA'S 

ESSENTIAL 

HOSPITALS 

Statement for the Record 

Committee on Energy and Commerce 

Subcommittee on Health 

Examining the Extension of Safety-Net Health Programs 

June 14, 2017 

Thank you for the opportunity to submit a statement for today's hearing on funding for 

programs vital to our nation's health care safety net. America's Essential Hospitals is the 

leading association and champion for hospitals and health systems dedicated to highquality care for all, including low-income working Americans and others who face 

financial hardships. Our more than 300 members serve as reliable sources of care for 

individuals and communities, providing primary care through trauma care, disaBter 

response, health professionals training, research, public health programs, and other 

services. America's Essential Hospitals is pleased the committee wants to ensure the 

health care safety net remains intact. 

Tbe Children's Health Insurance Program (CHIP) and federally qualified health centers 

(FQHCs) are both critical to providing coverage and access to care for people who might 

otherwise have few or no options. We are pleased the committee is actively working to 

extend funding for these critical programs. Tbey deserve your prompt attention. 

For millions oflow-incomc Americans, the safety net provides choices for affordable 

care-not only at FQHCs but also at many essential hospitals and children's hospitals. 

Due to their patient populations, these hospitals often face significant financial 

challenges compared with other hospitals. The nation's essential hospitals: 

operate with no margin, on average; 

provide 18.3 percent of all uncompensated care nationally, or about $7.8 billion 

dollars; 

care for a population that is half uninsured or Medicaid patients; and 

train nearly seven times as many medical and dental residents as other U.S. 

teaching hospitals. 

essf!:ntiatflt>spitats: ora, AMER!CA·s ESSENTIAL HOSPITALS 

401 Ninth St NW Ste 900 

Washington DC 20004 

t: 202 5H5 0100 

f: 202 585 010] 

e: info(f!:esscntialhm:pitals.org 
77 


28525.028

To keep their doors open and continue providing care, these hospitals rely on Medicaid 

disproportionate share hospital (DSH) payments. 

Under the Affordable Care Act (ACA), Medicaid DSH payment cuts were scheduled to 

begin in 2014. But for more than four years, a bipartisan Congress has delayed the cuts, 

recognizing the threat they pose to the stability of patients and essential hospitals. In 

fact, the original House majority proposal to repeal and replace the ACA included a full 

repeal of Medicaid DSH cuts across all states-a reflection of lawmakers' concern. 

The most recent dela.yofthe Medicaid DSH cuts came in the 2015 Medicare Access and 

CHIP Reauthorization Act (MACRA), which delayed the cut• in fiscal year (FY) 2017 by 

"rebasing'" the cuts to extend them by a year, to 2025. 

But like funding extensions for CHIP and FQHCs in MACRA, the DSH payment cnt 

delay is set to expire on September 30 of this year. DSH cuts would start October I with 

a $2 billion reduction in FY 2018 and increase by $1 billion annually through 2024, 

ending with an SS billion cut. Iftbe cuts take effect, DSH hospitals would see massive 

funding shortfalls at a time when the health care safety net faces other dire funding 

threats. 

So, as Congress continues to consider broader health care reform legislation, the 

imminent threat of DSH cuts remains. 

We believe it is critical to support safety-net programs collectively, to provide struggling 

Americans and underserved communities v,;th a "~der net. vVe respectfully request 

that, along with funding extensions for CHIP and FQHCs, Medicaid DSH cuts are 

delayed as quickly as possible and for the duration of time remaining until all 

stakeholders can work together for a more sustainable solution. 

Thank you for your prompt attention to this \1tal issue. 

2 
78 


28525.029

AMERICAN ACADEMY OF 

FAMILY PHYSICIANS 

STRONG MEOICINE FOR AMERICA 

Statement of 

American Academy of Family Physicians 

Submitted for the Record 

House Energy and Commerce Committee 

Health Subcommittee 

Examining the Extension of Safety Net Health 

Programs 

June 14, 2017 

AAFP Headquarters 

11400 Tomahawk Creek 

leawood. KS 

800.274.2237 • 913.906.6000 

fp@aafp.org 

AAFP Washington Office 

1133 Connecticut Avenue. NW, Ste. 1100 

Wasl1ington. DC 20036-1011 

202232.9033 • Fax: 202232.9044 

capito!@aafp.org 
79 


28525.030

On behalf of the American Academy of Family Physicians (AAFP), which represents 

129,000 family physicians and medical students across the country, thank you for the 

opportunity to submit testimony for the record to the US House Energy and Commerce 

Committee Health Subcommittee regarding the continuation of the Children's Health 

Insurance Program (CHIP). 

Congress Should Swiftly Approve a Long-Term Extension of CHIP Funding. 

The AAFP urges Congress to swiftly approve a bipartisan long-term extension of CHIP, 

in order to promote stability and health security for 8.9 million low-income children1 and 

their families. Time is of the essence in completing this work in order to ensure 

continuous access to primary and preventive services for this vulnerable population, 

protect progress in public health and allow States to adequately plan. 

The AAFP has supported CHIP since its inception in 1997, and during each subsequent 

reauthorization and extension of funding (2007, 2009, and 2015), as a way to extend 

health coverage to uninsured children whose families do not meet eligibility 

requirements for Medicaid. Since the enactment of the Medicare Access and CHIP 

Reauthorization Act of 2015 (MACRA), in April 2015, the AAFP has reiterated support 

for CHIP funding beyond the current end-date of September 30, 2017-through letters 

to this Committee and to Congressional Leadership. As a medical specialty, family 

medicine is committed to the success of all health insurance programs financed with 

public dollars, including CHIP. AAFP member data indicates that over two thirds of 

AAFP members accept new Medicaid patients. 2 Although the AAFP does not collect 

member survey data on CHIP participation, we know (due to the close connection 

between Medicaid and CHIP-including the fact that some states operate combined 

Medicaid I CHIP programs-and the fact that family physicians perform so many 

pediatric services) that family physicians are helping to carry out Congress's intent 

behind CHIP: treating low-income children, many of whom would be uninsured without 

the program. 

Family physicians play an important role in addressing American children's health 

needs. According to the AAFP's latest member census, published December 31, 2016, 

over 80 percent of AAFP members care for adolescents, and 73 percent care for infants 

and children. 3 Other AAFP member survey data reflect that about 20 percent of AAFP's 

members deliver babies as part of their practice, with roughly 6 percent delivering more 

than 30 babies in a recent calendar year. 4 Of AAFP active members with full hospital 

1 Centers for Medicare and Medicaid Services, 2016 Enrollment Report, available at 

https://www.medicaid.gov/chip/downloads/fy-2016-childrens-enrollment-report.pdf. 

2 AAFP, 2015 Practice Profile Survey (excerpt), available at 

http://www .aafp. org/abouUthe-aafp/family-medicine-facts/table-12. html. 

3 AAFP Member Census (Dec. 31, 2016), available at 

http://www .aafp .org/abouUthe-aafp/family-med icine-facts/table-13. htmf. 

4 AAFP, 2015 Practice Profile Survey (July 15, 2016). 

June 14, 2017 Page 2 of 5 
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privileges, 70 percent provide newborn care in the hospital, and 64 percent provide 

pediatric care in the hospital.5 This is consistent with family medicine's traditional role of 

practicing in the entire scope of the physician license in order to meet the needs of the 

community in which the family physician practices. A family physician who serves a 

small rural community without a pediatrician, for example, will often perform most or all 

pediatric care for that community. 

The AAFP also supports health care for all, consistent with the public-health mission of 

the specialty of family medicine. The AAFP promotes health care for all in the form of "a 

primary care benefit design featuring the patient-centered medical home, and a 

payment system to support it," for everyone in the United States.6 AAFP believes that 

all Americans should have access to primary-care services (e.g. in the case of infants 

and children, immunizations and other evidence-based preventive services, prenatal 

care, and well-child care), without patient cost sharing. The AAFP believes that 

universal health care also should include services outside the medical home (e.g. 

hospitalizations) with reasonable and appropriate cost sharing allowed, but with 

protections from financial hardship. Supporting universal access to care is also 

consistent with the "triple aim" of improving patient experience, improving population 

health, and lowering the total cost of health care in the United States. Having both 

health insurance and a usual source of care (e.g., through an ongoing relationship with 

a family physician) contributes to better health outcomes, reduced disparities along 

socioeconomic lines, and reduced costs? 

The AAFP urges Congress to pass a "clean" extension of CHIP with a minimum of 

unnecessary policy changes. Family physicians and their practices thrive on stability in 

the insurance market Unlike Medicare and Medicaid, which provide stable and reliable 

federal funding under current law, CHIP funding is contingent upon Congressional 

action at regular intervals. Given the importance of the program to almost 9 million 

children from low-income families, the AAFP urges the Committee to swiftly extend and 

stabilize the program on a long-term basis. 

Sid. 

6 AAFP, Health Care For All (2014), available at 

http://www.aafp.org/abouVpolicies/all/health-care-for-all.html. 

7 See, e.g., The Robert Graham Center, The Importance of Having Health Insurance 

and a Usual Source of Care, Am. Fam. Physician (Sept 15, 2004), available at 

http://www. aafp. org/afp/2004/0915/p 1 035.html. 

June 14, 2017 Page 3of5 
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Congress Should Also Provide Long-Term Support for Graduate Medical 

Education Through Continued Funding of the Teaching Health Center Program 

and Community Health Centers. 

As an additional note, the AAFP would like to emphasize to the Committee the 

importance of providing long-term support for the Teaching Health Center Graduate 

Medical Education (THCGME) program, which will also expire on September 30, 2017, 

absent Congressional intervention. THCGME is a successful primary-care training 

program, currently financing training for 742 medical and dental residents in communitybased ambulatory settings. Residents in the THCGME program train exclusively in 

primary-care specialties. 

Of relevance to the legislative process surrounding CHIP, two-thirds of the THCGME 

residents are training in family medicine or pediatrics.8 The THCGME program, 

administered by the Health Resources and Services Administration (HRSA), accounts 

for less than one percent of the annual federal spending devoted to graduate medical 

education, yet it is the only GME program that is devoted entirely to training primarycare physicians and dentists. Residents in the program train in community health 

centers (including federally qualified health centers), and tend to be concentrated in 

rural and underserved areas that need access to more providers, particularly primarycare physicians. American Medical Association Physician Masterfile data confirms that 

a majority of family medicine residents practice within 100 miles of their residency 

training location.9 By comparison, fewer than 5 percent of physicians who complete 

training in hospital-based GME programs provide direct patient care in rural areas. 10 

Thus, the most effective way to encourage family and other primary-care physicians to 

practice in rural and underserved areas is not to recruit them from remote academic 

medical centers but instead to train them in these underserved areas. 

Community health centers (CHCs) play an important role in primary care graduate 

medical education as well. The nation's 9,800 centers provide care for 25 million 

patients, 71 percent of whom are low-income. 11 CHC facilities, along with other safety 

8 Health Resources and Services Administration, Teaching Health Center Graduate 

Medical Education Program, Academic Year 2014-2015, available at 

https:l/bhw.hrsa.gov/sites/default/files/bhw/nchwa/teaching-health-center-graduatehighlights.pdf. 

9 E. Blake Fagan, M.D., et al., Family Medicine Graduate Proximity to Their Site of 

Training, Family Medicine, Vol. 47, No. 2, at 126 (Feb. 2015). 

1° Candice Chen, M.D., MPH, et al., Toward Graduate Medical Education (GME) 

Accountability: Measuring the Outcomes of GME Institutions, Academic Medicine, Vol. 

88, No. 9, p. 1269 (Sept. 2013). 

11 National Association of Community Health Centers, About Our Health Centers, 

available at http:l/www.nachc.org/about-our-health-centers/ 

June 14, 2017 Page 4 of 5 
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net providers, are valuable training settings for THCGME residents who care for 

patients like those they are likely to treat in primary care outpatient settings. Residents 

who train in CHCs also have the unique opportunity to be trained in delivery system 

models using electronic health records, providing culturally competent care, and 

following care coordination protocols. 12 Some are also able to operate in environments 

where they are trained in mental health, drug and substance use treatment, and chronic 

pain management.13 We know that residents who train in underserved communities are 

likely to continue practicing in those same environments. 14 

12 Candice Chen, Frederick Chen, and Fitzhugh Mullan. Teaching Health Centers: A 

New Paradigm in Graduate Medical Education." Academic Medicine: Journal of the 

Association of American Medical Colleges 87.12 (2012): 1752-1756. PMC. available at 

https :1/www .ncbi.n lm .nih .gov/pmc/articles/PMC3761371/ 

13 David Mitchell, Residency Directors Tout Benefits ofTeaching Health Center GME 

Program, AAFP News, (September 6, 2013), available at 

http://www.aafp.org/news/education-professionaldevelopmentl20130906thcroundtable .html 

14 Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching Health Center GME 

Funding Instability Threatens Program Viability, Am Fam Physician. (Feb. 

2015);91 (3):168-170. Available at http://www.aafp.org/afp/2015/0201/p168.html 

June 14, 2017 Page 5 of5 
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--A, 

AHIP 

STATEMENT FOR THE RECORD 

Submitted to the 

House Energy and Commerce Committee 

Subcommittee on Health 

The Children's Health Insurance Program 

June 14, 2017 

America's Health Insurance Plans 

601 Pennsylvania A venue, NW 

Suite 500, South Building 

Washington, D.C. 20004 

1 
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America's Health Insurance Plans (AHIP) is the national association whose members provide 

coverage for health care and related services to millions of Americans every day. Through these 

offerings, we improve and protect the health and financial security of consumers, families, 

businesses, communities and the nation. We arc committed to market-based solutions and 

public-private partnerships that improve affordability, value, access and well-being for 

consumers. 

We appreciate the committee's interest in the Children's Health Insurance Program (CHIP) and 

other safety net health programs. CHIP serves as a vitally important safety net for more than 8 

million children whose families have modest incomes. They depend on CHIP every day, and 

without the coverage and access to care it provides, many might fall through the cracks. We 

applaud the committee's interest in examining CHIP and ensuring that the program continues its 

mission of providing high quality health coverage to children. 

AHIP' s members are strongly committed to meeting the health care needs of children enrolled in 

CHIP and ensuring it remains an efficient, effective program. 

Many states rely on health plans to serve their CHIP populations. In fact, 80 percent of children 

covered by stand-alone CIIIP programs are enrolled in health plans. Health plans have a proven 

track record of success in providing high quality, affordable, patient-centered coverage with a 

strong emphasis on primary care for children. Many CHIP health plans have implemented 

innovative education and outreach initiatives to ensure that children receive complete physical 

examinations, hearing and vision checkups, dental care, immunizations, and other health care 

services they need to stay healthy. The delivery of these crucial primary care services is an 

important factor in promoting good health among children. 

The value of CHIP coverage is clearly indicated by research showing that children with public 

health coverage (including CHIP or Medicaid) are more likely- when compared to uninsured 

children- to have a usual source of care (97% vs. 73% ), receive a well-child check-up (85% vs. 

56%), and see a doctor for specialty care (13% vs. 7%) over a 12-month period. The same 

analysis found that children with CHIP or Medicaid coverage are less likely to delay or forgo 

medical care due to cost concerns, less likely to go more than two years without seeing a doctor, 

2 
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and less likely to have dental needs that are not addressed due to cost concerns. 1 Additional 

research has demonstrated that CHIP and Medicaid coverage has helped achieve reductions in 

both avoidable hospitalizations and child mortality/ and that improved health among children 

enrolled in CHIP and Medicaid programs "translates into gains in school performance and 

educational attainment over the longer term, with potentially positive implications for both 

individual economic well-being and productivity in the overall economy."3 

We Strongly Support a Five-Year Extension of Federal CHIP Funding 

AHIP and our member plans urge Congress to authorize a five-year extension of federal funding 

for CHIP, as recommended by the Medicaid and CHIP Payment and Access Commission 

(MACPAC). 

During this time of transition for our nation's health care system- with the potential for major 

changes emerging from the congressional debate on repealing and replacing the Affordable Care 

Act (ACA)- it is more important than ever to maintain CHIP as a strong, stable, and dependable 

coverage option for America's children. CHIP has been essential in reducing the rate of 

uninsured children from 13.9 percent in 1997 to 4.5 percent in 2015.4 This is a remarkable 

achievement, particularly in light of the success CHIP has demonstrated, as noted above, in 

improving health outcomes for children. By adopting MACPAC's recommendation to extend 

federal CHIP funding through 2022, Congress can sustain this progress and ensure the 

continuation of health coverage for children who rely on CHIP. 

As the committee knows, the current authorization for federal CHIP funding is scheduled to 

expire on September 30, 2017. It is critically important for Congress to approve a five-year 

funding extension in a timely fashion- not only to provide peace of mind to families that are 

served by CHIP, but also to ensure that states can plan ahead and make budget decisions for the 

new fiscal year. 

1 Kaiser Commission on Medicaid and the Uninsured, "Children's Health Coverage: The Role of Medicaid and 

CHIP and Issues for the Future," June 2016. 2 Embry Howell and Genevieve Kenney, "The Impact of the Medicaid/CI·IlP Expansions on Children: A Synthesis 

of the Evidence," Medical Care Research and Review 69(4). August 2012. 3 Kaiser Commission on Medicaid and the Uninsured, "The Impact of the Children's Health Insurance Program 

(CHIP): What Does the Research Tell Us?" June 2014. 4 Medicaid and CHIP Payment and Access Commission, "Recommendations for the Future of CHIP and Children's 

Coverage." January 2017. 

