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House | February 12, 2013 | Committee Room | Health

Full MP3 Audio File

But of life and death of this if they just assume anything to where they are having a mistrial by the council Ashton craft them aren't thing through service to the committee last seven days a john's fed lines national sales done that and and many more thank you much your service said serving, (SPEAKER CHANGES) can you tell likely and then goals of the staff of the senate committee senator john some said MF nine John Paul leather light and no buying back which like to welcome the opportunity to the first meeting of five HHS policy committee less like to welcome guests in the back of the room and (SPEAKER CHANGES ) Chairman Joe chairman comments as Chairman Ali got alumni are from plates that this war two welcome all members to the committee with 4 to 7 with you and the Chairman Colin fed survey which he thinks the two have one bill on the agenda 7743 titles no more fives change to make a special as PCs before the committee without objection that somebody presents bill thank you Mr. Chairman (SPEAKER CHANGES) any mention that what you have before us a out PCs that that makes if you let technical corrections to the bill out as a staff of address those in just a moment what they cover the admin major at the theme of the all the things I needed that really 43 issues and we're looking at that address into this bill five number one ¥ 96 state taking a position and nine been clear that we will not operate as a basic strength to the second and that is that the airline must stop, all would be a partnership implementations and return the remaining grant funding back to the Federal government that for is no Medicaid expansion and beyond the fourth as a working to ensure that the department of health and human services king continued high income in the necessary steps to ensure that IE is the fastest among ID System five is up and running the say that I was really important is this a can make its own of five eligibility determination in terms of our Medicaid enrollees 9:00 AM not sure what you say this morning and not by the end of a nice, an Allen had taken a position in support of this legislation and that were nine certainly grateful for for his support there and that that only are we have an ad that stance and his top five at http point out where welling in his press release said I've certainly are too many unknowns at this point, while we don't know, what good will risk as 52 taxpayers in the state other than there is a risk and we need to make sure that that's certainly a after the audit that was received nine by the auditor fax two weeks ago that from 22 had managed via cut Medicaid program we have in place to make sure that we are current Elsinore 40 ever, looking at any consideration expanding a Medicaid in North Carolina before I am not continue out would have liked for status to run to the bill as chairman (SPEAKER CHANGES) and also point out the exchange is that it may just be allowed me to the house and senate bid to come on out, just a great thing for the ballot in Grand Rapids will play out specifically to change as a gala tonight it up into three sacks SMC Michael E section………….

Additionally farsighted health benefit exchange DI will ACN… Benefit exchanges and allowed if they could choose to operate one I took Eleanor not take not required to adequately exchange method is not e-file federal HHS will Delahunt in exchange for the day if you notice the federally facilitated exchange that they really facilitated exchange a further option to contract for certain administrative functions with federal exchange that section 100 know permit any department agency or institution under faith locate Kenneth toward the formation of eight May 16 or enter into any contracts or in any resources to the partnership exchange model Christ is felt by the Gen. assembly it also reserves to the general assembly good afternoon to determine the level of interest in the federal exchange actually also the language to the contrary without it? 2011 125 and repeals either the commission of a strength that relate directly to the EPA further interaction Department of Insurance the expenditure funded by federal exchange related grant and to the extent possible of the reimbursement for the editors at Wikipedia getting in the next a few attractive Medicaid eligibility determination phentermine through the exchange whenever the federally facilitated at state action regarding Medicaid eligibility determination and if you are federal exchange make a brief And the applicant On-Q eight for the final determination said the state would retain control of the final Medicaid eligibility determination or a statement on choose to let the federally facilitated exchange with a final determination regarding Medicaid eligibility a figure like can still allow the federally facilitated exchange to make the final determination would need to maintain eligibility for a year and North Carolina that in a-or even developing a thief effect on that will handle Medicaid eligibility determination action of the Beryl direct it will handle does determination and the particularly interested how in the retirement that exceed me ensure that the technology is writing network and technical correction action our brining an interest in on it and health action has regarding Medicaid expansion and interaction three and its representatives are indicating that belt-eight will not be participating in allocating management in [to give the general assembly might be him and technical changes under there are three and L relate to issues related to the funding of of NC fast it doesn't bill for second edition came out Senate there was a sentence in section 1D this is been removed out that sentence reads any contract between the third party in the state to provide services funded by such grants is hereby terminated on the grounds that funding no longer exists home after dislocate publicly funded there are some some contracts are ongoing and by having an automatic termination migration difficulties with Nancy fastens that languages is removed to do with that issue now you'll see some new language online 24 the words to the extent possible have been added into that sentence message to your concern if there are any hiccups in drawing down grant funds that are even extended back Saddam state law will be violated by that inability to drop-down so it's home shall to the extent possible drawdown grant funds the third change Asterix on line 33 at the bottom of the first page album and language begins with the that is that sentence and it just says that if funds forsake match are available from our preparations for NC fast and and also if the total amount matching funds do not exceed $5 million then HHS shall seek available management Medicaid funding for NC fast ability to provide Medicaid eligibility determinations for the federally facilitated health benefit exchange out there is also some limiting fear out within the budget bill there are two boilerplate sections 15.1 that says of the states expecting to get any money pilots expropriated and is a section 5.2 which says the money comes up during the fiscal year here's what you have to go through to do it all and so this is saying this consultation requirement

There and since in such Medicaid funding frenzy fast-changing fiscal year 2012 2013 is not subject of consultation requirements of section 5.2 obsessional 21 145 that's consultation requirements make sure that the Gen. assembly know what's happening with money get with the journals in Windows what's happening with this money then disclaimer says that consultation requirement does not apply I'm secure those are the the the three technical changes I get all related to that in C fast funding with Mr. Rebecca Angelo and branded a pretty good job of explaining the differences for bill in the actually we did that income is from the committee budget and so I think Mr. chairman I like to make a statement and I have loved to men and sidelined since then forward this bill for will hurt not help the hard-working low and middle income people of North Carolina it will hurt and not help the small business owners of North Carolina undermines the future North Carolina it unnecessary that it is a very this guy did bill let me start by commenting on why this bill is bad for business if legality expand Medicaid small business owners who have 50 or more workers many of whom have incomes up to 133% of the federal poverty level will be required to provide health insurance for those workers or pay a fine by expanding Medicaid the small business owner is relieved the cost of providing the coverage and the small business owner has a healthier workforce by rejecting a partnership exchange it will be harder for small business owners to find the right policy for their employees on a federally run exchange and it will be more expensive because the fees that are charged a small business owners through a federal exchange will be higher than they would be through a partnership exchange under the ability for as a bill that business that purchased the group policy on a federal exchange is forced to depend on the federal government to resolve differences of insurers under a partnership exchange we would be able to employ our own consumer assistance people who would help help the uninsured find it right policy that would create 500 jobs in North Carolina and is jobs that pay between 20,000 and $30,000 each that would be good for our working class North Carolinians a be good for working-class business by rejecting the exchange and Medicaid the really hurt the working class were the middle-class guy working people in North Carolina and the hurt small businesses receiving checks and Medicaid is also wrong that will further undermine our low income middle families either working families are not people who are not responsible they are responsible their paying their fare share there doing their part to doing everything right here paying into the system but they still fall behind to no fault of their own of the 1.5 million people in North Carolina who do not currently have health care insurance more than 500,000 of these would be covered by the expansion of Medicaid 233% of the federal poverty level these are working families who don't make enough now to buy insurance that you get sick when these I'm sure people get fit they go to emergency rooms for care and hospital emergency rooms are required to provide that care that uncompensated care so how do hospitals manage to do that well you and I hate fat we pay for it in two ways first of all we pay for it through an increase on our own insurance premiums fell according to families USA for a family that has a group policy every family that has a group policy pays $1200 each year more in order to offset the indigent care for individuals they take close to $1000 a year extra in premiums that they shouldn't be paying back the clock that is to help understand or shift the cost I cannot pay hospitals for the indigent care another way is through our disproportionate share program at the federal program taxpayers support that my

Tax dollars go to that, your tax dollars go to that. When the affordable care act goes into effect the disproportionate share payments to hospitals, especially our rural hospitals who depend on this money to keep them viable, to keep them floating. That money is going to go away. And so in order to make up for that there's a projection that our insurance premiums will go up even further, that there will be an escalation in the cost of our insurance premiums to help rural hospitals offset that loss of the disproportionate share money. But that's going to be a struggle for our rural hospitals and those of you who represent rural districts right now I urge you to go meet with your hospital administrators and talk to them about how they're going to handle the disappearance of disproportionate share money without the expansion of Medicaid. No rationale reason exists to to expand Medicaid. Especially during the first three years when the federal government would pay 100% of the service cost and savings would more than offset any administrative cost. The expansion would create 25,000 new jobs in the first three years, that's in addition to the 500 that I was talking about before. It would produce $125 million in savings to the state, to the state tax payers, $124 million dollars of savings. Before I've sent forward these amendments I want to just add that access to affordable appropriate healthcare is really a national emergency. We are an unhealthy country. We are the only industrialized nation in the world that does not provide healthcare to all of its citizens because healthcare is an essential service. our military, our law enforcement, our military are rejecting more and more of people who want to go into the military because they fail the healthcare exam. And that's true also for our emergency workers, our policemen and our law enforcement officers, more of them are having healthcare problems. I don't want you to blame the auditors report. First of all I've talked with people at DMA, they assure me that the administrative issues in the auditors report should be fixed and they can be fixed, they have no problems with that, those problems will be taken care of by July 1, 2013. The $1.4 billion dollar shortfall that you see in the auditors report isn't $1.4 billion in state dollars, that's the federal state combination. The shortfall is about, is a little less than $400 million dollars in state. That's a lot of money still but that's the money that secretary canceller [??] said, the department would not be able to meet. That was an excessive cut in Medicaid that the department said they would not be able to save. The $90 million dollars savings in community care network of North Carolina we all said was not realistic given the way they rolled that program out. We knew that Medicaid was going to fall short. That's not something that the auditor had to tell us. And I would just say that democrats balanced the budget on the backs of Medicaid too. That wasn't new with republicans. So I think we all support getting all of those things on the books up front and dealing with them. But that's not a reason not to expand Medicaid and it's not a reason not to have a state partnership exchange. I also hope we won't blame the federal defect or the debt. Republicans and democrats are both responsible for that let's just take that off the table, and let's don't see repeal and replace. We have had a huge effort since maybe before President Truman, trying to get healthcare. President after president has tried to do that. We finally have a plan, an imperfect plan, a plan that needs to be fixed, but it doesn't need to be repealed and replaced, we need to go ahead and this is the law of the land. We need to go ahead and move forward, take the lead as North Carolina has on so many other things. Take the lead and help get it fixed but help roll it out and implement it. I just would like to send two - forward two amendments, but I do want to say that our community care network, we have a rich package, a rich Medicaid package in North Carolina. And we do pay more. Those are people that are age, blind and disabled, dependent children under the age of 19 who are poor, those are not...