3 
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Without an extension of federal CHIP funding, MACPAC has projected that four states and the 

District of Columbia would exhaust their existing federal CHIP allotments in October-December 

2017. Another 29 states would deplete their federal funds in January-March 2018, and 16 states 

would run out of funds in April-June 2018. All states are projected to exhaust their federal CHIP 

funds at some point in fiscal year 2018 if funding is not extended. The consequences for every 

state would be significant. 

Under the ACA's maintenance of effort requirement, states must maintain- through September 

30,2019 their eligibility standards and processes for children in Medicaid and CHIP that were 

in place in 20 l 0. However, states that operate a separate CHIP program are allowed to end 

coverage when federal funding runs out. States operating CHIP through an expansion of 

Medicaid must continue providing coverage through fiscal year 2019, but they would receive the 

lower Medicaid match rate instead of the enhanced CHIP match rate. 

While the impact would vary from state to state, there is no question that the loss of federal 

CHIP funding would be devastating for many CHIP enrollees and their families. In 2015, 

MACPAC estimated that 3.7 million children would lose their CHIP coverage if funding expired 

and that 1.1 million of these children would become uninsured. That would mean poorer health, 

higher utilization of emergency rooms, and more uncompensated care for rural hospitals across 

the country. Of the remaining children, MACPAC estimates that 1.4 million would obtain 

subsidized coverage through the ACA's Exchanges and 1.2 million would obtain coverage 

through a parent's employer-sponsored insurance.4 

MACPAC data show that CHIP coverage is significantly more affordable for families than 

commercial coverage. The average out-of-pocket cost for families with a child enrolled in CHIP 

is $158 per year, including premiums and cost sharing. By comparison, the average out-ofpocket cost for a child enrolled in subsidized Exchange coverage would be $1,073 for the second 

lowest cost silver plan. 5 Moreover, costs would be much higher for a child that has an acute 

health event or a chronic condition, putting coverage out of reach for some families. In light of 

these findings, we believe it is very clear that CHIP coverage remains the best option for families 

with modest incomes who are seeking affordable care for their children. 

5 Medicaid and CHIP Payment and Access Commission, "Chapter 5: Design Considerations for the Future of 

Children's Coverage: Focus on Affordability," Report to the Congress on Medicaid and CffiP, March 2016. 

4 
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We appreciate that members of the committee, both Republicans and Democrats, have expressed 

support for continuing to provide federal funding for CHIP. This committee played a leadership 

role in advancing the previous extension of federal CHIP funding, which was approved with 

strong bipartisan support- including the votes of92 senators- as part of the "Medicare Access 

and CHIP Reauthorization Act of 2015." 

We thank you for your past support of CHIP and strongly encourage you to take action, as soon 

as possible, on MACPAC's recommendation for a five-year extension of federal CHIP funding. 

5 
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June 14,2017 

The Honorable Michael C. Burgess, M.D. 

Chairman 

Subcommittee on Health 

Committee on Energy and Commerce 

U.S. House of Representatives 

Washington, D.C. 20515 

Dear Chairman Burgess: 

Thank you for your leadership of the Subcommittee on Health and your commitment to 

ensuring the healthcare safety net helps low-income individuals achieve better health 

outcomes. As the Subcommittee prepares to hold a hearing on this critical topic, the 

Health care Leadership Council (HLC) welcomes the opportunity to share our thoughts 

with you. 

HLC is a coalition of chief executives from all disciplines within American healthcare. It 

is the exclusive forum for the nation's health care leaders to jointly develop policies, 

plans, and programs to achieve their vision of a 21st century health system that makes 

affordable, high quality care accessible to all Americans. Members of HLC -hospitals, 

academic health centers, health plans, pharmaceutical companies, medical device 

manufacturers, laboratories, biotech firms, health product distributors, pharmacies, postacute care providers, and information technology companies- advocate for measures 

to increase the quality and efficiency of healthcare through a patient-centered approach. 

Safety net programs like the State Children's Health Insurance Program (SCHIP) and 

Federally Qualified Health Centers (FQHCs) are a critical part of our country's 

healthcare infrastructure, and HLC urges Congress to maintain support for our most 

vulnerable citizens by continuing to fund these programs. 

SCHIP 

SCHIP plays an important role in providing health coverage for children in families with 

low and moderate incomes. SCHIP has expanded children's eligibility for coverage and 

has encouraged participation by simplifying enrollment and renewal. Along with other 

factors, SCHIP has led to a steep decline in the number of uninsured children, from 10 

million in 1997 (when the program was enacted) to 3.3 million in 2015. 

HLC strongly believes that keeping children healthy by giving them access to care is 

essential to the wellbeing of our society. By diagnosing and treating problems at an 

early age, we can ensure that children will grow into healthy and productive adults. 

HLC members are at the forefront of developing and providing these health solutions to 

children, and we are grateful that the Subcommittee is looking at ways to ensure that 

SCHIP remains on a sound fiscal footing. Without congressional action to extend the 

1 
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program's funding beyond September 30, states will soon exhaust their SCHIP funds. 

In this time of limited state resources and tight budgets, without federal assistance 

states will have to remove children from SCHIP. Many of these children will not be 

eligible for Medicaid nor will their parents be able to afford a private insurance plan. 

The children will then become uninsured and will have to go without necessary doctor 

visits, prescriptions, and other healthcare services. They will not be able to access 

preventive care and instead will have to be treated in emergency rooms and other highcost settings. To avoid this costly situation and protect children's access to healthcare, 

HLC asks Congress to extend SCHIP funding. 

HLC also supports giving states flexibility in administering their SCHIP program. For 

example, states can reduce their costs by making SCHIP a wraparound option for 

children who are eligible for the program but who have private insurance through their 

parents. This option would fill in the gaps in what the private plan covers and would 

also cover the cost-sharing expenses of the private plan. States should also be given 

incentives for managing their program effectively and streamlining the enrollment 

process. 

FQHCs 

FQHCs are our nation's largest source of comprehensive primary care for the medically 

underserved. They provide care to over 25 million people in more than 9,000 rural and 

urban communities across America. These centers provide medical, dental, mental 

health, reproductive care, and other important healthcare services. This care is high 

quality, cost effective, and accessible. Furthermore, the centers serve as critical 

economic engines that benefit local economies. 

HLC supports continued funding of the FQHCs to ensure that the safety net is 

preserved and that our country's health is improved with adequate access to care. 

Without action before the end of this fiscal year, FQHCs will face a 70% cut in funding 

on October 1, which will result in an estimated 9 million patients losing access to care. 

We ask that Congress extending the Community Health Center Fund (CHCF). Without 

this support, many centers will have to close and their patients will have limited access 

to care. They will instead turn to the emergency room or other high-cost settings. 

Thank you again for your work on these important issues. HLC looks forward to 

continuing to collaborate with you. If you have any questions, please do not hesitate to 

contact Debbie Witchey at (202) 449-3435. 

Mary R. Grealy 

President 

2 
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<!Lnngre.s.s nf t}fe Jtniteil ~tates 

maslfittgton, i!l(!! 211515 

June 23, 2017 

Chairman Michael Burgess 

Energy and Commerce Subcommittee on Health 

2125 Rayburn House Office Building 

Washington DC, 20515 

Ranking Member Gene Green 

Energy and Commerce Subcommittee on Health 

2125 Rayburn House Office Building 

Washington DC, 20515 

Dear Chairman Burgess and Ranking Member Green: 

We write to you today in support of the community health center (CHC) program and thank you 

for conducting a timely hearing on extending health center funding. 

As you are aware, health center funding will decrease nearly 70% starting on October I", 2017 if 

we do not act to extend their "Section 330" funding. At the hearing, you will hear from a fellow 

Minnesotan, Mr. Michael Holmes, who has been invited by the Subcommittee to testify on the 

"primary care cliff' health centers face. Mr. Holmes is CEO of Scenic Rivers Health Services 

based in Cook, Minnesota. He leads an organization tasked with caring for over 12,000 patients 

at a number of medical and dental clinics located throughout rural northern Minnesota. 

In our conversations with Minnesota's health centers, they have shared with us that if we do not 

address this funding cliff by October I 51, the State's 17 CHCs serving 181,000 low-income 

Minnesotans will lose nearly $27 million of their overall revenue. Individual health centers 

would see an average drop of 15% in funding. Such a decrease would cause CHCs in Minnesota 

and other health centers in the United States to dramatically scale back services, if not close sites 

altogether. Ultimately, this loss of revenue jeopardizes access to primary care services for lowincome Minnesotans across the state - not only in rural areas such as Cook, but also in the Twin 

Cities Metro, where residents face challenges accessing primary care services. 

In short, by extending Section 330 funding, health centers will be able to continue their mission 

of providing primary care while saving precious state and federal resources. We ask that you act 

favorably on this important issue of health center funding and the "primary care cliff." 

Sincerely, 

Member of Congress 

~ .. {fEe""'" • <~ Keith llison · 

Member of Congress 

-

Timothy J. \lrarZ 

Member of Congress 

Collin Peterson 

Member of Congress PRINTED ON RECYCLED PAPER 
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Erik Paulsen 

Member of Congress 
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June 12, 2017 

The Honorable Mitch McConnell 

United States Senate 

Washington, DC 20510 

The Honorable Chuck Schumer 

United States Senate 

Washington, DC 20510 

The Honorable Paul Ryan 

United States House of Representatives 

Washington, DC 20515 

The Honorable Nancy Pelosi 

United States House of Representatives 

Washington, DC 20515 

The Honorable Orrin Hatch 

United States Senate 

Washington, DC 20510 

The Honorable Ron Wyden 

United States Senate 

Washington, DC 20510 

The Honorable Greg Walden 

United States House of Representatives 

Washington, DC 20515 

The Honorable Frank Pallone 

United States House of Representatives 

Washington, DC 20515 

Dear Majority Leader l'vicConnell, Minority Leader Schumer, Speaker Ryan, Minority Leader Pelosi, 

Chairman Hatch, Ranking Member Wyden, Chairman Walden and Ranking Member Pallone: 

As leading national, state, tribal, and local organizations concerned about the hea1th and well-being 

of America's children and pregnant women, we are writing to urge you to turn your attention as 

quickly as possible to enacting a long-term funding extension of the Children's Health Insurance 

Program (CHIP). CHIP funding is currently set to expire on September 30, 2017. Swift action on a 

CHIP funding extension bill would provide much-needed certainty to states and families and ensure 

that health coverage for the 8.9 million children who rely on CHIP will not be disrupted. Congress 

last extended CHIP as part of the Medicare and CHIP Reauthorization Act of2015 (MACRA), 

legislation that passed with overwhelming bipartisan majorities. A longterm CHIP funding extension 

bill would not only avert a coverage crisis for children, families, and states, it would also provide an 

opportunity for Members and Senators on both sides of the aisle to work together toward the 

collective goal of protecting children's coverage. To be clear, states are already crafting their FY 

2018 budgets and lack of timely congressional action will soon cause states to begin the process of 

disenrolling children from coverage. 

For two decades, CHIP has been an essential source of children's coverage, ensuring access to highquality, affordable, pediatric-appropriate health care for children in working families whose parents 

earn too much to qualify for Medicaid but too little to purchase private health insurance on their 

own. It has strong bipartisan roots and was developed as a state-federal partnership that gives 

governors broad flexibility to design their programs to target the needs of their child populations. 

CHIP is a model program that has played a critica1 role in reducing the number of uninsured 

children by more than 68 percent, from nearly 15 percent in 1997 to a record of less than five 

percent in 2015, while improving health outcomes and access to care for children and pregnant 

women. If Congress fails to act in a timely manner, the 8.9 million children enrolled in CHIP will be 

at risk of losing their health coverage. It is worth noting that the children who stand to lose CHIP 
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would likely have no other affordable coverage option available to them. The resulting increase in 

the rate of uninsured children would be an enormous step backwards. 

CHIP's uncertain funding future is a significant problem for states as they are already developing 

their FY 2018 budgets and negotiating contracts with insurers and providers. In order for states to 

continue their CHIP programs without interruption, they must know as soon as possible that federal 

support for CHIP will exist beyond September 30, 2017, when CHIP funding is set to expire. If 

funding is not stabilized quickly, states will have no choice but to begin planning for the impending 

funding shortfall, which will require drastic program cuts through enrollment caps, benefit 

reductions, reductions in eligibility, or provider payments cuts. At a time when children's coverage 

rates have hit record highs- with more than 95 percent of our children enrolled in some type of 

health coverage- it would be devastating if states begin to dismantle their CHIP programs. 

Given the uncertainty in the insurance market and as Congress continues to look at broader health 

system reforms, it is important that CHIP remains a stable source of coverage for children. 

Coverage provided through CHIP and Medicaid must be protected. As advocates who are 

concerned about the health and well-being of children, we are hopeful that our nation's leaders can 

work together to continue the current CHIP policy that is working well for states and families. We 

urge Congress to make swift action on a long-term CHIP funding extension an immediate priority. 

Sincerely, 

NATIONAL ORGANIZATIONS 

First Focus 

1,000 Days 

American Academy of Nursing 

American Academy of Pediatric Dentistry 

9to5, National Association of Working American Academy of Pediatrics 

Women American Association for Community Dental 

A Father's Walk 

AASA, The School Superintendents 

Association 

Academic Pediatric Association 

Academy of Nutrition and Dietetics 

ACCSES 

AFL-CIO 

African American Health Alliance 

AFSCME 

AIDS Alliance for Women, Infants, Children, 

Youth, & Families 

Alabaster 

Allergy and Asthma Foundation of America 

Allergy & Asthma Network 

Alliance for Strong Families and Communities 

America's Essential Hospitals 

America's Promise Alliance 

American Academy of Family Physicians 

Programs 

American Association for Dental Research 

American Association of Birth Centers 

American Association of Child & Adolescent 

Psychiatry 

American Association of Poison Control 

Centers 

American Association on Health and 

Disability 

American Cancer Society Cancer Action 

Network 

American College of Allergy, Asthma and 

Immunology 

American College of Cardiology 

American College of Physicians 

American College of Surgeons 

American Congress of Obstetricians and 

Gynecologists 

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American Dental Association 

American Dental Hygienists' Association 

American Diabetes Association 

American Federation of Teachers 

American Foundation for the Blind 

American Heart Association 

American Lung Association 

American Medical Association 

American Network of Oral Health Coalitions 

American Pediatric Society 

American P.ediatric Surgery Association 

American Psychological Association 

American Public Health Association 

Asian & Pacific Islander American Health 

Forum 

Assistive Technology Law Center 

Association for Community Affiliated Plans 

Association of Asian Pacific Community 

Health Organizations (AAPCHO) 

Association of Clinicians for the Underserved 

Association of Educational Service Agencies 

(AESA) 

Association of Maternal & Child Health 

Programs 

Association of Medical School Pediatric 

Department Chairs 

Association of School Business Officials 

International (ASBO) 

Association of University Centers on 

Disabilities (AUCD) 

Augustinian Friars 

Bazelon Center for Mental Health Law 

Birth Defects Research & Education 

Foundation 

Brain Injury Association of America 

Bread for the World 

Catholic Health Association of the United 

States 

Center for Autism and Related Disorders 

Center for Global Policy Solutions 

Center for Law and Social Policy (CLASP) 

Center for Medicare Advocacy 

Center for the Study of Social Policy 

Centering Healthcare Institute 

Child Care Aware of America 

Child Welfare League of America 

Children's Advocacy Institute 

Children's Defense Fund 

Children's Dental Health Project 

Children's Environmental Health Network 

Children's Health Fund 

Children's Health Watch, Boston Medical 

Center 

Children's Home Society of America 

Children's Hospital Association 

Children's Leadership Council 

Children's Mental Health Network 

Children's Rights 

CHRISTUS Health 

Coalition on Human Needs 

Commissioned Officers Association of the 

U.S. Public Health Service, Inc. (COA) 

Communities In Schools 

Community Catalyst 

Consortium for Children 

Consumer Advisory Council 

Council of Administrators of Special 

Education 

Cystic Fibrosis Foundation 

Daughters of Charity USA 

Delta Dental Plans Association 

Democrats Abroad 

Dental Trade Alliance 

DentaQuest 

Division for Early Childhood of the Council 

for Exceptional Children (DEC) 

Doctors for America 

Doctors for Global Health 

Early Care and Education Consortium 

Earth Evolution 

Easterseals 

Endocrine Society 

Epilepsy Foundation 

Every Child Matters 

Every Life Foundation for Rare Diseases 

Families USA 

Family Focused Treatment Association 

Family Promise 

Family-Run Executive Director Leadership 

Association 

Family Voices 

First Five Years Fund 

Forum for Youth Investment 

Franciscan Action Network 

Futures Without Violence 

Girls Inc. 

3 
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28525.046

Global Alliance for Behavioral Health and 

Social Justice 

Global Healthy Living Foundation 

Global Justice Institute, Metropolitan 

Community Churches 

Green & Healthy Homes Initiative 

Hadassah, The Women's Zionist Organization 

of America, Inc. 

Health Resources in Action 

Health Connect One 

Healthy Schools Campaign 

Healthy Schools Network 

Healthy Teen Network 

Hemophilia Federation of America 

High Flight Arts and Letters 

HIV Medicine Association 

Home Instruction for Parents of Preschool 

Youngsters, H!PPY 

Holy Spirit Missionary Sisters -]PIC - USA 

Human Facets International 

Huntington's Disease Society of America 

IDEA Infant Toddler Coordinators 

Association 

Immune Deficiency Foundation 

Immunization Action Coalition 

Institute for Child Success 

Juvenile Law Center 

Kaiser Permanentc 

Lakemary Center 

League of Women Voters of the United States 

Learning Disabilities Association of America 

Leukemia & Lymphona Society 

LIFT 

Lupus and Allied Diseases Association, Inc. 

Lutheran Services in America 

March of Dimes 

Medicaid I Medicare I CHIP Services Dental 

Association (l'v!SDA) 

Mended Little Hearts 

Methodist Federation for Social Action 

MomsRising 

National Advocacy Center of the Sisters of 

the Good Shepherd 

National Alliance for Medicaid in Education 

National Alliance of Children's Trust and 

Prevention Funds 

National Alliance on Mental Illness 

National Association for Bilingual Education 

National Association for Children's 

Behavioral Health 

National Association of Community I lealth 

Centers 

National Association of Counsel for Children 

National Association of Counties 

National Association of County and City 

Health Officials 

National Association of County Behavioral 

Health & Developmental Disability 

Directors 

National Association of County Human 

Services Administrators 

National Association of Dental Plans 

National Association of Pediatric Nurse 

Practitioners 

National Association of School Nurses 

National Association of Social Workers 

National Association of State Directors of 

Special Education 

National Association of State Head Injury 

Administrators 

National Association of State Mental Health 

Program Directors 

National Birth Equity Collaborative 

National Black Child Development Institute 

National Black Justice Coalition 

National Center for Healthy Housing 

National Center for Law and Economic 

Justice 

National Center for Transgender Equality 

National Center on Adoption and 

Permanency 

National Coalition on Health Care 

National Committee for Quality Assurance 

National Council for Behavioral Health 

National Council of La Raza 

National Council on Alcoholism and Drug 

Dependence 

National Disability Rights Network 

National Education Association 

National Family Planning & Reproductive 

Health Association 

National Foster Parent Association 

National Health Law Program 

National Hispanic Medical Association 

National Immigration Law Center 

National Indian Child Welfare Association 

4 
96 


28525.047

National Institute for Children's Health 

Quality (NICHQ) 

National Institute for Reproductive Health 

National Network for Youth 

National Organization for Rare Disorders 

(NORD) 

National Partnership for Women & Families 

National Physicians Alliance 

National Prevention Science Coalition 

National Respite Coalition 

National Rural Education Advocacy 

Collaborative 

National Rural Education Association 

National School Boards Association 

National Urban League 

National WIC Association 

National \'X! omen's Law Center 

National Women's Health Network 

Nemours Children's Health System 

Network for Public Education 

NE1WORK Lobby for Catholic Social 

Justice 

Non-Profit Evolution, Inc. 

North American Society for Pediatric 

Gastroenterology, Hepatology and Nutrition 

Nurse-Family Partnership 

Nursing Students for Sexual and 

Reproductive Health 

Oral Health America 

Parent Watch 

Parents as Teachers 

Partnership for America's Children 

Passport To Languages 

Pediatric Policy Council 

PICO Center for Health Organizing 

PICO National Network 

Policy Lab at the Children's Hospital of 

Philadelphia 

Prevent Child Abuse America/ Healthy 

Families America 

Project Inform 

Provincial Council Clerics of St. Viator 

Public Advocacy for Kids 

Racial and Ethnic Health Disparities Coalition 

Raineth Housing 

Raising Women's Voices for the Health Care 

We Need 

Redstone Global Center for Prevention and 

Wellness 

RESULTS 

Rights4Girls 

Sisters of Charity Ministry Foundation 

School Social Work Association of America 

School-Based Health Alliance 

SchoolHouse Connection 

Seed co 

Service Employees International Union 

(SEIU) 

Show of Hands: Our Children, Our Future 

Shriners Hospitals for Children 

Sisters of Charity of Nazareth Congregational 

Leadership 

Sisters of Charity, BVM 

Sisters of Mercy South Central Community 

Sisters of Mercy U.S. Province 

Sisters of St. Joseph of Carondelet 

Society for Maternal-Fetal Medicine 

Society for Pediatric Research 

Society for Public Health Education 

Society of St. Vincent de Paul 

Society of State Leaders of Health and 

Physical Education 

Sparki\ction 

Spina Bifida Association 

StMary's Conference of Society of St. 

Vincent de Paul 

Stuart Cen tcr 

TASH 

The AIDS Institute 

The Arc of the United States 

The Cave Institute 

The Children's Cause for Cancer Advocacy 

The Hemophilia Alliance 

The National Alliance to Advance Adolescent 

Health 

The National Campaign to Prevent Teen and 

Unplanned Pregnancy 

The National Crittenton Foundation 

The Praxis Project 

The Remmer Family Foundation, Inc. 

The Sargent Shriver National Center on 

Poverty Law 

The Trevor Project 

Treatment Communities of America 

Trust for America's Health 

5 
97 


28525.048

U.S. Breastfeeding Committee 

U.S. Pain Foundation 

United Church of Christ 

United Food and Commercial Workers 

International Union 

United Methodist Church- General Board of 

Church and Society 

United Way Worldwide 

What to Expect Foundation 

Women's International League for Peace & 

Freedom 

Wyman Center, Inc. 

Young Invincibles 

Youth MOVE National 

YWCA USA 

ZERO TO THREE 

STATE, TERRITORY AND LOCAL 

ORGANIZATIONS 

Alabama 

Alabama Chapter-American Academy of 

Pediatrics 

American Lung Association in Alabama 

Children's Poli~y Cooperative of Jefferson 

County 

Epilepsy Foundation of Alabama 

Envision 2020 

Lakeshore Foundation 

United Way of Southwest Alabama 

University of South Alabama Children's and 

Women's Hospital 

VOICES for Alabama's Children 

Alaska 

American Academy of Pediatrics-Alaska 

Chapter 

American Lung Association in Alaska 

Stone Soup Group 

United Way of Anchorage 

Arizona 

American Lung Association in Arizona 

Arizona Academy of Family Physicians 

Arizona Chapter of the American Academy of 

Pediatrics 

Arizona Dental Hygienists' Association 

Concilio Latino de Salud 

Epilepsy Foundation of Arizona 

Maricopa County Oral Health Leaders 

Advocates and Resources Coalition 

National Association of Pediatric Nurse 

Practitioners Arizona Chapter 

Pan Asian Community Alliance 

Phoenix Children's Hospital 

The Mindfulness Education Exchange 

United Way of Northern Arizona 

United Way of Tucson and Southern Arizona 

Valley of the Sun United Way 

West Valley Neighborhoods Coalition 

Arkansas 

American Lung Association in Arkansas 

Arkansas Advocates for Children and Families 

Arkansas Chapter, American Academy of 

Pediatrics 

Arkansas Children's Hospital 

Arkansas Poison and Drug Information 

Center 

Project Hope Teen Pregnancy Prevention 

Project 

United Way of the Ouachitas 

California 

Alameda Health Consortium 

American Academy of Pediatrics, California 

American Academy of Pediatrics, CA Chapter 

3 

American Academy of Pediatrics - Orange 

County Chapter 

American Lung Association in California 

Arrowhead United Way 

Asian Americans Advancing Justice - Los 

Angeles 

Asian Law Alliance 

California Academy of Family Physicians 

California Children's Hospital Association 

California Coverage and Health Initiatives 

(CCHI) 

California Dental Association 

California Health Advocates 

California Pan-Ethnic Health Network 

(CPEHN) 

California Poison Control System 

California School-Based Health Alliance 

California School Nurses Organization 

6 
98 


28525.049

California State Association of Counties 

California WIC Association 

Cavityfree SF Collaborative 

Children Now 

Children's Defense Fund - California 

Children's Hospital Los Angeles 

CHOC Children's at Mission Hospital 

Coalition for Humane Immigrant Rights 

(CHIRLA) 

Community Health Centers of the Central 

Coast 

Community Health Councils 

Community Resources for Independent 

Ijving (CRIL) 

County Welfare Directors Association of 

California 

Epilepsy California 

Epilepsy Foundation of Greater Los Angeles 

Family Care Network, Inc. 

First 5 Association of California 

First 5 LA 

First 5 Santa Cruz County 

First 5 Sonoma County 

Give for a Smile 

Hemet Unified School District 

Jewish Family Service of San Diego 

Kids in Common 

Lincoln 

Lama Linda University Children's Hospital 

Lucile Packard Children's Hospital Stanford 

Making Change For Children 

Maternal and Child Health Access 

Miller Children's and Women's Hospital Long 

Beach 

National Association of Pediatric Nurse 

Practitioners -- Orange County, California 

Chapter 

National Association of Pediatric Nurse 

Practitioners -- San Francisco Bay Area 

Chapter 

Orange County United Way 

Partnership for the Children of San Luis 

Obispo County 

PI CO California 

Placer Independent Resource Services 

Public Health Advocates 

Rady Children's Hospital San Diego 

Reach Out 

Shriners Hospitals for Children Northern 

California 

Silicon Valley Leadership Group 

The Children's Partnership 

The Los Angeles Trust for Children's Health 

United Way Bay Area 

United Way Fresno Madera Counties 

United Way of Kern County 

United Way of Northern California 

United Way of San Luis Obispo County 

United Way of Stanislaus County 

United \'l?ay of Ventura County 

United Ways of California 

UCSF Benioff Children's - Oakland 

Valley Children's Healthcare 

Western Center on Law & Poverty 

Colorado 

All Kids Covered Colorado 

American Academy of Pediatrics - Colorado 

Chapter 

American Lung Association in Colorado 

Center for Health Progress 

Children's Hospital Colorado 

Colorado Academy of Family Physicians 

Colorado Children's Campaign 

Colorado Consumer Health Initiative 

Colorado Cross-Disability Coalition 

Colorado Dental Association 

Colorado Organization for Latina 

Opportunity and Reproductive Rights 

Epilepsy Foundation of Colorado 

Focus Points Family Resource Center 

Mental Health Colorado 

One Colorado 

Oral Health Colorado 

Posada 

St. Vrain Valley Schools 

The Consortium 

Connecticut 

American Lung Association in Connecticut 

Connecticut Association for Human Services 

Connecticut Children's Medical Center 

Connecticut Voices for Children 

Greater Hartford Legal Aid 

National Association of Social Workers, CT 

Chapter 

7 
99 


28525.050

Unitarian Society of New Haven 

United Way of Connecticut 

United Way of Western CT 

Yale New Haven Children's Hospital 

Delaware 

American Lung Association in Delaware 

Delaware Ecumenical Council on Children 

and Families 

Delaware Oral Health Coalition 

Epilepsy Foundation of Delaware 

Medical Society of Delaware 

Nemours Children's Health System 

District of Columbia 

American Lung Association in District of 

Columbia 

Children's National Health System 

D.C. Hunger Solutions 

La Clinica del Pueblo 

The HSC Health Care System 

United Way of the National Capital Area 

Florida 

American Lung Association in Florida 

Catalyst Miami 

Democratic Women's Club of Florida 

Epilepsy Foundation of Florida 

Farmworker Association of Florida, Inc 

Florida Association of Children's Hospitals 

Florida Chapter of the American Academy of 

Pediatrics, Inc. 

Florida Dental Association 

Healthy Start Coalition 

Heart of Florida United Way 

Holy Cross Hospital, Inc. 

Immokalee Multicultural Multipurpose 

Community Action Agency 

Johns Hopkins All Children's Hospital 

Oral Health Florida 

Shriners Hospitals for Children- Tampa 

St. Joseph's Children's Hospital of Tampa 

Suncoast Health Council, Inc. 

The Children's Campaign 

United Way ofBroward County 

United Way of Florida 

United Way of Miami-Dade 

United Way South Sarasota County 

Cnited Way Suncoast 

Voices for Florida 

Wolfson Children's Hospital 

Georgia 

American Lung Association in Georgia 

Children's Healthcare of Atlanta 

Easterseals Southern Georgia, Inc. 

Georgia Academy of Family Physicians 

Georgia Chapter-American Academy of 

Pediatrics 

Georgia Dental Association 

Georgia Watch 

Georgians for a Healthy Future 

Parent to Parent of Georgia 

St. Vincent de Paul Georgia 

United Way of Greater Atlanta 

United Way of Northeast Georgia 

Voices for Georgia's Children 

Hawaii 

American Lung Association in Hawaii 

Assistive Technology Resource Centers of 

Hawaii 

Big Brothers Big Sisters Hawaii 

Child & Family Service 

Epilepsy Foundation of Hawaii 

Feeding Hawaii Together 

Habilitat, Inc. 

Hawaii Children's Action Network 

Hawaii Dental Association 

Hawaii Public Health Institute 

Healthy Mothers Healthy Babies Coalition of 

Hawaii 

Ho'ola Na Pua 

Kapi'olani Medical Center for Women & 

Children 

Lfe Foundation 

Mental Health America of Hawaii 

Parents And Children Together 

People Attentive to Children (PATCH) 

Shriners Hospitals for Children Honolulu 

Susan G. Komen Hawaii 

Idaho 

American Lung Association in Idaho 

Idaho Chapter of the American Academy of 

Pediatrics 

8 
100 


28525.051

Idaho Oral Health Alliance 

Idaho Parents Unlimited 

Idaho Voices for Children 

SelectHealth 

St. Luke's Health System 

Illinois 

American Lung Association in Illinois 

Ann & Robert H. Lurie Children's Hospital of 

Chicago 

Chicago Women's AIDS Project 

Child Care Association of Illinois 

Comer Children's Hospital, University of 

Chicago Medicine 

Epilepsy Foundation of Greater Chicago 

Epilepsy Foundation of Greater Southern 

Illinois 

Epilepsy Foundation of North Central 

Illinois, Iowa, & Nebraska 

Erikson Institute 

Ever Thrive Illinois 

Fox Valley Citizens for Peace & Justice 

Illinois Academy of Family Physicians 

Illinois Chapter, American Academy of 

Pediatrics 

Illinois Coalition for Immigrant and Refugee 

Rights 

La Rabida Children's Hospital 

Legal Council for Health Justice 

Ounce of Prevention Fund 

Park Ridge Housing Initiative 

Project IRENE 

Shriners Hospital for Children Chicago 

The Alliance 

United Way of Illinois 

United \X'ay of Lake County 

United Way of Metropolitan Chicago 

Indiana 

American Lung Association in Indiana 

Cardinal Services, Inc. of Indiana 

Covering !<ids and Families of Indiana 

DJ Center for Youth, Inc 

Epilepsy Foundation oflndiana 

Family and Children's Ministries, Disciples 

Home Missions, Christian Church (Disciples 

of Christ) 

Family Voices Indiana 

Indiana Association of United Ways 

Indiana Chapter of the American Academy of 

Pediatrics 

Indiana Dental Association 

Indiana Oral Health Coalition 

Indiana Resource Center for Families with 

Special Needs 

Indiana Small and Rural Schools Association 

Indianapolis Public Schools 

Lake Area United Way 

National Association of Social Workers, 

Indiana 

Opportunity Enterprises Inc. 

Passages, Inc. 

Prevent Child Abuse Indiana, a Division of 

The Villages 

Riley Hospital for Children at Indiana 

University Health 

The Phoenix Institute 

United Way of Madison County, Indiana 

Iowa 

Access for Special !<ids (ASK) Resource 

Center, Inc. 

American Lung Association in Iowa 

Blank Children's Hospital 

Child and Family Policy Center 

Child Serve 

Congregation of the Humility of Mary, 

Leadership Team 

Epilepsy Foundation of North Central 

Illinois, Iowa, & Nebraska 

Iowa Chapter American Academy of 

Pediatrics 

Iowa Public Health Association 

National Association of Pediatric Nurse 

Practitioners Iowa Chapter 

Prevent Child Abuse Iowa 

United Way of Johnson & Washington 

Counties 

United Ways of Iowa 

University of Iowa Health Care 

Kansas 

Achievement Services for Northeast Kansas, 

Inc. 

American Lung Association in Kansas 

9 
101 


28525.052

Children's Alliance of Kansas 

Community Developmental Disability 

Organization (CDDO) of Butler County 

Community Health Council 

Developmental Services of Jackson County 

Developmental Services of Northwest Kansas 

Doniphan County Services and Workskills 

InterHab 

Junior League of Wichita 

Kansas Academy of Family Physicians 

Kansas Action for Children 

Kansas Chapter, American Academy of 

Pediatrics 

Mosaic 

New Beginnings Enterprises, Inc. 

Oral Health Kansas, Inc. 