People who we can expect to take responsibility for their own care. Those are our vulnerable population, people that we have historically said, if you're an American and it's not your fault if you're vulnerable, you can't do it yourself, we're going to make sure that there's a safety net that works for you. So I would like to send forward two amendments.[SPEAKER CHANGES]Representative Insko, would you hold your amendments for just a minute please. Thank you. Representative Brisson.[SPEAKER CHANGES]Thank you, Mr. Chair. Question for Representative Burr. Representative Burr, would you just define the present system? And I know, I've sat on this Committee for six years, and I know that Medicaid, we've with the present system we've been able to expand throughout the last six years with new folks, patients that apply. We'll always have new patients coming into the Medicaid system. If you glance at this title, No Medicaid Expansion, that might send the wrong signal to some of the people, particularly the new Representatives just getting introduced to the program. Can you define what this would do when new patients still apply, that patients would still be able to apply in the present system. You understand what I'm talking about? Just a short ??[SPEAKER CHANGES]I get what you're saying pretty much. You correct me if I'm going down the wrong direction. But it is the intent of this bill, and I believe the intent of the Governor's comments today and the Legislature, to make very clear that with those folks that are currently enrolled in Medicaid, or eligible to enroll in Medicaid under the current program as it is today, we want that program to be successful. We want to see healthy outcomes for those individuals. And yes, we were pretty much, I think the Governor, or the auditor's audit wasn't a big shock to anyone in this room. I think it just reinforced very much that this General Assembly and this state has really got to take a serious look at the current Medicaid program and the current way that we do things within Medicaid, and get those things fixed. As I said earlier, when you've got a house in shambles you don't build onto it at that point. You fix what you've got and then you move forward from there. And I believe at this point, Representative Brisson, we've got to take care of what we've got and we've got to make sure that we're fully meeting the needs of those folks that currently qualify for Medicaid before we ever consider looking at any type of expansion.[SPEAKER CHANGES]Representative Dollar.[SPEAKER CHANGES]Just a quick question. Representative Burr, is it fair to say that if we pass this legislation it's not a decision for all time, whether we're talking about the Exchange or whether we're talking about expansion, these are issues that the General Assembly, in accordance with this legislation, would be able to come back at some point in time, if the desire was there, and make a different decision? Is that fair to say?[SPEAKER CHANGES]That's correct, Representative Dollar.[SPEAKER CHANGES]Thank you.[SPEAKER CHANGES]Representative Fulghum.[SPEAKER CHANGES]Thank you, Mr. Chairman. Representative Burr, is it fair to say that there is ?? cost to this expansion over the next six years, and how much would that be in a dollar figure as far as the state's share?[SPEAKER CHANGES]There is. Perhaps staff could give us that number. I think Susan Morgan, if you'll allow Susan to speak in this chair, she could give us a precise number.[SPEAKER CHANGES]Ms. Morgan.[SPEAKER CHANGES]Representative Burr, members of the Committee, we have the document that talks about the expansion through 2020 that's been prepared by Steve Owen with the Division of Medical Assistance. I believe that he is here. In looking at the impact to state funds associated with expansion

[0:00:00.0] And couple of things are going on and that is assuming that the offsets that he is including that is serving people who are currently in the correction system, you can now talk about the expand in medicate and also the mental health funds that are currently state only would be eligible to be covered by the new expansion. During the first four years of his analysis it shows that there is an increase in revenue for the state, once you get to 2018 the cost that state associated with the expansion that’s because there is a step-down in the Federal match right beginning of that year. The cost that first year 7.8 million dollars by 2019 the cost increases to 34 million dollars according to his analysis. [SPEAKER CHANGES] And Mr. Chairman if I could end that as well I think it should be said that there is no guarantee, there is no certainty at all Representative ___[00:50] that with all the uncertainty we have in Washington DC right now with the budget and the deficit and all the issue they are facing that they potentially couldn’t come up in future years and change that match and that number could grow even larger and potentially after 2020 it will be ___[01:11]. [SPEAKER CHANGES] Representative Insko, would you like to send forward an amendment? [SPEAKER CHANGES] I would like to ask a question if I ask the staff I believe in response to a question that was asked before about I agree that we could come back in approve state run exchange or the expansion of medicate, could the staff just tell me when we would have to notify the Federal Government in order for us to start expanding medicate in 2015 instead of 2014? What's the deadline for that? [SPEAKER CHANGES] So, staff would like to comment? [SPEAKER CHANGES] At this time there is actually no deadlines the state is able to opt-into the expansion when they to choose. [SPEAKER CHANGES] And how about for the excuse me, I have a follow up, how about for the expansion for the state, partnership exchange is there a deadline for them? [SPEAKER CHANGES] For the 2014, the deadline has passed to do a state based exchange, the partnership exchange deadline is actually this Friday, with regards to the future for an exchange in 2015 the deadline for a state based exchange would be sometime in this November. So, it will always be the November a year and a couple of months before the state based exchange. With regards to future deadlines for the partnership they have not put any of that information out yet. [SPEAKER CHANGES] Thank you and so Mr. Chairman I would like to just point out to the members that they have on their desks letters of support for medicate expansion from the North Carolina Hospital Association, The North Carolina Medical Society and for partnership exchange from the health care underwriters and the first I would like to send first forward the amendment S4AME-6V4. [SPEAKER CHANGES] Clerks have the copies, the members of the committee have the copies. Okay, Representative Insko. [SPEAKER CHANGES] Thank you Mr. Chairman, you will see on your bill, if I can find my bill, on line 10 Section 1BGS52-240 ___[03:48] is repealed, I believe that is an overreach and an unnecessary overreach and one that actually is probably can be easily, fairly easily fixed and that we should probably have broad consensus on fixing this, this is the language that gives authority to our own department of insurance to resolve issues between insures and industries and providers and individuals and the way this is worded it would prevent the department if insurance from dealing with all of those things that have currently been rolled out already for example whether or not about pre-existing conditions, about providing insurance for children under the age of 21, about some preventive care or there is whole long list of Federal, provisions that have already rolled out and already in place and this would force individual people or… [0:04:59.9] [End of file…]

businesses to actually go to the federal government to resolve differences and I believe that the bill sponsors intended really to limit that to the industry. And if I could have the staff, this is fairly complex even though a lot of us in here spent a lot of time on medicade and healthcare it's something that I think that it would be better for the staff to explain so that I make sure we get the details right. [SPEAKER CHANGES] Staff? [SPEAKER CHANGES] Yes, Mr. Chairman, members of the committee, there are several provisions within the affordable care act that put requirements on insurance plans, Representative Insko mentioned a few of them, our authorization for our commisioner of insurance, however, in the powers and duties says enforce the state law. This is number one within the powers and duties. There's this additional authority that was added in the budget bill, the ten which you'll see excerpted on the ammendment form, what this would do would make just enough changes to the existing statute to be in line with the rest of the bill. And that is saying no state run exchange, no partnership exchange, explicitly says this authority does not, the authority intent does not include the authority to do those things, but it would include that information, that authority that's in there to enforce the provisions of the affordable care act. And I have a list of some of those that I can run down, however it was something that was provided to me by the department of insurance so it might be more appropriate for perhaps Rose to run through those if she's in here or someone else from DOI. [SPEAKER CHANGES] Mr. Chairman if we could ask Rose Von Williams from the insurance department to explain that issue, I have some of those here too, but if she's in the audience she would know more about that than I do. [SPEAKER CHANGES] ?? please identify yourself. [SPEAKER CHANGES] Thank you Mr. Chairman, and Representative Burr, My name is Rose Von Williams and I'm legislative council to the department of insurance, and I think the question is to go over those things that this would prohibit the state from enforcing. Is that correct? Without the clear authority from the general assembly as the general assembly did with HIPAA and other things we're certainly going to try and do our job and enforce all we can, but I think that this would affect those things in the affordable care act so that enforcement of all those new items that are coming down in this large federal law would all be then answered to by the federal government. Disputes between hospitals and doctors or when individuals have questions or problems with their health insurance company, that maybe some of the provisions of the new act are not being followed. Maybe you are being charged more for a preexisting condition or maybe your child is not being allowed to stay on your health insurance policy even though he or she is within the dependent age limit, but the other list would include the no lifetime or annual limits, preventative services, uniform explanation of coverage documents, appeals, recisions, premium rating, and the essential health benefits package or plan. That answers that. [SPEAKER CHANGES] Ok, Representative Insko? [SPEAKER CHANGES] Well, thank you. I really do believe that our hospitals and our physicians and our patients who have healthcare prefer to go a state department of insurance to get these issues resolved. And they would be more quickly resolved with people who knew the state who knew the people who knew the companies without involving the federal government. So I would move adoption of the ammendment. [SPEAKER CHANGES] Any other comments on the ammendment, Representative Burr. [SPEAKER CHANGES] Thank you Mr. chairman. Representative Insko, you raised an issue that we've all been looking at, I find to ?? best how to address this one piece. I'm not sure this is it. I'm certainly willing to work with you to find a vehicle and a place and a way to do that, but at this time I would ask, right now, that members oppose this ammendment and we can certainly carry on discussions in the future about how to address this. [SPEAKER CHANGES] Could I ask for show of hands please? [SPEAKER CHANGES] Ok. Any other discussion on the ammendment? [SPEAKER CHANGES] Mr. Chairman. [SPEAKER CHANGES] Representative Lewis? [SPEAKER CHANGES] Yes sir, just a quick inquiry either to the bill sponsor or staff or even Representative