Rogers Family Dentistry 

TARC, Inc 

Kentucky 

American Lung Association in Kentucky 

Bon Secours Kentucky Health System 

Covering Kentucky Kids and Families 

Epilepsy Foundation of Kentuckiana 

Family & Children's Place 

Kentucky Dental Association 

Kentucky Equal Justice Center 

Kentucky Youth Advocates 

Metro United Way 

Norton Health care 

Our Lady of Bellefonte Hospital 

Shriners Hospitals for Children - Lexington 

United Way of Greater Cincinnati- Northern 

Kentucky 

Louisiana 

American Lung Association in Louisiana 

First Christian Church of Greater New 

Orleans 

Health and Education Alliance of Louisiana 

Kingsley House 

Louisiana Association of United Ways 

Louisiana Budget Project 

Louisiana Chapter of the American Academy 

of Pediatrics 

Louisiana Democracy Project 

Louisiana Dental Association 

Louisiana Partnership for Children and 

Families 

Shriners Hospitals for Children--Shreveport 

Stone Creek Nursery & Landscapes 

United Way of Northwest Louisiana 

United Way of Southeast Louisiana 

Maine 

American Lung Association in Maine 

Community Concepts Inc 

Families And Children Together 

Maine Chapter, American Academy of 

Pediatrics 

Maine Children's Alliance 

Maine Public Health Association 

MaineHealth 

The Diaper Fund 

United Way of Greater Portland 

United Way of Mid-Maine 

United Way of the Tri-Valley Area 

United Way of York County Maine 

Maryland 

Addiction Connections Resource 

Advocates for Children and Youth 

American Lung Association in Maryland 

CASA 

Consumer Health First 

Epilepsy Foundation Chesapeake Region 

Johns Hopkins Children's Center 

Maryland Academy of Family Physicians 

Maryland Center on Economic Policy 

Maryland Chapter, American Academy of 

Pediatrics 

Maryland Dental Action Coalition 

Maryland Family Network 

Maryland Hunger Solutions 

Maryland National Organization for Women 

MD Coalition of Families 

Mt. Washington Pediatric Hospital 

National Association of Pediatric Nurse 

Practitioners Maryland Chesapeake 

Chapter 

National Organization for Women, 

Montgomery County, MD, Chapter 

PeterCares House 

Public Justice Center 

Washington County NOW 

10 
102 


28525.053

Massachusetts 

American Lung Association in Massachusetts 

Association for Behavioral Healthcare 

Boston Children's Hospital 

Brookline Department of Diversity, Inclusion, 

and Community Relations 

Community Action Committee of Cape Cod 

& Islands 

Epilepsy Foundation New Iongland 

Federation for Children with Special Needs 

Floating Hospital for Children at Tufts 

Medical Center 

Franciscan Children's 

Health Care For All 

Massachusetts Chapter of the American 

Academy of Pediatrics 

Massachusetts Immigrant & Refugee 

Advocacy Coalition 

Massachusetts Law Reform Institute, Inc 

Massachusetts Medical Society 

Massachusetts Organization of Educational 

Collaboratives 

Mercy LIFE 

Shriners Hospitals for Children - Boston 

Shriner's Hospitals for Children - Springfield 

United Way of Franklin County 

United Way of Massachusetts Bay and 

Merrimack Valley 

Watertown Citizens for Peace, Justice and the 

Environment 

Michigan 

Advocates for Benzie County 

!\leona Citizens for Health, Inc., 

Allegan County United Way 

American Lung Association in Michigan 

Baldwin Family Health Care 

Capital Area Community Services, Inc., Head 

Start and Early Childhood Programs 

Char-Em United Way 

Cherry Health 

Children's Hospital of Michigan 

Epilepsy Foundation of Michigan 

Great Start Collaborative of Traverse Bay 

Groundcover News 

Kent County Oral Health Coalition 

Leelanau Children's Center 

MI Chapter American Academy of Pediatrics 

Michigan Academy of Family Physicians 

Michigan Association ofintermediate School 

Administrators 

Michigan Association of School 

Administrators 

Michigan Association of United Ways 

l\fichigan Council for Maternal and Child 

Health 

l\fichigan Dental Association 

l\fichigan Health & Hospital Association 

Michigan League for Public Policy 

Michigan Oral Health Coalition 

Moveon.org - Michigan 

Munson Healthcare 

Shiawassee United Way 

Starr Vista 

The Leelanau Early Childhood Development 

Commission's Parenting Communities 

Program 

TrueNorth Community Services 

United Health Organization 

United Way for Southeastern Michigan 

United Way of Delta County 

United Way of Manistee County 

United Way Montcalm-Ionia Counties 

United Way of Washtenaw County 

University of Michigan, C.S. Mott Children's 

Hospital, Michigan Medicine 

Washtenaw County Public Health 

Washtenaw Health Plan 

Minnesota 

40outofPoverty 

American Lung Association in Minnesota 

AspireMN 

Children's Defense Fund-Minnesota 

Children's Minnesota 

Gillette Children's Specialty Healthcare 

Greater Friendship Missionary Baptist Church 

Impetus Let's Get Started LLC 

Minnesota Chapter of the American Academy 

of Pediatrics 

Minnesota !-lead Start Association, Inc. 

Sherburne County Area United Way 

Shriners Hospitals for Children - Twin Cities 

University of Minnesota Masonic Children's 

Hospital 

11 
103 


28525.054

Mississippi 

American Lung Association in Mississippi 

Children's Defense Fund Southern Region 

Mississippi Chapter, American Academy of 

Pediatrics 

Mississippi Human Services Coalition 

Southern Rural Black Women's Initiative for 

Economic and Social Justice 

Missouri 

A Red Circle 

Almost Home 

American Lung Association in Missouri 

Behavioral Health Response, Inc 

Bilingual International Assistant Services 

Capital Area Missouri NOW 

Child Care Aware of Missouri 

Children's Haven of Southwest Missouri, Inc. 

Children's Mercy Kansas City 

Empower Missouri 

Generate Health 

Howell County Health Department 

Judevine Center for Autism 

Kids In The Middle 

LlJME Institute 

Lydia's House, Inc. 

Missouri Chapter of the American Academy 

of Pediatrics 

Missouri Children's Leadership Council 

Missouri Coalition for Oral Health 

Missouri Coalition of Children's Agencies 

Missouri Developmental Disabilities Council 

Missouri Health Care for All 

Missouri Hospital Association 

Missouri KIDS COUNT 

Missouri !<ids First 

Missouri Parents as Teachers Association 

NAMI St. Louis 

No Kid Hungry Missouri 

Nurses for Newborns 

Places for People, Inc. 

Presbyterian Children's Homes and Services 

Provident, Inc. 

Safe Connections 

Saint Louis University Department of 

Pediatrics 

Saint Vincent Home for Children 

Shriners Hospitals for Children - St. Louis 

SSM Health Cardinal Glennon Children's 

Hospital 

St. Louis Center for Family Development 

St. Louis Children's Hospital 

St. Louis County Children's Service Fund 

St. Martha's Hall 

The Family and Community Trust 

United 4 Children 

Vision for Children at Risk 

Montana 

American Lung Association in Montana 

Montana Academy of Family Physicians 

Montana Chapter of the American Academy 

of Pediatrics 

Montana Dental Association 

Montana Small Schools Alliance 

Rocky Mountain Hemophilia & Bleeding 

Disorders Association 

Western Native Voice 

Nebraska 

American Lung Association in Nebraska 

Children's Hospital and Medical Center 

Epilepsy Foundation Foundation of North 

Central Illinois, Iowa, & Nebraska 

"-!ebraska Appleseed 

Nebraska Foster and Adoptive Parent 

Association 

Sisters of Mercy West Midwest Justice Team 

Voices for Children in Nebraska 

Nevada 

Acting in Community Together Orgartizing 

Northern Nevada (ACTIONN) 

American Academy of Pediatrics, Nevada 

Chapter 

American Lung Association in Nevada 

Children's Advocacy Alliance 

Epilepsy Foundation of Nevada 

Immunize Nevada 

Family TIES of Nevada 

Nevada Primary Care Association 

Positively !<ids 

Service Employees International Union 

Nevada Local1107 (SEIU) 

12 
104 


28525.055

New Hampshire 

American Lung Association in New 

Hampshire 

Children's Hospital at Dartmouth-Hitchcock 

Granite State Diabetes Educators, Inc. 

New Jersey 

Advocates for Children of New Jersey 

American Lung Association in New Jersey 

Caregivers of New Jersey 

Children's Specialized Hospital 

Coalition of Mental Health Consumer 

Organizations 

Coastal Habitat for Humanity 

Epilepsy Foundation of New Jersey 

Family Voices New Jersey 

Hackensack Meridian Health 

Jewish Federation of Ocean County 

K. Hovnanian Children's Hospital 

Lunch Break 

New Jersey Association of Mental Health and 

Addiction Agencies, Inc. 

New Jersey Chapter, American Academy of 

Pediatrics 

New Jersey Citizen Action 

New Jersey Tenants Organization 

!\iorthern New Jersey Chapter, National 

Organization for Women 

Ocean County YMCA, Inc. 

RE.SULTS Central New Jersey 

Rutgers Center on Law, Inequality and 

Metropolitan Equity 

St. Francis Center, LBICC, Inc. 

Statewide Parent Advocacy Network 

The Children's Home Society of New Jersey 

The Hope Center at The House of Hope of 

Ocean County, Inc. 

Union County Peace Council 

United Way of Central Jersey 

United Way of Greater Philadelphia and 

Southern New Jersey 

United Way of Hunterdon County 

United Way of Monmouth and Ocean 

Counties 

United Way of Northern New Jersey 

United Way of Passaic County 

New Mexico 

All Faiths Children's Advocacy Center 

American Lung Association in New Mexico 

Community Action Agency of Southern New 

Mexico 

Health Action New Mexico 

High Plains Regional Education Cooperative 

Interfaith Worker Justice- New Mexico 

National Association of Social Workers- New 

Mexico 

New Mexico Academy of Family Physicians 

New Mexico Pediatric Society 

New Mexico Voices for Children 

RESULTS Santa Fe 

New York 

Acacia Network 

African Services Committee 

Albany Behavioral Health Services 

American Academy of Pediatrics, New York 

State 

American Lung Association in New York 

Association of Perinatal Networks 

Blythedale Children's Hospital 

Brooklyn Center for Independence of the 

Disabled 

Buffalo Prenatal Perinatal Network 

Catholic Charities of Chemung/Schuyler 

Counties, NY 

Center for Independence of the Disabled, NY 

Center for Research on Physical Activity, 

Sport & Health at D'Y ouville College 

Child Care Council, Inc. 

Child Care Resources of Rockland, Inc. 

Children's Defense Fund--New York 

Citizens' Committee for Children of New 

York, Inc. 

Claire Heureuse Community Center, Inc 

Community Resource Exchange 

Community Service Center of Greater 

Williamsburg 

Concerned Citizens For Change 

Dental Hygienists' Association of the State of 

New York 

Early Childhood Development Initiative 

Elmcor Youth and Adult Activities 

Empire Justice Center 

EPIC Long Island, Inc. 

13 
105 


28525.056

Epilepsy Foundation of Metropolitan New 

York 

Every Child Matters Coalition 

Families Together in New York State 

Family & Children's Service of Niagara 

Federation of Protestant Welfare Agencies 

Greater New York Labor Religion Coalition 

Health and Welfare Council of Long Island 

Health Care For All New York 

Independence 

Make The Road New York 

Metro New York Health Care for All 

Mohawk Valley Perinatal Network 

Mothers & Babies Perinatal Network of 

SCNY, Inc 

Mount Sinai K.ravis Children's Hospital 

National Association of Pediatric Nurse 

Practitioners -- E-Chapter 

National Association of Pediatric Nurse 

Practitioners -- Greater New York Chapter 

New York Immigration Coalition 

New York Legal Assistance Group 

New York- Presbyterian 

New York State Coalition for Children's 

Behavioral Health 

New York State Council for Community 

Behavioral Healthcare 

New Yorkers for Accessible Health Coverage 

North Country Prenatal Perinatal Council, Inc 

OneGroup-Benefits Advisory Service 

Oxford Family Group Day Care 

Prevent Child Abuse New York 

Quality Consortium 

Recovery Coaching Services of NY 

Rochester Child first Network 

Rockland Immigration Coalition 

Rural Schools Association of New York State 

Schenectady Inner City Ministry 

Schuyler Center for Analysis and Advocacy 

The Alcoholism and Substance Abuse 

Providers of New York State (ASAP) 

The Children's Agenda 

United Way of Buffalo & Eric County 

United Way of the Southern Tier, Inc. 

Violence Intervention Program 

Vocal Voters of Rockland 

West Side Campaign Against Hunger 

Westchester Children's Association 

Y\'VCA of the Greater Capital Region 

North Carolina 

American Lung Association in North Carolina 

Epilepsy Foundation of North Carolina 

Goldsboro Pediatrics, PA 

Jewish Family Services of Greater Charlotte 

Legal Services of Southern Piedmont 

National Association of Pediatric Nurse 

Practitioners - Charlotte, North Carolina 

Chapter 

National Association of Social Workers, 

North Carolina Chapter 

NCChild 

North Carolina Justice Center 

The National Alliance on Mental Illness 

North Carolina 

United Way of Moore County 

United WayofNorth Carolina 

Wayne Initiative for School Health 

Working America North Carolina 

North Dakota 

American Lung Association in North Dakota 

North Dakota Dental Association 

United Way of Grand Forks, East Grand 

forks & Area 

Ohio 

Achievement Centers for Children 

Akron Children's Hospital 

American Lung Association in Ohio 

American Sickle Cell Anemia Association 

Art House, Inc. 

Asian American Community Services 

Asian Services In Action 

Center for Closing the Health Gap 

Children's Defense Fund-Ohio 

Cincinnati Children's Hospital Medical Center 

Cleveland Clinic Children's 

Cleveland Tenants Organization 

Community Assisted Restoration Services 

Community of Faith 

Contact Center 

Dayton Children's Hospital 

family Connections of Northeast Ohio 

Family Promise of Greater Cleveland 

First Presbyterian Church 

14 
106 


28525.057

Friendly Inn Settlement, Inc 

Grace United Church of Christ 

Juvenile Justice Coalition (Ohio) 

K.ings Local Food Pantry 

Lutheran Metropolitan Ministry 

Meigs County Health Department 

National Association of Pediatric Nurse 

Practitioners -- Ohio Chapter 

Nationwide Children's Hospital 

Needy Basket of Southern Miami County, Inc. 

Ohio Academy of Family Physicians 

Ohio Association of Community Health 

Centers 

Ohio Chapter, American Academy of 

Pediatrics 

Ohio Children's Hospital Association 

Ohio Family Care Association 

Ohio United Way 

Pathways of Central Ohio 

Positive Education Program 

ProgressOhio 

ProMedica Toledo Children's Hospital 

Providence House, Inc. - Crisis Nursery 

Rainey Institute 

Results Columbus 

Schubert Center for Child Studies 

SEM Food Pantry 

Shriners Hospital for Children Cincinnati 

Sisters of Charity of St. Augustine 

Society of St Vincent De Paul, Diocesan 

Council of Columbus 

Somali Communi tv Association of Ohio 

South Communiry Inc. 

Talbert House 

The Achievement Centers for Children 

The Ohio Council of Behavioral Health & 

Family Services Providers 

United Way of Central Ohio 

United Way of Greater Cincinnati 

United Way of Greater Cleveland 

United Way of Greater Stark County 

United Way of Hocking County 

United Way of Summit County 

Universal Health Care Action Network of 

Ohio 

University Hospitals Rainbow Babies & 

Children's Hospital 

Valley Voices United for Change 

Voices for Ohio's Children 

West Side Catholic Center 

Westland Ecumenical Community Food 

Pantry 

Oklahoma 

American Lung Association in Oklahoma 

Epilepsy Foundation of Oklahoma 

Oklahoma Chapter of the American Academy 

of Pediatrics 

Oklahoma Dental Association 

United Way of Central Oklahoma 

Oregon 

American Lung Association in Oregon 

Children First for Oregon 

Children's Institute 

National Association of Pediatric Nurse 

Practitioners -- Oregon Chapter 

Oregon Pediatric Society 

Oregon Poison Center 

The Family Place Therapeutic Services Inc. 

United Way of Columbia County 

Pennsylvania 

AIDS Resource 

All About Children Pediatric Partners, PC 

Allies for Children 

Amarcord 

American Lung Association in Pennsylvania 

Bhutanese Community Association of 

Pittsburgh 

Bucks County Medical Society 

Bucks County Women's Advocacy Coalition 

Catholic Social Services 

Centre County United Way 

Centro Nueva Creaci6n 

Children's Hospital of Philadelphia 

Children's Hospital of Pittsburgh of UPMC 

Clinton County Housing Coalition 

Coalition of African Communities 

Community Action Partnership 

Consumer Health Coalition 

Epic Health Services 

Epilepsy Foundation Eastern PA 

Epilepsy Foundation Western/Central 

Pennsylvania 

Family Promise of Harrisburg Capital Region 

15 
107 


28525.058

Family Service Association of Bucks County 

Family Services of Western Pennsylvania 

GRANDS AS PARENTS INC 

Health Care Access 

HIAS Pennsylvania 

Keystone Progress 

Maternity Care Coalition 

Mental Health Association in PA 

Mental Health Association of Southeastern 

PA 

Montgomery County Community Action 

Development Commission 

National Association of Pediatric Nurse 

Practitioners - Pennsylvania-Delaware Valley 

Chapter 

New Start Medical 

Pediatric Dental Associates, LTD 

Pediatric Palliative Care Coalition 

Penn State Health Children's Hospital 

Pennsylvania Association of Community 

Health Centers 

Pennsylvania Association of School Nurses 

and Practitioners 

Pennsylvania Catholic Health Association 

Pennsylvania Chapter of the American 

Academy of Pediatrics 

Pennsylvania Coalition for Oral Health 

Pennsylvania Council of Churches 

Pennsylvania Dental Association 

Pennsylvania Health Access Network 

Pennsylvania Health Funders Collaborative 

Pennsylvania Health Law Project 

Pennsylvania Partnerships for Children 

Pittsburgh Association for the Education of 

Young Children (PAEYC) 

Public Citizens for Children and Youth 

Reclaim Philadelphia 

Shriners Hospitals for Children Erie 

Shriners Hospitals for Children- Philadelphia 

Sickle Cell Disease Association of America, 

Philadelphia/Delaware Valley Chapter 

Southeastern Pennsylvania Oral Surgery 

Special Smiles, LTD 

Survivors) Inc. 