[0:00:00.0] Representative Insko, we talked about that there were some date certain one of which has passed and I think one of which is Friday in which the state would need to declare that it was going to run it’s own exchange or not. Could someone help me understand even if it was the direction that the General Assembly wants to take to establish a state and exchange has that ship not sailed? [SPEAKER CHANGES] For 2014, the state no longer has the ability to have a state based exchange. However, for 2015, 2016, 2017 that window is still open. [SPEAKER CHANGES] Representative Farmer-Butterfield. [SPEAKER CHANGES] Thank you Mr. Chairman. I wanna to speak in favor of Representative Insko’s amendment, I think it’s a good amendment, I think it would allow people in North Carolina who are uninsured and under insured to receive the necessary services and wanna to save the state dollars. [SPEAKER CHANGES] Any other comments from the committee, Representative Baskerville… [SPEAKER CHANGES] Thank you Mr. Chairman… [SPEAKER CHANGES] Question, how can it be better for the citizens of North Carolina that have an issue with being denied a service or coverage or having an issue with payments or anything like that, they have to go to a Federal Authority to have those issues ___[01:50] down or concerns address? How it could be better to have that approach then to come to a state regulator or agency to address those concerns I mean that seems like that’s the opposite of how we should approach this. [SPEAKER CHANGES] Well, Representative Baskerville never said that it was a better idea for folks have to go to Federal Government, what he said is this is an issue that we are aware of and we are trying and figure out how to best address that and certainly I’m willing to sit down with Representative Insko and try to address that not at this time in this committee but address that in future to make sure that we have the best possible solution to make sure that folks were able to rely on our state assets here versus having to rely on the Federal Government. [SPEAKER CHANGES] Okay, Representative Insko moves for adoption of the amendment, she wish to have the vote, those in favor of the amendment raise your hand, please give them up. Okay, those oppose to the amendment raise your hand. Okay, the ayes seven votes, No’s 14 votes the amendment fails. Do you wish to send forward another amendment? [SPEAKER CHANGES] Yes, I send forward an amendment S4-AME-9V1. [SPEAKER CHANGES] The members of the committee have the amendment. Representative Insko, do you wanna explain the amendment? [SPEAKER CHANGES] Thank you Mr. Chairman, members this actually a delete section 3 and replaces it with a language that would authorize the expansion of medicate according to the Affordable Care Act for the first three years only that’s during the time when the Federal Government would pay a 100% of the cost of services and when there is ample return on and savings for example that have already been mentioned during those first three years we would actually, the revenue would actually increase state revenue, there would be no loss of state revenue that the offsets in mental health and other savings would more than pay for any administrative cost. So, there are and this is very important that we go ahead and do this for the first three years, we have learned from community care network of North Carolina… [0:04:59.9] [End of file…]

To know that when we have people who are uninsured they are a lot sicker than the general population. The way to save money in healthcare is to keep people well. It costs less money to provide healthcare to well people than it does to sick people. And so we've learned in community care network that those - when we take in a new group of people that the first 12 to 18 months we actually spend more money on them than we do in the long run because in the long run what we're doing is maintaining health. What we're doing in those first 12 to 18 months is treating really serious chronic conditions and high cost conditions. We need the federal government to pick that money, to pick that cost up. If we delay the cost of - the time we expands Medicaid and we lose that window, this is the law of the land and we will eventually be moving in that direction because of the other things I mentioned about how the lack of expanding the Medicaid is going to hurt our business community. And so we're going to - I think that you all have seen the editorial from the Wall Street Journal about businesses now looking more closely at the costs associated with not expanding Medicaid. That the chamber of commerce in Virginia, that predicament of chamber of commerce in Virginia actually supports the expansion of Medicaid because of the benefits that it's going to bring to businesses. So this issue of our impact on business I think is going to be here too in this state so it is very important for us to go ahead and take advantage of these first three years. This bill automatically sunsets at the end of this period when the affordable care act, when the federal government quits paying the 100% of costs. So I'll be glad to answer questions and I move adoption of the amendment. [SPEAKER CHANGES] Representative Avila. [SPEAKER CHANGES] Thank you Mr. Chairman, if I may I'd like to ask Representative Ensco a question. [SPEAKER CHANGES] I yield. [SPEAKER CHANGES] Ms. Jacobs referred earlier to a document that Mr. Owen had done regarding the finances of the first, second and third year. What after the third year are we going to do? Have you had a physical note or a memo or anything done as to what will happen as that match from federal government decreases and do we know what beyond 2019 or 2020 the decrease is going to be? [SPEAKER CHANGES] This bill does not, this bill sunsets at the end of three years so we wouldn't have this program unless the general assembly took affirmative action to continue the program. This bill sunsets at the end of three years. It would treat our sickest people during those first three years at no cost to the state. There is no reason for us not to do this. [SPEAKER CHANGES] Follow up? [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] We are currently having a significant issue where we have to eliminate by necessity because of financing services. So you're telling me that we're going to expand this to 500,000 people which as I've heard the estimate that will be covered for three years and then we're just going to throw them off the boat at that time? [SPEAKER CHANGES] Well, if I could respond to that. [SPEAKER CHANGES] Go ahead. [SPEAKER CHANGES] At that time I believe that there will not be a reduction in the federal, I think there's good reason to believe that there will not be a reduction in the federal timeline. They would go down to 93% which would leave us with 7%, and then at the end of 10 years I think it goes down to 90%. We currently pay a third of the cost for every person whose enrolled in Medicaid. So paying only 10% to get our people healthy and insured is a huge savings. the money that would - there are numbers about the money that would come in during that time, about the jobs that would be created, about the increase in revenue from those jobs that are created. every person who has a job, who is going to make more money because of the increase, all that federal dollars goes to the private sector in the form of jobs. And so those people are all going to be paying state taxes and that's going to increase our state tax revenues. So there are numbers that show that, I don't have them with me right here but I'd be glad to get those for - and I think that this program is going to be so popular in the public that the federal government will not reduce its share. [SPEAKER CHANGES] Representative Burke [SPEAKER CHANGES] Thank you Mr. Chairman. Member, I'd ask you to oppose this amendment for many obvious reasons. This is exactly what's wrong in our country is the fact that the federal government constantly comes and dangles some dollars down in front of our faces and we think we instantly have to grab it and we have to take those dollars, and then we forget that when we get those dollars there's all kinds of strings...