The Sisters of St. Francis of Philadelphia 

Unitarian Universalist Pennsylvania 

Legislative Advocacy Network 

United Methodist Advocacy in Pennsylvania 

United Way of Adams County 

United Way of Beaver County 

United Way of Butler County 

United Way of Chester County 

United Way of Greater Hazleton 

United Way of Greater Philadelphia and 

Southern New Jersey 

United Way of Monroe County 

United Way of Susquehanna County 

United Way of the Titusville Region 

United \Vay of Western Crawford County 

United Way of Wyoming Valley 

United Way of York County, PA 

West Chester Food Cupboard 

Western Pennsylvania Diaper Bank 

Women's Law Project 

YWCA Greater Pittsburgh 

Puerto Rico 

Colegio de Cirujanos Dentistas de Puerto. 

Rico 

Rhode Island 

Adoption Rhode Island 

American Lung Association in Rhode Island 

Rhode Island KIDS COUNT 

South Carolina 

Access Family Services 

American Lung Association in South Carolina 

Bible Way Community Learning Center 

Black River United Way 

Children's Hospital Greenville Health System 

Medical University of South Carolina 

Children's Hospital 

National Association of Pediatric Nurse 

Practitioners -- South Carolina Chapter 

Palmetto Association for Children and 

Families 

Palmetto Project 

SC Appleseed Legal Justice Center 

SC Dental Association 

Shriners Hospitals for Children - Greenville 

South Carolina Chapter of the American 

Academy of Pediatrics 

South Carolina Children's Hospital 

Collaborative 

Southern Georgetown Leadership Group 

16 
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Still Learning, Inc 

United Way Association of South Carolina 

United Way of Aiken County 

United Way of Greenville County 

United Way of Hartsville SC 

United Way of Pickens County 

United Way of the Midlands 

Youth Collaboratives of Georgetown County 

South Dakota 

American Lung Association in South Dakota 

National Association of Social Workers, 

South Dakota Chapter 

South Dakota Chapter American Academy of 

Pediatrics 

Tennessee 

American Lung Association in Tennessee 

Black Children's Institute of Tennessee 

Children's Hospital Alliance of Tennessee 

East Tennessee Children's Hospital 

Epilepsy Foundation of East Tennessee 

Le Bonheur Children's Hospital 

Mental Health America of Middle Tennessee 

Monroe Carell Jr. Children's Hospital at 

Vanderbilt 

Niswonger Children's Hospital 

Tennessee Academy of Family Physicians 

Tennessee Chapter of the American Academy 

of Pediatrics 

Tennessee Justice Center 

United Ways of Tennessee 

Texas 

American Lung Association in Texas 

Bread Fellowship 

Children's Defense Fund - Texas 

Children's Health System of Texas 

Children's Hospital Association of Texas 

Children's Hospital of San Antonio 

Clarity Child Guidance Center 

Coalition of Texans with Disabilities 

Cook Children's Health Care System 

Dell Children's Medical Center of Central 

Texas 

Driscoll Children's Hospital 

Epilepsy Foundation Central & South Texas 

Epilepsy Foundation Texas -

Houston/Dallas-Fort Worth/West Texas 

Get Up Project 

Healthy Futures of Texas 

Houston Women March 

Insure-A-kid 

Mental Health America of Greater Houston 

Methodist Healthcare Ministries of South 

Texas, Inc. 

National Association of Pediatric Nurse 

Practitioners -- Austin, Texas Chapter 

National Association of Pediatric Nurse 

Practitioners -- Greater Texas Chapter 

National Association of Social WorkersTexas Chapter 

PediPiace 

Shriners Hospitals for Children Galveston 

Shriners Hospitals for Children - Houston 

Teaching Hospitals of Texas 

Texans Care for Children 

Texas Academy of Pediatric Dentistry 

Texas Association of Charitable Clinics 

Texas Association of Community Health 

Centers 

Texas Children's Hospital 

Texas Dental Association 

Texas Doctors for Social Responsibility 

Texas Foster Family Association 

Texas Kids Can't Wait 

Texas Medical Association 

Texas Pediatric Society - Texas Chapter of the 

American Academy of Pediatrics 

Texas Rural Education Association 

Texas Scottish Rite Hospital for Children 

Trinity Lutheran Church 

Unitarian Universalist Fellowship of Hidalgo 

County 

United Way of Brazoria County 

United Way of Central Texas 

United Way of Greater Houston 

United Way of Metropolitan Dallas 

United Way of Tarrant County 

United Way of the Coastal Bend 

United Ways of Texas 

Voices for Children of San Antonio 

Utah 

American Lung Association in Utah 

17 
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Disabled Rights Action Committee 

Epilepsy Foundation of Utah 

Intermountain Healthcare 

Primary Children's Hospital 

SelectHealth 

Shriners Hospital - Salt Lake City 

United Way of Cache Valley 

United Way of Northern Utah 

United Way of Salt Lake 

Utah Health Policy Project 

Voices for Utah Children 

Vermont 

Addison County Community Trust 

Addison County Transit Resources 

American Academy of Pediatrics Vermont 

Chapter 

American Lung Association in Vermont 

Disability Rights Vermont 

Epilepsy Foundation of Vermont 

Green Mountain United Way 

Mary Johnson Children's Center 

United Way of Addison County 

United Way of Lamoille County 

United \'<hy of Windham County 

United \\iays of Vermont/Vermont 211 

Vermont Adult Learning 

Vermont Coalition for Disability Rights 

Vermont Family Network 

Vermont Federation of Families for 

Children's Mental Health 

Virginia 

American Lung Association in Virginia 

Blue Ridge Independent Living Center 

Children's Hospital of Richmond at Virginia 

Commonwealth University 

Cornerstones, Inc. 

Department of Community and Human 

Services, City of Alexandria 

Epilepsy Foundation of Virginia 

Inova Children's Hospital 

Jackson-Feild Behavioral Health Services 

Prevent Child Abuse Virginia 

Rappahannock United Way 

Social Action Linking Together (SALT) 

United Way of the National Capital Area 

Virginia Chapter, American Academy of 

Pediatrics 

Virginia Coalition of Latino Organizations 

Virginia Oral Health Coalition 

Virginia Parents as Teachers State OfficeCHIP of Virginia 

Virginia Society of Pediatric Dentistry 

Voices for Virginia's Children 

Washington 

American Lung Association in Washington 

Anti-Hunger & Nutrition Coalition 

Children's Alliance 

Community Health Network of Washington 

Community Health Plan of Washington 

Conscious Talk Radio 

Epilepsy Foundation Northwest 

Hope Sparks 

Muslim County Resource Center- Islamic 

Civic Engagement 

National Association of Pediatric Nurse 

Practitioners 

North Mason Coalition of Churches & 

Community 

Northwest Harvest 

Northwest Health Law Advocates 

Ocean Beach Hospital and Medical Clinics 

OneAmerica 

Partners for Our Children 

Sea Mar Community Health Center 

Seattle Children's Hospital 

Shriners Hospitals for Children - Spokane 

Triumph Treatment Services 

United Way of Island County 

United Way of Snohomish County 

Washington Academy of Family Physicians 

Washington Association of Community & 

Migrant Health Centers 

Washington Chapter of the American 

Academy of Pediatrics 

Washington Community Action Network 

Washington Dental Service Foundation 

Washington Health care Access Alliance 

Washington Rural Health Association 

Washington State Labor Council, i\FL-CIO 

West Virginia 

American Lung Association in West Virginia 

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Hoops Family Children's Hospital at Cabell 

Huntington Hospital 

TEAM for West Virginia Children 

West Virginia Chapter, American Academy of 

Pediatrics 

West Virginia Dental Association 

West Virginia Oral Health Coalition 

West Virginians for Affordable Health Care 

Wisconsin 

American Lung Association in Wisconsin 

Children's Hospital of Wisconsin 

Community Advocates, Inc. 

End Domestic Abuse WI 

Epilepsy Foundation Heart of Wisconsin 

Epilepsy Foundation of Western Wisconsin 

Great Rivers United Way 

Marshfield Clinic Health System 

Marshfield Community Development 

Authority 

Mental Health America of WI 

National Association of Social WorkersWisconsin Chapter 

United Way of Sheboygan County 

United Way of Wisconsin 

Wisconsin Alliance for Women's Health 

Wisconsin Chapter of the American Academy 

of Pediatrics 

Wisconsin Council on Children and Families 

Wisconsin Faith Voices for Justice 

Wisconsin Family Ties, Inc. 

Wisconsin Oral Health Coalition 

Wisconsin Rural Schools Alliance 

Wyoming 

American Lung Association in Wyoming 

UPLIFI' 

Wyoming Dental Association 

19 
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GREG WALDEN, OREGON 

CHAIRMAN 

Mr. Michael Holmes 

CEO 

ONE HUNDRED FIFTEENTH CONGRESS 

FRANK PALLONE, JR,, NEW JERSEY 

RANKING MEMBER 

ct.Congregg of tbe ltniteb !Stateg 

~ott!lc ot ~epre!lentatibe!l 

COMMITTEE ON ENERGY AND COMMERCE 

2125 RAYBURN HousE OFFICE BuilDING 

WASHINGTON, DC 20515-6115 Majontv !202)225-2927 

Mirtotity\202)226·3641 

July 7, 2017 

Scenic Rivers Health Services 

20 5th Street, S.E. 

Cook, MN 55723 

Dear Mr. Holmes: 

Thank you for appearing before the Subcommittee on Health on June 23,2017, to testifY at the 

hearing entitled "Examining the Extension of Safety Net Health Programs." 

Pursuant to the Rules of the Committee on Energy and Commerce, the hearing record remains 

open for ten business days to permit Members to submit additional questions for the record, which are 

attached. The format of your responses to these questions should be as follows: (I) the name of the 

Member whose question you are addressing, (2) the complete text of the question you are addressing in 

bold, and (3) your answer to that question in plain text. 

To facilitate the printing of the hearing record, please respond to these questions with a 

transmittal letter by the close of business on July 21,2017. Your responses should be mailed to Jay 

Gulshen, Legislative Clerk, Committee on Energy and Commerce, 2125 Rayburn House Office Building, 

Washington, DC 20515 and e-mailed in Word format to jay.gulshen@mail.house.gov. 

Thank you again for your time and effort preparing and delivering testimony before the 

Subcommittee. 

cc: The Honorable Gene Green, Ranking Member, Subcommittee on Health 

Attachment 
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Scenic ~Rivers Cook Area Health Services, Inc. 

HEALTH SERVICES 

Pin<:> D1 

PO Bo>.. 

L)1gfor~, MN 56628 

Ph:218-7<U-3232 

218"7<:3-4223 

r·: 410 :,cc0nd St. NW 

PO Box 218 

Biy fdlls, 1>-lN 56621 

Ph: 21,8-276-2403 

218-276-2456 

Fiflh 

MN ')5723 

F~: 2 ~8-666-5099 

f·lFDlCAl 

666 

DtNTt\l 

Ph: 21S.6b6·S9S8 

f·1fDtC<\! 

'-- 126 w s~'VQnth Ave. 

P\) Box 

Hnodwcofl, MN 5Sl36 

PO 8ox 66 

~orthon:e. f·lN 'i666! 

July 20,2017 

Michael C. Burgess, MD 

Chairman 

Subcommittee on Health 

Committee on Energy and Commerce 

2125 Rayburn House Office Building 

Washington, DC 20515 

RE: Hearing Entitled "Examining the Extension of Safety net Health Programs" 

Dear Chairman Burgess: 

Thank you for the opportunity to deliver testimony before the Subcommittee on Health on 

June 23, 1017. 

In response to your letter dated July 7, 2017 and pursuant to the Rules of the Committee on 

Energy and Commerce, I am providing responses to the additional questions from the 

Members. 

Please contact me if you require additional information. 

Sincerely, 

l~LDG.~~ Michael A. Holmes 

CEO 

Cc: The Honorable Gene Green, Ranking Member, Subcommittee on Health 

Attachment 
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Questions for the Record- Michael Holmes 

The Honorable Michael C. Burgess 

1. The Community Health Center Program's annual funding has more than tripled between FY2002 

and FY2016, largely due to increases in the Community Health Center Fund. The grants have been 

used for broad purposes, and the types of grant-supported program activities have expanded and 

changed over time. Since the establishment of the Community Health Center Fund in 2011, in 

general, how have these grant funds been used? How have new investments changed over time? 

The Community Health Center Fund has been essential in helping health centers meet the health 

needs for over 25 million individuals and expand the range of services provided at community 

health centers. Specifically, the funding provided through the Community Health Center Fund has 

gone toward 1,110 new access points (new facilities where individuals can access care); 1,138 

awards to community health centers to make capital improvements, facility upgrades, and site 

expansions; and also allowed all community health centers to offer expanded services like dental, 

behavioral health, substance abuse or mental health services that weren't offered as widely before 

the creation of the Community Health Center Fund. Finally, the grants provided via the Community 

Health Center Fund have helped health centers around the nation lower the cost of delivering care 

and drive innovation through delivery system reform, quality improvement and health information 

technology (HIT) utilization. In short, the grants provided via the Community Health Center Fund 

help health centers expand access, lower cost, and improve the quality of health care delivered at 

CHCs. Over time, this focus has broadened from capital and new access point awards, to 

incorporate more investments in expanded services, quality and health IT. 

2. In rural communities like the ones I represent, Federally Qualified Health Centers are a critical 

piece of the delivery system, and so are Critical Access Hospitals. How do you partner with the 

Critical Access Hospitals in your area, and is there more potential for better collaboration 

between the two nationwide? 

Our health center was started with assistance from a small hospital long before the critical 

access hospital designation. Our first new access point expansion was added with collaboration of 

another critical access hospital. Today, our physicians staff the emergency rooms under agreements 

with two hospitals. Our patients use the hospital's laboratory & imaging services. The hospitals also 

operate labs in three of our other clinic sites. The Bigfork Valley Hospital retail pharmacy is our 340B 

contract pharmacy. The hospitals participate in physician recruitment with us and share in the cost 

of recruitment incentives for new physicians. One of the hospitals built a new clinic for us in their 

facility and we are leasing it at market rate. They are currently expanding that space to add more 

exam rooms for our two new physicians joining us this fall. There is always potential for new 

partnerships between health centers and critical access hospitals. We have always taken the 

approach of doing what's best for our patients and what is the best way to deliver care in their 

areas. Our patients are hospital patients and hospital patients are our patients. As the healthcare 

delivery system changes there will be new partnership opportunities with the development of 

accountable care organizations and whatever the future of health care reform may bring. 
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3. In Texas, Federally Qualified Health Centers serve a large proportion of both the Medicaid and the 

CHIP populations. Can you give any specific examples of productive collaboration between the 

CHIP/Medicaid program and health centers? 

While I am sure there are many examples of this kind of collaboration across the country, we are 

not currently engaged in any specific effort at my health center that I can highlight for you at this 

time. Nationally, health centers are deeply involved with state Medicaid programs in many states as 

they collaboratively explore payment and delivery system reform efforts. A 2015 article in Health 

Affairs highlighted the increasing involvement of CHCs in safety net Accountable Care Organizations 

(ACOs), which are increasingly involved in Medicaid reform. 

4. You say in your testimony that health centers were a critical part of the response to public health 

threats like the Zika virus and the Flint water crisis. What role did community health centers play 

in responding to these crises and how was their response unique compared to other safety-net 

providers? 

Health centers are trusted community partners and serve as the source of primary and preventive 

care for over 25 million individuals throughout the nation, including some of the most vulnerable 

individuals and families. As such, they are often serving on the front lines during public health 

crises, providing needed and timely education, outreach, and access to care in their communities. 

Last year, Congress recognized the important role of health centers in responding to the Zika virus 

by providing $40 million to health centers in Puerto Rico, American Samoa and the U.S. Virgin 

Islands to expand the availability of preventive and primary health care services to meet the 

immediate and anticipated Zika-related needs in these territories. These resources enabled health 

centers to expand their response efforts to continue providing high quality services, including 

outreach, education, and screening for underserved populations. In addition, earlier in the year, 

HHS made similar investments in health centers in Puerto Rico through $5 million in funding 

alongside a similar investment of $742,000 for health centers in American Samoa and the U.S. Virgin 

Islands. 

During the Flint water crisis, two health centers in Flint each received $250,000 from HHS to hire 

additional personnel and provide more lead testing, treatment, outreach, and education to meet 

the increased health needs of the people of Flint and the surrounding communities. This funding 

complimented and enhanced ongoing efforts by health centers to meet community needs around 

lead blood level testing, assistance obtaining bottled water, emotional support and tracking of 

blood levels of all children under age 6 who receive services at the health centers. 