Attached to it, and it puts you all, us all, the citizens of the state on the hook for many many years to come for something that is advertised as just a temporary free - this idea that it's free money. There's no such thing as free money. It's either coming out of the taxpayers right pocket or the left pocket or the one in the back, and it makes absolutely no sense to take money that's coming form the taxpayers or to take money that is really being borrowed at this point and to say that as well taking it through that direction through the taxpayers you'll also be taking it through premiums because I believe there's a great chance that you'll see the premiums on north Carolinian's rise as you see the hospitals start to do cost shifting more and more through having additional Medicaid patients on the rolls. And certainly they will be paying from both ends at that point and we simply don't need to be moving in that direction, as I said earlier we need to manage what program we currently have and maintain that and better maintain that for those people that are truly at need, and beyond that we need to be willing to say no and step back and assess what we have. [SPEAKER CHANGES] Representative Earl. [SPEAKER CHANGES] Thank you. I'm certainly speaking in support of the amendment. I think we need to kind of look at the big picture. We've only been here a few days and already we're rushing through two major pieces of legislation and I think that they are very much connected. we just passed out the unemployment piece and I don't know whether a lot of the new people realize that if you don't fit into certain categories you don't qualify for Medicaid regardless to how poor you are or whether you have income or not. And we've just passed this major piece of unemployment legislation whereas after 20 weeks if you're lucky you're not going to have any money coming in and you probably didn't have but $100 or $200 coming in anyway, after a couple of a few months you're not going to have anything coming in. Our economy is just starting to kind of make a forward move. What we've done with the unemployment is going to certainly hurt the economy and then you've got people that are not going to have any safety net anywhere to go when they've exhausted this limited amount of unemployment. And I'm just wondering, and if anybody's even thought about it, where this is going to bubble. This is a safety net for people that would otherwise have nowhere to go, they'd be on the street or knocking on some of our heads trying to feed their families. And I think that North Carolina ought to be better than this. We talk about the federal government dangling money, well they're dangling money for a cause, for a reason, to help people that otherwise would not have any services or have anywhere to go. And I'm sure the hospitals would love to have these people covered because right now anybody that presents at the door has to get served so I'm sure that they would love to have it and this would just be a boost to our economy that seems to be starting to make an upward move. But I think with the two major things that we're doing right now I think we certainly are going to see some impact on the economy. [SPEAKER CHANGES] Representative Farmer-Butterfield. [SPEAKER CHANGES] Thank you Mr. Chair. I want to speak in favor of the amendment. I understand that the hospitals in North Carolina have incurred a debt of $1.6 billion dollars because of the uninsured and under-insured not being able to pay for the cost of care. So that is indeed a concern to me and representative Ensco's bill or amendment rather will address that to a certain extent. I also understand that five governors who are republicans so it's nonpartisan have agreed to the expansion of Medicaid and that's Ohio, Arizona, North Dakota...