5. One of the issues the Committee must consider is whether to retain the ACA's enhanced 

matching rate for CHIP. In MACRA, House Republicans agreed to the enhanced match as part of 

SGR repeal. Now CBO is telling us that spending money on CHIP over the next couple of years 

won't increase the number of children with health insurance. In fact, if we extend the program 

for two years with the enhanced match compared to without the enhanced match, we would be 

spending $8 billion- and are not projected to increase the rate of children with insurance. So I 

would like to know- wouldn't you and other health centers prefer we use some of this money to 

extend health center funding, vs. just buy out state contributions? 
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CHIP is an important source of coverage for children and families and I would not advocate for any 

policy that might undermine the program. Health centers are certainly facing a devastating funding 

cliff if Congress does not act by September 30, 2017, as is the CHIP program. I see these as 

complimentary but separate programs, each of which have longstanding bipartisan support and 

proven track records in improving access to quality healthcare. Both are worthy of Congress's 

continued investment. 

6. Can you describe the patient population that typically seeks care at a community health center? 

How do these patients differ from other safety net providers? 

Health center patients are among the nation's most vulnerable populations- people who even 

when insured, nonetheless remain isolated from traditional forms of medical care because of where 

they live, who they are, the language they speak, and their higher levels of complex health care 

needs. As a result, patients are disproportionately low income, uninsured or publicly insured, and 

minority. 

By statute, all health centers are located in medically underserved areas or serve a medically 

underserved population as designated by HHS. Of the 25 million patients served at health centers 

nationwide, 7.6 million are children and over 300,000 are veterans. Over 70% of health center 

patients have incomes below 100% of the Federal Poverty Level (FPL) and if these individuals are 

uninsured they are charged no more than a nominal fee to access the full range of services provided 

by the health center. An additional 21% of health center patients have incomes between 101%-

200% FPL, and these individuals are charged base on a sliding fee scale. Nationally, health centers 

serve 1 in 3 people below the FPL, 1 in 5 uninsured persons and 1 in 6 Medicaid beneficiaries .. In 

order to serve the diverse needs of health center patients, health centers work in close 

collaboration with other safety net providers who provide needed specialty and other health care 

services for their patients. 

7. Health centers serve nearly 8 million children- about one-third of patients of all patients seen. 

However, CHIP only represented about 1% of health centers' revenue for FY 2016. Is that because 

these children are enrolled in Medicaid? 

According to the 2015 Uniform Data System (UDS) report (the most recent data publicly available at 

this time), the vast majority of children seen by health centers in 2015 were covered by Medicaid. 

Of the roughly 7.6 million children (0-17 years old) seen that year, 5.6 million were covered by 

Medicaid, including 146,000 CHIP enrollees who were folded in to their state's Medicaid program. 

Another 996,000 were uninsured and 870,000 were privately insured. Roughly 244, 000 children on 

CHIP were seen by health centers during this time, making it an important source of coverage for 

families, but nowhere near as large a coverage source for health center patients as Medicaid. 

Additional information on the can be found at https:/ /bphc.hrsa.gov/uds/datacenter.aspx 

8. I understand that some 70% of Federally Qualified Health Centers are now certified as PatientCentered Medical Homes. Can you speak to the importance of that designation, and overall to 

quality improvement efforts at your health center? 
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The PCMH designation provides a framework and numerous metrics by which a CHC (or other 

primary care provider) can benchmark its progress toward a unified goal of offering responsive, 

patient-centered and comprehensive care. 

Several organizations, such as the National Committee for Quality Assurance (NCQA), the Joint 

Commission (TJC), and the Accreditation Association for Ambulatory Health Care (AAAHC), have 

taken the PCMH principles and operationally defined PCMH to support current implementation 

within primary healthcare systems. Some states have also developed their own PCMH programs 

(e.g., Minnesota, Oregon). Primary healthcare systems, including health centers, are utilizing these 

programs to formally demonstrate they are PCMHs to various stakeholders in the healthcare 

marketplace. 

At our health center we have a robust quality improvement program. Our goal is to provide quality 

and compassionate care for every patient at every visit. We monitor and evaluate the quality and 

appropriateness of patient care. Our medical and dental providers, along with our Board of 

Directors, have instrumental roles in identifying specific goals for evaluation and analysis. Our goals 

are reviewed in terms of opportunity, potential for impact on patient outcomes and the ability to be 

specific, measurable, achievable, realistic and time framed. We believe in continuous quality 

improvement. We score our measures quarterly and compare our results over time. Not only do 

we evaluate our organization as a whole, but we evaluate each delivery site and each provider. Our 

current quality measures include ones for optimum diabetic care, optimum cardiovascular care, 

asthma care, opioid prescribing reduction, immunization rates and preventive disease 

management. In addition, we compare our results to other medical practices in Minnesota through 

Minnesota Community Measures. Through these processes we believe that we can deliver better 

care and improve the health of our patients. 

9. FQHCs are critical to Florida's safety net. During my tenure in Congress, I've helped raise 

awareness of their national importance and educated constituents on the services offered by 

community health centers in my district. Data from the last year on record, 2015, shows Florida 

has the 3rd largest network of community health centers serving 1.3 million Floridians over nearly 

5 million visits each year. What is the average cost of care per patient versus other comparable 

provider settings? What is the national network size of community health centers? What is the 

scope of services provided? 

While it's difficult to make an apples-to-apples comparison of community health centers and other 

providers due to differences in patient mix, a recent study published in the American Journal of 

Public Health in 2016 found that community health center patients who are Medicaid enrollees 

have 24% lower health care spending compared to those treated at other primary care settings. 

This is a testament to the diligent work of practitioners at roughly 1,400 health center organizations 

at nearly 10,000 sites nationwide. It is not only primary care medical services that help attain these 

results, but also services in dental, behavioral health, substance abuse, pharmacy, vision care, 

nutrition, health education and obesity prevention. In total, these practitioners provide care for 

over 25 million patients. 

10. Can you speak to the quality and continuity of care received in community health centers? How 

does this compare with other care settings? Can you speak to the importance of having 

patient/consumer representation on each health center's board of directors? How does your 
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board work in concert with the leadership and medical staff to ensure the health center is 

addressing the most pressing community needs? 

Our health center physicians, physician assistants, nurse practitioners and dentists are the only 

providers in our communities. We see our patients not only in the clinic, but also in the emergency 

room, nursing home and hospital. We provide care to the entire community because there is no 

one else. When we refer patients for specialty care those patients come back to us. Our quality 

improvement plan contains clinical performance measures on diabetic, cardiovascular and asthma 

care along with depression screening targets and other measures. We not only track changes in our 

performance quarterly but we also compare ourselves to other community health centers. The 

State of Minnesota has mandatory clinical performance reporting and we compare our 

performance with all of the other medical practices in the state. Even though we serve a remote 

rural patient population with health disparities, we believe that our clinical performance is 

comparable to other group practices. 

With a service area of 8300 square miles, it is extremely important for us to have 

community/consumer/patient involvement in what we do. We now have six medical clinics and 

four dental clinics. Each clinic has been added in response to consumer/patient needs brought to 

us by our board members. We just opened a new dental clinic in Bigfork, MN. One of the 

community's dentists closed his practice and left the area. The other announced his retirement. 

The community was very concerned about losing all access to dental care so they asked our Bigfork 

board members if we could help. Our board decided to add a new dental clinic for the community 

even though there were no additional federal resources. They helped the community secure a 

foundation grant to replace old & failing dental equipment. We this support we opened this clinic 

on July 3, 2017. Consumer input is extremely helpful in assessing and addressing community needs 

and to also provide a feedback mechanism to the community when some services are not viable. 

11. As Vice-Chairman of the Committee on Veterans Affairs in addition to my role on this committee, 

I understand that Health Centers already provide quality care to more than 300,000 veterans 

across the country and are an important source of care for veterans in rural areas who may not be 

able to easily access a VA facility. Can you share with the Committee some of the ways in which 

health centers are working with the VA to address the health care needs of our nation's veterans? 

What more can be done to improve veteran's access to care at health centers? 

In our community health center sites, all of our physicians, dentists, nurse practitioners and 

physician assistants are enrolled providers in the Veterans Choice program. Last year more, than 

800 of our 12,000 patients identified themselves as veterans and we have a veteran on our Board of 

Directors. We are strong believers in improving access to care for our veteran patients. 

Nationally, health centers serve approximately 305,000 veterans. In 2015, nearly 9 in 10 health 

centers served veteran patients and offered a wide range of serves including dental, mental health, 

substance abuse, and enabling services. 

Health centers work closely with the VA as part of the Veterans Choice Program. Notably, Federally 

Qualified Health Centers (FQHCs) are the only type of health care provider which is specifically 

named in the Veterans Choice Program statute as eligible to care for participating veterans (See 

Section 101(a)(l)(B)(ii)). This special attention suggests that Congress intended for FQHCs to play a 
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central role in assisting the VA to implement the program successfully. And health centers take this 

role seriously given that they may often be located in communities with many low-income veterans, 

but with few or no other care providers. 

I also want to highlight that the Senate FY18 Milcon-VA Appropriations Subcommittee report 

included language to direct the VA to submit a report to both Houses of Congress regarding the role 

FQHCs play in providing veterans care through the Veterans Choice program and outlining 

opportunities for further collaboration. This again signals the important role of health centers in 

caring for our nation's veterans now and for the future. 

12. I understand that according to the Public Health Service Act (PHSA) section 330 requires that a 

health center be located in an area designated as medically underserved or as serving a 

population designated as "Medically Underserved," however in Oklahoma we are still lacking 

providers and care, while other cities seem to have a large number of community health centers. 

Do you believe that HRSA is doing a good job at awarding the community health center grants 

according to need? 

I believe that HRSA is doing the best job that they can in awarding community health center grants 

according to need. It has been my experience over the past 38 years that there has been 

approximately a 50/50 rural/urban split in grant funding. Depending on funding opportunities and 

the directions by Congress, the statute allows for up to 60/40 rural/urban or up to 60/40 

urban/rural. The Medically Underserved Designation is based upon the Population/Primary Care 

Physician Ratio, Percentage of Population with Incomes Less than 100% of Poverty, Percentage of 

Population Over the Age of 65 and the Infant Mortality Rate. I believe that this Medically 

Underserved Designation does not favor either urban or rural areas. There are 17,000 Health 

Professional Shortage Areas and over 4200 Medically Underserved Areas in the United States. 

strongly believe that we still need more Community Health Centers to serve these shortage areas 

and populations. 

13. Community Health Centers have seen a large uptick in funding since FY2011, especially in 

mandatory funding. In your opinion, how have health centers used this increase in funds? 

Congress' support for the Community Health Center Fund, which received a broad and bipartisan 

extension via MACRA in 2015, has allowed health centers across the country to expand the breadth 

of services they offer, upgrade and expand their facilities, hire additional practitioners, and open up 

additional sites to offer care to individuals in need. Due to the grants provided via the Community 

Health Center Fund, not only have millions of additional patients gained access to care, but patients 

at health centers around the nation are now able to access a broader range of services, including 

behavioral health and substance abuse treatment, dental and vision care, and nutrition education 

and obesity prevention. In 2016, over 1,300 health centers used grants from the Community Health 

Center Fund to invest in quality improvements, health information technology (HIT), and delivery 

system reforms that will help drive down the cost of delivering care and improve patient 

experiences at health centers. 

14. What are some of the services that Community Health Centers provide that aren't covered under 

Medicare and Medicaid? What are ways that Community Health Centers can better leverage 

existing dollars to serve rural areas like Eastern Oklahoma? 
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Health centers have been leaders in taking a patient-centered, holistic approach to patient care, 

dedicating time and resources to maximizing their patients' ability to fully access care. By designing 

systems of care that remove geographic, socioeconomic, linguistic, and cultural barriers to care 

while addressing social determinants of health, health centers are better able to improve health 

outcomes and lower costs, even when these services are not reimbursed by insurance. As such, 

community health centers provide a wide array of critical non-medical enabling services and social 

service interventions, many of which are not reimbursed by Medicaid or Medicare. Common 

examples include services like translation, interpretation, health education, and transportation, 

none of which are covered by Medicare, and only some of which are covered by certain state 

Medicaid programs that have elected to reimburse for optional services. Additionally, Medicare 

does not reimburse for dental services at all, and Medicaid coverage for adult dental services varies 

by state. 

Telehealth is a clear example of a service that is currently only reimbursed by Medicare and 

Medicaid in a limited way, but could be expanded upon to help health centers better leverage 

existing dollars to serve rural areas. By supporting policies that improve utilization of telehealth, 

Congress could enable health centers to serve more patients in low cost settings and improve care 

coordination, patient compliance with care plans, and health outcomes, while at the same time 

overcoming challenges posed to health centers by critical workforce shortages. 

15. Studies comparing health center patients with non-health center patients found that patients 

receiving most of their primary care in health centers experienced lower utilization and spending 

for care. How are health centers saving dollars in care delivery? 

Several main items factor into the fact that the health center model generates lower overall 

utilization and spending in the health care system. First, health centers focus on prevention and 

well ness- often treating conditions before they become more acute and/or chronic, and thus 

preventing not only bad outcomes but higher costs. Second, the health center model encourages 

the integration of care, in recognition that physical health care services are only one piece of the 

puzzle when it comes to maintaining patient and population health. Behavioral health integration, 

in particular, helps address these issues in the context of primary care, before they can spiral out 

and become much more serious- and costly- conditions. lastly, due to the unique governance 

structure of consumer-majority boards, each health center is designed to be responsive to the 

particular needs of its community. This responsiveness helps ensure patients access the right care, 

at the right time, in the right place, and in the most affordable setting possible. 

16. According to HRSA, there are 10,760 Health Center Service Delivery Sites and 224 Health Center 

Look-Alike Service Delivery Sites. What is a health center program "look-alike" and how does it 

differ from a Health Center Program award recipient? 

Health Center look-alikes operate and provide services consistent with Health Center Program 

requirements, but do not receive Health Center Program grant funding. They are, however, eligible 

to apply to the Centers for Medicare and Medicaid Services (CMS) for reimbursement under FQHC 

Medicare and Medicaid payment methodologies. look-alikes are also eligible to purchase 

discounted drugs through the 340B Federal Drug Pricing Program, receive automatic Health 

Professional Shortage Area designation, and may access National Health Service Corps providers. 
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Look-alikes were established to maximize access to care for medically underserved populations and 

communities by allowing entities that do not receive Health Center Program funding to apply to 

become part of the Health Center Program. Both Health Center Program award recipients and looka likes provide comprehensive primary health care services that are responsive to identified health 

care needs, provide services to all persons regardless of ability to pay, and must meet all Health 

Center Program requirements. 

17. As a former businessman, I often say, "In God We Trust, All Others Bring Data." The data on CHIP 

shows there is much to commend the program. The program has help dramatically lower the 

number of children without health insurance. The program is more affordable for low-tomoderate- income children and their families that the Exchanges- yet there is reasonable costsharing. What I would to know is how in what ways do you think CHIP has lessons we can learn 

from to help improve Medicaid? CHIP is a flexible program for states, great for patients and 

families, and high value for taxpayers. What do we do in CHIP- as part of the program design or 

benefits or tools for states- that we should carefully consider for helping improve Medicaid? 

This is a question that my co-panelists might be able to provide additional detail on, but from my 

perspective I would point to CHIP's success in streamlining enrollment and renewals, practices that 

Medicaid subsequently adopted in most states. Furthermore, to your point, CHIP charges 

reasonable premiums and ensures affordable cost-sharing for visits to make sure families can 

continue to maintain and utilize their coverage. Another key success of the CHIP program is 

ensuring coverage for pediatric-focused provider networks and including pediatric expertise in 

program administration, both of which are essential for children covered by Medicaid as well. 

The Honorable Larry Bucshon 

1. HRSA-funded health centers are evaluated on a set of performance measures emphasizing health 

outcomes and the value of care delivered. Grantees must establish quality and performance 

goals, and assess their progress through this process. How do health centers collect and report 

their data? With Medicaid being the largest source of health center revenue {42.2% for FY 2016) 

how can states and health centers work together to improve the consistency of data and quality 

reporting? 

Each year, Health Center Program grantees and look-alikes report on their performance using the 

measures defined in the Uniform Data System (UDS). The UDS offers a comprehensive look at a 

number of different measures and performance relative to national and individual health center 

goals. UDS data is posted online so that the public and the taxpayer can examine these results and 

statistics, and so that researchers can access the data for analysis. HRSA offers manuals, webinars, 

trainings online and at various state/regional/national meetings, and other technical assistance 

resources to assist health centers in collecting and submitting their data. 

In terms of Medicaid, one of the biggest opportunities I see is for states, Medicaid managed care 

companies, and health centers to partner together with regard to data sharing. Without access to 

Medicaid MCO claims data, in many states health centers face a challenge in being able to 

statistically prove their value in terms of lowering system-wide costs. 

The Honorable Tim Murphy 
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1. Federal law allows states to establish alternative payment models for health centers as long as 

the both the state and health center agree on it and the alternative payment model revenue is at 

least what the prospective payment system would have been. How many states have created 

alternative payment models and how do these payment structures compare to the traditional 

prospective payment system in terms of outcomes and savings? 