Nevada and New Mexico. So I'm concerned that we're looking at the Institute of Medicine's report, some of us have read it, and the first three years it talks about the fact there there will be 25,000 jobs created in the state of North Carolina and we indeed are concerned about jobs in the state. I'm also concerned that the net savings for the state for the first three years would be over two billion dollars. So why are we taking two billions dollars off the table each year of the first three years? Thank you. [SPEAKER CHANGES] Representative Hurley. [SPEAKER CHANGES] Thank you, Mr. Chair. My question is where is the money coming from? The government has no money, the federal government. We're 16 or 17 trillion dollars in debt, that's just my concern. I know it might do jobs but where is that money coming from? Also, why are our military being rejected for service? I'd like to know the reasons for that. That they're unhealthy or is it because of the drug situation or whatever. I just feel that we need to look at this closer. I just feel that we don't have the money to expand this even though we want to help those less fortunate. [SPEAKER CHANGES] Representative Baskerville. [SPEAKER CHANGES] Thank you, Mr. Chair. Just a question. If the problem is how the federal government operates and the problem is the federal government danging 500 million dollars in front of us, why are we advocating our authority as a body to the federal government to establish these exchanges because it's going to happen, we're just giving them the authority, But they are the ones that are operating in a way that giving them the authority, advocating our authority as a body to them to establish these exchanges. Now, in support of Representative Insko's amendment. When the full contribution from the feds is reduced this amendments sunsets. Now, where are those folks gonna go that were receiving this expanded coverage? They're going right to the hospitals, they're gonna receive care in the most inefficient, expensive way possible. Do we have money to pay for it that way? Where is this money coming from? The money is coming from our taxes that we pay to the federal government, our federal taxes that we pay. Why would we pay federal taxes and then not have any say on what the feds do with that money? We're giving them the authority to spend our federal tax money that we pay them but we're not having any say in it. That's just about three questions actually. [SPEAKER CHANGES] Were those directed at anyone particular? [SPEAKER CHANGES] To anyone that might have an answer. [SPEAKER CHANGES] Representative Burke. [SPEAKER CHANGES] I'll try to address your questions and simply say that in terms of the exchange, the federal government passed the exchange, they created this monster. And they created something that basically they're gonna come say, "Well, Representative Baskerville we're gonna let you handle this, we're gonna let you operate this but here's the guide book and you have to do exactly what we say and basically mirror what we want to the T and you have no real control". It's an illusion to think that the state is gonna have any say in what would be involved in a state partner, in either a partnership or a state run exchange, it's all already determined. It was determined when they passed the bill back in 2009, that's already passed so that's a done issue. In terms of the Medicaid and, again, I won't repeat myself, I've already tried to make the case with Representative Insko. To me it's not a very good argument to say, "Well, we have a chance to get money, let's get more federal money". That's the problem in this country right now, we've got too many people trying to figure out how to draw down more federal dollars and it's federal dollars we don't have. At this point, you're not talking about even necessarily all tax dollars that are coming from the state of North Carolina, you're talking about money we're borrowing from other countries, it's a big difference. So to try to address your question but those are my opinions of why we need to pass this bill and move forward with trying to work with what we've got now. And Mr. Chairman, if I could also make the point that I don't think at all that it's the intention of this legislature or...

for anyone, really, let me start over, it is the effort I believe fully of the speaker, the governor, the pro-team, the legislature, to put people back to work. That's the best way we can help people in this state, let's put them back to work and make sure they have a job and they have opportunities to succeed. And if we do that then we are succeeding and that's why you're seeing this effort to move some very important legislation early on to make sure that we're serious about this and that we want to see that, that all North Carolinians have an opportunity to succeed. But they can't do it if we continue to have this wet blanket which is the federal government suffocating our state and suffocating our citizens at every turn. [SPEAKER CHANGES] Representative Dollar. [SPEAKER CHANGES] Thank you Mr.Chairman. Just a couple of points. One point that the gentleman made, just to kind of go back for a second. With respect to the exchanges supposedly there are three options, there's a federal exchange, there's a state federal exchange, and then there's a state exchange. Well the reality is is the state federal exchange is a federal exchange for which the state picks up part of the tab. And that's the reality and I think that's not just an opinion that's a very objective assessment of what we have seen over the last couple of years. Because remember this, a lot of the affordable care act or Obama care however you want to say it, is still being written and it's being written by the federal HHS. And it is constantly being massaged and changed and altered and the like. So some of this stuff is a real moving target. So the real question with respect to the exchange really is whether or not we want to have a state exchange or let the federal government do it. I think we don't lose anything particularly where we are today time wise to see for example if Utah's exchange is actually going to be accepted by the federal government. It's been sort of provisionally, I wouldn't say approved but it's been, they've got some provisional authority to move forward on their exchange but I think the Utah exchange which really doesn't match the federal legislation, it really doesn't, but if that exchange which is very much a market based exchange which would probably be much more in line with I would think we would want to look at in North Carolina, if that is able to get up and to run and Utah actually has the authority and flexibility to make that work and the state does have control, then that's something for us to take a look at down the road. So there's no harm in us waiting to see what's going to happening that regard before we make some sort of a commitment that's not advantageous to us. As far as the amendment is concerned, obviously it's an unworkable amendment. As representative Avila pointed out and representative Burke pointed out, there's no way that you can put 500,000 people into your healthcare system and then take them out in three years, that's just completely nonsensical, it doesn't work. And one other quick thing I would point out and that is, we were talking a moment ago about where some of the various groups are, I noted in the letter form the medical society in the end of the third paragraph it says, we believe the expansion of Medicaid should occur only if stable financing can be identified and the state can be assured of it. Well we're not there. We're not there by any stretch of the imagination. And I think until we get there there's no point in launching out saying we're going to expand until we know that we have stable financing, before we sit here and say, okay, were going to take on the healthcare for 500,000 more people in this state. [SPEAKER CHANGES] Representative Lewis. [SPEAKER CHANGES] Thank you Mr. Chair. I guess this would probably be best directed to staff and let me apologize I hate to use acronyms but another member spoke earlier today about the DISH program which goes largely to rule [??], well it goes to all but it makes up a larger chunk in the rural hospitals to help provide for uncompensated care. Does - is part of...