As of 2016, 23 states were operating under Alternative Payment Models (APM) as allowed for under 

the FQHC Medicaid statute (SSA Sec. 1902(bb)). These models range from more traditional payment 

systems to value-based models incorporating capitation. Perhaps furthest along in testing the latter 

category of payment model is the state of Oregon, which began its APM in March of 2013 after 

getting approval the prior year. Begun as a pilot involving three health centers, the Oregon APM has 

since expanded to 17 health centers statewide, and is showing promising early results. 

For more information on the Oregon APM, please visit: http://www.nachc.org/wpcontent/ upload s/2.016/ 12./0regon-FQHC-APM-Dece mber-2.017 .pdf 

The Honorable Morgan Griffith 

1. I understand that according to the Public Health Service Act {PHSA) section 330 requires that a 

health center be located in an area designated as medically underserved or as serving a 

population designated as "Medically Underserved," however in Oklahoma we are still lacking 

providers and care, while other cities seem to have a large number of community health centers. 

Do you believe that HRSA is doing a good job at awarding the community health center grants 

according to need? 

I believe that HRSA is doing the best job that they can in awarding community health center grants 

according to need. It has been my experience over the past 38 years that there has been 

approximately a 50/50 rural/urban split in grant funding. Depending on funding opportunities and 

the directions by Congress, the statute allows for up to 60/40 rural/urban or up to 60/40 

urban/rural. The Medically Underserved Designation is based upon the Population/Primary Care 

Physician Ratio, Percentage of Population with Incomes Less than 100% of Poverty, Percentage of 

Population Over the Age of 65 and the Infant Mortality Rate. I believe that this Medically 

Underserved Designation does not favor either urban or rural areas. There are 17,000 Health 

Professional Shortage Areas and over 4200 Medically Underserved Areas in the United States. 

strongly believe that we still need more Community Health Centers to serve these shortage areas 

and populations. 

a. Community Health Centers have seen a large uptick in funding since FY2011, especially in 

mandatory funding. In your opinion, how have health centers used these increased funds? 

Congress' support for the Community Health Center Fund, which received a broad and bipartisan 

extension via MACRA in 2.015, has allowed health centers across the country to expand the breadth 

of services they offer, upgrade and expand their facilities, hire additional practitioners, and open up 

additional sites to offer care to individuals in need. Due to the grants provided via the Community 

Health Center Fund, not only have millions of additional patients gained access to care, but patients 

at health centers around the nation are now able to access a broader range of services, including 
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behavioral health and substance abuse treatment, dental and vision care, and nutrition education 

and obesity prevention. In 2016, over 1,300 health centers used grants from the Community Health 

Center Fund to invest in quality improvements, health information technology (HIT), and delivery 

system reforms that will help drive down the cost of delivering care and improve patient 

experiences at health centers. 

b. What are some of the services that Community Health Centers provide that aren't covered 

under Medicare and Medicaid? 

Health centers have been leaders in taking a patient-centered, holistic approach to patient care, 

dedicating time and resources to maximizing their patients' ability to fully access care. By 

designing systems of care that remove geographic, socioeconomic, linguistic, and cultural 

barriers to care while addressing social determinants of health, health centers are better able to 

improve health outcomes and lower costs, even when these services are not reimbursed by 

insurance. As such, community health centers provide a wide array of critical non-medical 

enabling services and social service interventions, many of which are not reimbursed by 

Medicaid or Medicare. Common examples include services like translation, interpretation, 

health education, and transportation, none of which are covered by Medicare, and only some 

of which are covered by certain state Medicaid programs that have elected to reimburse for 

optional services. Additionally, Medicare does not reimburse for dental services at all, and 

Medicaid coverage for adult dental services varies by state. 

c. What are ways that Community Health Centers can better leverage existing dollars to serve 

rural areas like Eastern Oklahoma? 

Telehealth is a clear example of a service that is currently only reimbursed by Medicare and 

Medicaid in a limited way, but could be expanded upon to help health centers better leverage 

existing dollars to serve rural areas. By supporting policies that improve utilization of telehealth, 

Congress could enable health centers to serve more patients in low cost settings and improve 

care coordination, patient compliance with care plans, and health outcomes, while at the same 

time overcoming challenges posed to health centers by critical workforce shortages. 

The Honorable Gus Bilirakis 

1. FQHCs are critical to Florida's safety net. During my tenure in Congress, I've helped raise 

awareness of their national importance and educated constituents on the services offered by 

community health centers in my district. Data from the last year on record, 2015, shows 

Florida has the 3rd largest network of community health centers serving 1.3 million Floridians 

over nearly 5 million visits each year. 

a. What is the average cost of care per patient versus other comparable provider 

settings? 

While it's difficult to make an apples-to-apples comparison of community health centers 

and other providers due to differences in patient mix, a recent study published in the 
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American Journal of Public Health in 2016 found that community health center patients 

who are Medicaid enrollees have 24% lower health care spending compared to those 

treated at other primary care settings. This is a testament to the diligent work of 

practitioners at roughly 1,400 health center organizations at nearly 10,000 sites 

nationwide. 

2. What is the national network size of community health centers? What is the scope of services 

provided? 

Nationally, more than 1,400 health center organizations operate roughly 10,400 locations, 

serving over 25 million patients. It is not only primary care medical services that help attain 

these results, but also services in dental, behavioral health, substance abuse, pharmacy, vision 

care, nutrition, health education and obesity prevention. 

Can you speak to the quality and continuity of care received in community health centers? 

a. How does this compare with other care settings? b. Can you speak to the importance 

of having patient/consumer representation on each health center's board of 

directors? c. How does your board work in concert with the leadership and medical 

staff to ensure the health center is addressing the most pressing community needs? 

Our health center physicians, physician assistants, nurse practitioners and dentists are 

the only providers in our communities. We see our patients not only in the clinic, but 

also in the emergency room, nursing home and hospital. We provide care to the entire 

community because there is no one else. When we refer patients for specialty care 

those patients come back to us. Our quality improvement plan contains clinical 

performance measures on diabetic, cardiovascular and asthma care along with 

depression screening targets and other measures. We not only track changes in our 

performance quarterly but we also compare ourselves to other community health 

centers. The State of Minnesota has mandatory clinical performance reporting and we 

compare our performance with all of the other medical practices in the state. Even 

though we serve a remote rural patient population with health disparities, we believe 

that our clinical performance is comparable to other group practices. 

With a service area of 8300 square miles, it is extremely important for us to have 

community/consumer/patient involvement in what we do. We now have six medical clinics and 

four dental clinics. Each clinic has been added in response to consumer/patient needs brought 

to us by our board members. We just opened a new dental clinic in Bigfork, MN. One of the 

community's dentists closed his practice and left the area. The other announced his retirement. 

The community was very concerned about losing all access to dental care so they asked our 

Bigfork board members if we could help. Our board decided to add a new dental clinic for the 

community even though there were no additional federal resources. They helped the 

community secure a foundation grant to replace old & failing dental equipment. We this 

support we opened this clinic on July 3, 2017. Consumer input is extremely helpful in assessing 

and addressing community needs and to also provide a feedback mechanism to the community 

when some services are not viable. 
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3. As Vice-Chairman of the Committee on Veterans Affairs in addition to my role on this 

committee, I understand that Health Centers already provide quality care to more than 

300,000 veterans across the country and are an important source of care for veterans in rural 

areas who may not be able to easily access a VA facility. 

a. Can you share with the Committee some of the ways in which health centers are 

working with the VA to address the health care needs of our nation's veterans? b. 

What more can be done to improve veteran's access to care at health centers? 

In our community health center sites, all of our physicians, dentists, nurse practitioners and 

physician assistants are enrolled providers in the Veterans Choice program. Last year more, 

than 800 of our 12,000 patients identified themselves as veterans and we have a veteran on 

our Board of Directors. We are strong believers in improving access to care for our veteran 

patients. 

Nationally, health centers serve approximately 305,000 veterans. In 2015, nearly 9 in 10 

health centers served veteran patients and offered a wide range of serves including dental, 

mental health, substance abuse, and enabling services. 

Health centers work closely with the VA as part of the Veterans Choice Program. Notably, 

Federally Qualified Health Centers (FQHCs) are the only type of health care provider which is 

specifically named in the Veterans Choice Program statute as eligible to care for 

participating veterans (See Section 101(a)(1)(B)(ii)). This special attention suggests that 

Congress intended for FQHCs to play a central role in assisting the VA to implement the 

program successfully. And health centers take this role seriously given that they may often 

be located in communities with many low-income veterans, but with few or no other care 

providers. 

I also want to highlight that the Senate FY18 Milcon-VA Appropriations Subcommittee 

report included language to direct the VA to submit a report to both Houses of Congress 

regarding the role FQHCs play in providing veterans care through the Veterans Choice 

program and outlining opportunities for further collaboration. This again signals the 

important role of health centers in caring for our nation's veterans now and for the future. 

The Honorable Leonard Lance 

1. Can you describe the patient population that typically seeks care at a community health 

center? How do these patients differ from other safety net providers? 

Health center patients are among the nation's most vulnerable populations people who even 

when insured, nonetheless remain isolated from traditional forms of medical care because of 

where they live, who they are, the language they speak, and their higher levels of complex 

health care needs. As a result, patients are disproportionately low income, uninsured or publicly 

insured, and minority. 

By statute, all health centers are located in medically underserved areas or serve a medically 

underserved population as designated by HHS. Of the 25 million patients served at health 

centers nationwide, 7.6 million are children and over 300,000 are veterans. Over 70% of health 
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center patients have incomes below 100% of the Federal Poverty Level (FPL) and if these 

individuals are uninsured they are charged no more than a nominal fee to access the full range 

of services provided by the health center. An additional 21% of health center patients have 

incomes between 101%- 200% FPL, and these individuals are charged base on a sliding fee 

scale. Nationally, health centers serve 1 in 3 people below the FPL, 1 in 5 uninsured persons and 

1 in 6 Medicaid beneficiaries .. In order to serve the diverse needs of health center patients, 

health centers work in close collaboration with other safety net providers who provide needed 

specialty and other health care services for their patients. 
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GREG WALDEN, OREGON 

CHAIRMAN 

ONE HUNDRED FIFTEENTH CONGRESS 

FRANK PALLONE, JR., NEW JERSEY 

RANKING MEMBER 

C!Congtc~!S of tbr llnitrb ~tate~ 

~oust of ~epresentatibes 

COMMITTEE ON ENERGY AND COMMERCE 

2125 RAveuRN HousE OFFICE BuiLDING 

WASHINGTON, DC 20515--6115 

Ms, Jami Snyder 

Associate Commissioner 

Medicaid/CHIP Services 

Health and Human Services Commission 

4900 North Lamar Boulevard 

Austin, TX 78751 

Dear Ms. Snyder: 

Mtljority 

Mmomy 

July 7, 2017 

Thank you for appearing before the Subcommittee on Health on June 23, 2017, to testify at the 

hearing entitled "Examining the Extension of Safety Net Health Programs." 

Pursuant to the Rules of the Committee on Energy and Commerce, the hearing record remains 

open for ten business days to permit Members to submit additional questions for the record, which are 

attached. The format of your responses to these questions should be as follows: ( 1) the name of the 

Member whose question you are addressing, (2) the complete text of the question you are addressing in 

bold, and (3) your answer to that question in plain text. 

To facilitate the printing of the hearing record, please respond to these questions with a 

transmittal letter by the close of business on July 21, 2017. Your responses should be mailed to Jay 

Gulshen, Legislative Clerk, Committee on Energy and Commerce, 2125 Rayburn House Office Building, 

Washington, DC 20515 and e-mailed in Word format to jay.gulshen@mail.house.gov. 

Thank you again for your time and effort preparing and delivering testimony before the 

Subcommittee. 

cc: The Honorable Gene Green, Ranking Member, Subcommittee on Health 

Attachment 
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House Energy & Commerce Committee 

Written Questions and Answers 

Jami Snyder, Associate Commissioner, Texas Health and Human Services Commission 

The Honorable Michael C. Burgess 

1. In your testimony, you noted Texas has seen the overall uninsured rate for children 

below 200 percent of the federal poverty level drop to about 6 percent in 2015- down 

from 18 percent in 1998. Congratulations on that. I understand Texas's CHIP eligibility is 

about 200 percent. But some states in CHIP have eligibility above 300, 350, even 400 

percent of the federal poverty level. The federal poverty level for a family of four in 

2017 is $24,600, so 300 percent of the federal poverty level is $98,400. The median 

household income in the U.S. is just under $54,000 according to Census data. So I am 

curious: do you think it is fair that taxpayer dollars are used to pay for health coverage 

for upper income children above 300, 350, or 400 percent of the federal poverty level? 

Response: The annual income eligibility limit in Texas for Children's Health Insurance 

Program (CHIP) participation is 201% percent of the federal poverty level (FPL), 

equating to $48,852 a year for a family of four or $4,071 a month. Texas is not among 

the states covering families with higher incomes in CHIP and the Texas Health and 

Human Services Commission takes no position regarding states that have elected to 

do so. 

2. Texas has a stand-alone CHIP program, so there is a lot of flexibility under current law. 

Do you face any federal statutory or regulatory barriers in you CHIP program that you 

think the Committee should be aware of and potentially re-examine? What about on 

the Medicaid side- are there barriers to innovation in that critical program that the 

Committee to better understand? 

Response: As noted in my testimony, the statutory and regulatory framework affords 

states considerable flexibility in designing and operating CHIP programs and has 

contributed to the success of the CHIP program in Texas. I have no recommendations 

related to the CHIP statutory framework. 

In regard to Medicaid, current statutory requirements around cost-sharing (including 

premiums, deductibles, and copays) found in Sections 1916 and 1916A of the Social 

Security Act and 42 CFR Chapter 447 make it administratively complex for states to 

obtain federal approval and operationalize cost-sharing requirements for most 

Medicaid beneficiaries. In particular, existing law excludes certain Medicaid eligibility 

groups and limits copayment to nominal amounts. These regulations pose a barrier for 

Texas and other states interested in implementing commonsense cost-sharing 

mechanisms that would serve to increase the investment Medicaid beneficiaries have 

in their medical care. 

a. Follow-up: In the Medicaid program, one of the bills the Committee has been 

examining is the ACE Kids Act. We had a great bipartisan hearing last Congress and 

plan to reintroduce updated legislation within days. The goal is to help incentivize 

care coordination services for children with special medical needs in Medicaid. 1 

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think we have a good bill that will work for Medicaid directors and stakeholders. 

Would you commit to looking at the new legislation and working to provide 

feedback to the Committee to inform our process moving forward? 

Response: Texas is committed to examining financially responsible proposals that 

will provide the care necessary for children who need it. 

3. A report last fall from the HHS Office of the Inspector General examined the Express 

Lane Eligibility program which lets states use data from other programs to determine 

eligibility for CHIP and Medicaid. The report examining CHIP spending in states with 

Express Lane found some of the spending on children was for children not eligible for 

CHIP. A sister report from the OIG reported that $284 million taxpayer dollars, 20% of 

total Medicaid spending in ELE programs, was on potentially ineligible beneficiaries. If 

Congress were to extend Express Lane authority, what are some oversight 

recommendations or practices that you would think could help safeguard tax dollars so 

they only provide coverage for children who qualify? 

Response: To date, Texas has not implemented the Express Lane Eligibility option and 

therefore does not have recommendations related to oversight of the program. 

4. In your testimony, you noted that CHIP has allowed Texas to "design a system that 

aligns with the state's philosophy of ensuring accountability and stewardship in the 

management of public funds and increasing personal responsibility for program 

participants." You note that "federal CHIP regulations afford states flexibility to tailor 

their CHIP benefit package to meet the unique needs of the population served." Can you 

give us some examples of how the flexibilities in CHIP have allowed Texas to provide 

high-quality care for children? 

Response: As noted in my written testimony, federal CHIP regulations allow states to 

place reasonable limitations on the scope of services members may receive. For 

example, Texas imposes a $20,000 annual cap on durable medical equipment. Texas' 

CHIP program also has a $564 limit on dental benefits per enrollment period, 

excluding emergency dental services. By way of comparison, such hard caps on 

services are not possible in the Medicaid program under federal Early and Periodic 

Screening, Diagnosis, and Treatment (EPSDT) requirements, which mandate states 

cover all medically necessary Medicaid services for qualified children. Reasonable 

service limitations within CHIP, in contrast, allow states to more effectively operate 

the program within federal allotments and provide for more predictable budgeting. 

Such limitations also allow CHIP coverage to align more closely with benefit packages 

offered in the commercial market. 

5. I understand many state fiscal years start July 1. And I understand Texas and many other 

states built their budgets around the 23 percent match. But this Committee is on record 

repealing it just last March- we did so in The Common Sense Savings Act of 2016. So 

why would you plan on retaining it? I know some states say they planned for current 

law, but how can you say that when, under current law, all CHIP funding expires? How is 

it fiscally responsible and fair to assume a higher match rate that means more federal 

spending, but doesn't increase coverage for kids? We have lots of other important 

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extenders, and I think we need to consider not retaining the match to help pay for 

health centers and other priorities. 

Response: The Common Sense Savings Act of 2016, (H.R. 472S, 1141

h Congress) would 

have repealed the Affordable Care Act provision which amended Title XXI of the Social 

Security Act to increase the CHIP Enhanced Federal Medical Assistance Percentage (EFMAP) rate by 23 percent through September 2019. During the time the Texas 

Legislature was considering appropriations for the FY 2018-2019 biennium (January 

through May of 2017) the 23 percent provision was (and still is) in effect. 

6. I have a question about the Pediatric Quality Measures program that has often been 

funded alongside CHIP. A March 2017 report by MACPAC stated that "current grantees 

"are assessing the feasibility and usability of the measures at the state, health plan, and 

provider levels." A HHS Secretary report on in 2015 noted that higher numbers of states 

are reporting on quality measures. Everyone on this committee believes quality is 

important and data is important. So my question is not one of value, but effect. What do 

states do with the pediatric quality data they report for this program? Do you know 

what CMS does with the quality measures that are reported? 

Response: Texas uses this data for a number of its quality initiatives, including: 

> The integration of quality metrics in MCO report cards which assist consumers 

in selecting the best health plan to meet their needs. 

> The integration of key quality metrics in the state's Pay-for-Quality program, 

which places a percentage of the health plans' capitation at risk based on 

their performance on the identified metrics. 

CMS makes available state-by-state results for these measures. CMS may use the 

measures for other purposes. I would recommend contacting CMS officials directly for 

additional insight. 

7. The ACA created an enhanced matching rate (E-FMAP) of 23 percentage points (not to 

exceed 100%) for most CHIP expenditures from FY2016 through FY2019. Some have 

expressed concern that the elevated federal spending upsets the federal-state 

partnership that has historically characterized a successful SCHIP program. Others have 

noted that the elevated spending would cost federal taxpayers billions of additional 

dollars, but would result in no significant net increase in the number of children with 

health coverage. Certainly, retaining such a policy would increase the federal cost of 

extending SCHIP funding. Can you help the Committee understand why Texas found it 

appropriate to assume a higher matching rate and build your budget around it, when 

CHIP funding itself expires this Congress? As a conservative, that sounds like liberal 

math. 

Response: In Texas, budgets are constructed in accordance with existing federal and 

state law. The state constitution requires the Texas Legislature to meet every two 

years for 140 days and produce a balanced budget during that period for the next two 

years. The regular session of the Texas Legislature concluded in May 2017. The state's 

budget for FY 2018 -2019 was approved during that session. 

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If the 23 percent E-FMAP for CHIP were to be repealed by Congress and the President 

during the FY 2018 - 2019 biennium, the state would act accordingly to reduce the 

impact to the state budget. If Congress decided not to reauthorize CHIP, under state 

law, CHIP would terminate in Texas (Texas Health & Safety Code, Chapter 62). 

8. One of the things that health care research shows is that low-income families who may 

be marginally attached to the traditional workforce may have fluctuations in income 

that mean they move in and out of programs like Medicaid and CHIP. For example, how 

long is the average length a child is on the CHIP program in Texas? Can you talk about 

how CHIP provides a continuity of health coverage for such families? 

Response: In Texas, the average length of time a child is on CHIP is fourteen months. 

Texas provides children with a continuous eligibility period, during which, income 

changes do not impact a child's eligibility. 

)> Children receiving Medicaid benefits receive six months continuous 

eligibility. 

)> Children receiving CHIP benefits receive twelve months continuous 

eligibility. 

o Households with incomes at or above 185 percent of the federal 

poverty level are subject to income re-verification at the sixth 

month of the twelve month certification period. 

An increase in income can potentially impact CHIP eligibility. When income 

verifications are conducted after the Medicaid continuous eligibility period ends and 

indicate a change in program eligibility, Texas ensures a smooth transition of coverage 

between Medicaid and CHIP. In general, families with children who are no longer 

eligible for Medicaid but are eligible for CHIP are automatically enrolled into CHIP and 

provided a grace period to pay the CHIP enrollment fee, if required, to ensure 

continuity of coverage. 

9. I want to ask you about a policy the Committee has examined in the past to close a 

loophole and reduce federal and state Medicaid spending- because this policy could 

potentially help offset extending CHIP funding. States are required to provide temporary 

Medicaid coverage to individuals who have not provided documentation oftheir 

citizenship or satisfactory immigration status. The policy idea would be to close the 

loophole in current practice by ensuring that federal taxpayer dollars in the Medicaid 

program only go to individuals who have proven they are citizens or are here legally in 

the U.S. This would save hundreds of millions of federal dollars- and cut state costs. Do 

you think this policy and policies like this that prioritize the most vulnerable and close 

loopholes are a reasonable way to help pay to extend CHIP funds? 

Response: Under current law, as you note, Medicaid applicants are afforded a 

"reasonable opportunity" to provide proof of citizenship and can receive Medicaid 

benefits during that period if their application is otherwise deemed complete. Texas 

would support the tightening of this requirement. 

10. Both the National Governors' Association and MACPAC have recommended Congress 

extend CHIP funding for five years. Such an extension would be unprecedented in its 

duration, since it's my understanding the historical record shows that longest period of 

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time that has passed without Congress providing additional funding or adjusting the 

funding formula is two years. But I think many in Congress could support a longer 

extension if the funding is appropriately offset. Neither NGA nor MACPAC endorsed 

policies to offset the more than $7 billion in costs for a 5-year extension. Do you have 

any policies to cut costs and help pay for extension that you or other Medicaid directors 

would recommend? Do you think it's fair for the states to ask Congress to spend billions 

of dollars but not make any recommendations on offsets? 

Response: I am aware that members of Congress and others have a variety of views 

regarding the CHIP reauthorization period. In his confirmation hearing on January 24, 

2017, Secretary Price (then Representative Price) suggested that an eight-year 

reauthorization may be preferable to five years. 

As I testified, Texas has implemented a variety of cost-savings initiatives in both CHIP 

and Medicaid. We remain committed to ensuring both programs are administered in 

an efficient and effective manner, understanding our obligation to both state and 

federal taxpayers. 

11. As a former businessman, I often say, "In God We Trust, All Others Bring Data." The data 

on CHIP shows there is much to commend the program. The program has help 

dramatically lower the number of children without health insurance. The program is 

more affordable for low-to-moderate- income children and their families that the 

Exchanges- yet there is reasonable cost-sharing. What I would to know is how in what 

ways do you think CHIP has lessons we can learn from to help improve Medicaid? CHIP 

is a flexible program for states, great for patients and families, and high value for 

taxpayers. What do we do in CHIP- as part of the program design or benefits or tools 

for states- that we should carefully consider for helping improve Medicaid? 

Response: CHIP offers each state the administrative flexibility to design a program 

that meets the state's needs, the ability to infuse concepts of personal responsibility 

and accountability into the program's benefit design and the opportunity to pursue 

innovative strategies aimed enhancing outcomes for beneficiaries. Understanding that 

the demographic composition of the Medicaid and CHIP populations differs notably 

and those differences must be taken into account, Texas would welcome 

modifications to regulatory requirements in the Medicaid program which offer similar 

flexibility, allowing for the development of a delivery system that meets the needs of 

Texans and aligns with core principles espoused by the state. 

12. One of the committee's priorities has been to improve access to treatment for those 

struggling with opioid addiction. How has opioid epidemic impacted community health 

centers? Can you tell me what health• centers are doing in this area, and how health 

center grants help expand this work? 

Response: Various efforts have been initiated by public and private entities to support 

federally qualified health centers (FQHCs) in confronting the opioid epidemic. I would 

recommend contacting the National Association of Community Health Centers for 

more information on the FQHCs' success in addressing the needs of individuals 

struggling with opioid addiction. 

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13. In your testimony, you explained that in Texas, "all CHIP families make co-payments for 

office visits, prescription medications, inpatient hospital care, and non-emergent care 

provided in an emergency room setting." I know fees and co-payments vary based on 

family income and the total amount a family is required to contribute out of pocket 

toward the cost of health care services is capped at five percent of family income. But 

what is the amount a family might reasonably be asked to pay, on average under CHIP? 

Response: Co-pays range from $0-$35 for lower income families (up to and including 

151 percent of the federal poverty level) to $10-$125 for higher income families 

(above 186 percent of the federal poverty level, up to and including 201 percent of the 

federal poverty level). There are no co-pays for preventive services or for CHIP 

perinatal members. Total cost-sharing (sum of enrollment fees and co-pays) is capped 

for each family at five percent of household income. 

In fiscal year 2016, less than one-tenth of one percent of CHIP members reported 

meeting the five percent cap. 

a. Is $1,230 about the maximum a family could be expected to pay if their income is 

about 100 percent ofthe federal poverty level? 

Response: Since implementation of the ACA and changes to Medicaid eligibility 

levels, the lowest income level in CHIP is 133 percent of the federal poverty level 

(FPL). A family of two with an annual income of $21,599 (133 percent of the 

federal poverty level) would pay no enrollment fee and copayments would be 

capped at $1,080 per year. A family of one with an annual income of $16,040 (133 

percent of the federal poverty level) would pay no enrollment fee and 

copayments would be capped at $802 per year. 

b. While I know there are strong differences of opinion on the ACA, I assume you 

would all agree with me that CHIP makes coverage more affordable for low-income 

families than many of the products commercially available? 

Response: Enrollment fees for Texas CHIP are lower than subsidized premiums 

available through the federal health insurance exchange. Co-pays in Texas CHIP 

are also lower than state employee health plan co-pays. Furthermore, CHIP copays are capped at five percent of family income. 

The Honorable Larry Bucshon 

1. According to MACPAC data, in FY2013, almost 85 percent of children in separate CHIP 

coverage lived in households with one parent working. Do you happen to know what 

percentage of children in Texas's CHIP program have at least one parent working? 

Response: Texas does not have data available to determine the percentage of children 

in CHIP with at least one parent working. 

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a. Follow-up: One idea I am interested in is making it easier for states to use premium 

assistance models to help take a defined amount of federal dollars and put folks in 

private coverage. Conceptually, it's a good public-private partnership. Can you help 

me understand what would be the policy or mechanical challenges to just letting a 

mom or dad take their child's CHIP dollars and buy into a family plan- either in the 

Exchanges or in employer-sponsored insurance? 

Response: While there may be advantages to having families in CHIP purchase 

health insurance, states may face challenges in doing so, including: 

);> Costly systems and operational changes, necessary for the state to assess 

a family's allocated "CHIP dollars" in order to facilitate their ability to "buy 

into" a family plan while ensuring coverage commensurate with that 

offered under the program. 

);> Implementation of a comprehensive education and outreach campaign, 

aimed at supplying families with the knowledge needed to successfully 

purchase coverage through the Exchange or their employer. 

It should be noted that Texas prohibits enrollment in CHIP if a child has private 

insurance coverage. As such, all CHIP enrolled members would be required to fully 

transition to private coverage, should the state elect to pursue that avenue. 

The Honorable Tim Murphy 

1. Mathematica analyzed the outreach and enrollment grants that have often been funded 

with CHIP. They found these grants "played an important role in supporting and 

supplementing state outreach efforts." However, there is limited data able to quantify 

just how successful these programs have been in terms of number enrolled. State 

officials gave support for extending the grants, stating they "had been particularly 

helpful in bolstering otherwise underfunded outreach efforts, and played a significant 

role in supporting and sustaining community-based groups involved in outreach." While 

the support of these grants is wide spread, and utilization is clear, why is it difficult to 

quantify on their ability to increase enrollment and retention in Medicaid and CHIP 

programs? We need to be data-driven in our policy making, so how should we think 

about extending funding where we have anecdotes instead of hard data? 

Response: The overall impact of outreach and enrollment grants is difficult to 

quantify because grant activities constitute only one of many factors impacting 

outreach and retention. Increases in enrollment may be influenced by other variables 

such as changes in the economy. The implementation of the insurance marketplace 

under the Affordable Care Act also created a mechanism to test individuals for 

Medicaid and CHIP eligibility, which ultimately resulted in increased enrollment. 

Because outreach and enrollment grants were implemented over the course of the 

economic downturn and following passage of the Affordable Care Act, it is difficult to 

infer a direct causal relationship between the grant activity and enrollment and 

retention changes impacting CHIP. 

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The Honorable Morgan Griffith 

1. I want to ask you about a policy the Committee has examined in the past to close a 

loophole and reduce federal and state Medicaid spending- because this policy could 

potentially help offset extending CHIP funding. States are required to provide temporary 

Medicaid coverage to individuals who have not provided documentation of their 

citizenship or satisfactory immigration status. The policy idea would be to close the 

loophole in current practice by ensuring that federal taxpayer dollars in the Medicaid 

program only go to individuals who have proven they are citizens or are here legally in 

the U.S. This would save hundreds of millions of federal dollars- and cut state costs. Do 

you think this policies and policies like this that prioritize the most vulnerable and close 

loopholes are a reasonable way to help pay to extend CHIP funds? 

Response: Under current law, as you note, Medicaid applicants are afforded a 

"reasonable opportunity" to provide proof of citizenship and can receive Medicaid 

benefits during that period if their application is otherwise deemed complete. Texas 

would support the tightening of this requirement. 

The Honorable Gus Bilirakis 

1. How do you engage a patient population driving the majority of health costs whose 

health challenges are exacerbated by socio-economic status? 

Response: As noted in my testimony, Texas CHIP has operated through a managed 

care model since its inception. One of the advantages of a managed care delivery 

system is the ability to increase access to and promote the utilization of primary care 

by assigning each member a primary care provider (PCP). Under the model, families 

are encouraged to engage with their PCP. In turn, the provider has the opportunity to 

intervene with families and potentially detect and ameliorate medical issues resulting 

from the inability to access related supports and services due to socio-economic 

status. A PCP can, for instance, more quickly identify that recurring, uncontrolled 

asthma symptoms are due to issues within a substandard housing complex, whereas 

such issues would not be identified through analysis of medical claims. 

The managed care framework also relies heavily on effective service coordination. 

Because MCOs are fundamentally at risk for the total cost of their members' care, they 

are incentivized to proactively identify and offer additional service coordination and 

case management to members with special health care needs, including those whose 

needs stem from their socio-economic circumstances. Early intervention through 

effective and holistic referrals to both medical and social services improves the health 

and well-being of the individual while also driving down cost by avoiding expensive 

treatments in settings such as the emergency room. 

2. The Centers for Centers for Disease Control and Prevention estimates that 1 of every 68 

children and 1 in 42 boys are diagnosed with autism spectrum disorder. What should 

states be doing to protect this vulnerable population and ensure that children with 

autism can continue to access the treatment they need? 

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Response: Children with autism spectrum disorder (ASD) often have complex needs. 

One of the primary ways states can serve this population is to ensure that children 

with ASD, like all children with complex needs, have robust care coordination. Care 

coordination can play a vital role in ensuring children receive all medically necessary 

services available to them in the most efficient and effective manner possible. 

The Honorable Richard Hudson 

1. There are 234,000 kids enrolled in CHIP in North Carolina and I want them to know they 

will be taken care of. We can accomplish this by extending CHIP for at least five years, 

but we have to do so responsibly. It is imperative we craft a bill that will not continue to 

pile on to the massive debt and deficit we are already running, a scary burden I worry 

constantly will be handed down to members of the next generation, like my son. Both 

the National Governors' Association and MACPAC have recommended Congress extend 

CHIP funding for five years. Such an extension would be unprecedented in its duration, 

as the longest Congress has gone without providing additional funding or adjusting the 

formula is two years. I think many in Congress could support a longer extension if the 

funding is appropriately offset. 

(a) Do you have any policies to cut costs and help pay for extension that you or other 

Medicaid directors would recommend? 

(b) Do you think it's fair for the states to ask Congress to spend billions of dollars but 

not make any recommendations on offsets? 

Response: As I testified, Texas has implemented a variety of cost-savings 

initiatives in both CHIP and Medicaid. We remain committed to ensuring both 

programs are administered in an efficient and effective manner, understanding 

our obligation to both state and federal taxpayers. 

The Honorable leonard lance 

1. A March 2017 report by MACPAC stated that "current grantees "are assessing the 

feasibility and usability of the measures at the state, health plan, and provider levels." A 

HHS Secretary report on in 2015 noted that higher numbers of states are reporting on 

quality measures. Within the context of the Pediatric Quality Measures Program that 

has often been funded alongside CHIP, what do states do with the pediatric quality data 

they report? Do you know what CMS does with the quality measures that are reported? 

Response: Texas uses this data for a number of its quality initiatives, including: 

);> The integration of quality metrics in MCO report cards which assist consumers 

in selecting the best health plan to meet their needs. 

);> The integration of key quality metrics in the state's Pay-for-Quality program, 

which places a percentage of the health plans' capitation at risk based on 

their performance on the identified metrics. 

CMS makes available state-by-state results for these measures. CMS may use the 

measures for other purposes. I would recommend contacting CMS officials directly for 

additional insight. 

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2. Health centers serve nearly 8 million children -about one-third of patients of all patients 

seen. However, CHIP only represented about 1% of health centers' revenue for FY 2016. 

Is that because these children are enrolled in Medicaid? 

Response: Texas' utilization data shows FQHCs serve substantially more Medicaid 

clients than CHIP clients, which is reflective of the size of Texas Medicaid program 

relative to state's CHIP program. Texas Medicaid payments to FQHCs, for example, 

totaled more than $8.5 million in fiscal year 2016, versus approximately $425,000 in 

the CHIP program. 

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