the Affordable Care Act for these reforms that we're discussing. Does that go away in 2014? [SPEAKER CHANGES] Staff. [SPEAKER CHANGES] Representative, Board Members of the Committee the Affordable Care act does decrease DSS over several years. I do not believe it is eliminated by 2014, but the concept being that if you expand medicaid and the clients are actually covered with health insurance or medicaid the need for the DSS funds actually decrease. But we have someone here from Medicaid is she'd like specifics on how that might impact North Carolina's current DSS Program. [SPEAKER CHANGES] Mr. Cherry I not to belabor this point but I think that is relevant to this discussion because the inverse of what the lady just said is if you don't expand Medicaid then we're going to take away the only small percentage of compensation that we're paying now. I'm just curious what that amount is and what those dates are. [SPEAKER CHANGES] Mr. Owen would you like to comment? [SPEAKER CHANGES] Good afternoon I'm not Mr. Owen. I am Carol Steckel, the new Medicaid Director. I will bring in the ringer if we need specific numbers, but on this issue I am very familiar. The DSS statute in the regulation, or in the statute has a direct link. The secretary's required to cut $500 million dollars a year over the next three to four years, however it has to be tied to the reduction in a specific state of the uncompensated care of the uninsured amount. The secretary has not released the regulations related to the DSS reductions yet, so it's yet to be determined how she's going to calculate that. But there is specific statutory language that says whatever formula she comes up with has to vary a state's reduction in uninsured numbers of people that are uninsured. [SPEAKER CHANGES] OK thank you. Representative Burr. [SPEAKER CHANGES] Thank you. I just wanted to followup on something that Representative Burr said. I'm assuming he was addressing part of my comments when he said about wanting everybody to have a job and I certainly want you to know that we all have that same we have constituents that we certainly want to be employed but we all know that if everybody wanted to work there are not enough jobs in this state that are available for folk. And if we did not anticipate there being more layoffs we probably would not have been rushed to do the unemployment bill. So I think we all know that there will be more people laid off with no income coming in. [SPEAKER CHANGES] Representative Dollar. Do you have anything else? OK. Representative Insko. [SPEAKER CHANGES] I thank you Mr. Chairman. I do think it's important for us to recognize that this is a jobs bill, that this would all of this money would go into the private sector. It would create jobs. It would support jobs. It would help put our people back to work. The healthcare jobs over the next 10 to 20 years are going to really expand. Plus our tax dollars now are still gonna go to those other states that are expanding Medicaid. We're taking our tax dollars and sending them to the Federal government and they're gonna go to the other 25 or 30 states that are going to expand their Medicaid. There's no reason for us to be sending North Carolina tax dollars to other places when we could have it here benefiting our own citizens. Once again this seems to me, this bill seems to be really an attack on poor people, a disregard for their situation, an unwillingness to take a reasonable, logical, step that would support our poor people in our shrinking middle class. And in the long run that is gonna hurt North Carolina and so I would urge members to vote for my amendment. [SPEAKER CHANGES] Representative Dollar. [SPEAKER CHANGES] Well just to comment on that, I mean, as a point was made a moment ago there're a host of unknown but

Part of the way that the federal government is talking about funding all this is taking money out of medicare. People are gonna be shocked in 2014 when they see how much money comes out of medicare programs. You know, they're gonna wonder what it is they were buying into, and they're also, to the extent that dish comes out of the other side have you really had a net gain, or in terms of assessment. There's discussion that assessment would be ramped down from 6% down to 3.5%, that's money out on the other end. So, this is not just some grand flood of new money out there and we really need to see how all of this is actually going to be written in the federal regulations. We need to see where the money is actually coming from. We need to do a much better assessment with more information down the road before we just simply leap into saying that we are going to take on the healthcare responsibilities for an additional half a million people, and let me mention one other thing that we, need to be concerned about, the MMIS program. Now, we've been on this for the last couple of years. There's a concern now in the latter half of the year that if the system goes live it can't, that they're gonna have to manually enter some of the claims. That they're really not gonna be able to pay the claims with the new system. We gotta know that we're gonna be able to operate that claims payment system correctly before we come around and say "oh, well we're just gonna add another half a million people to that system" that is completely irresponsible in my mind. [Speaker Changes] Representative Earl [Speaker Changes] I just, I just wanna- Excuse me I'm sorry, I didn't intend to speak again. I just wanted to address something that Representative Donald said about taking money from Medicare. The money that's coming from Medicare is coming through savings that has already been identified. It's not like a clump of money is going to be coming out to go to, to cover Medicaid. That is not, that is not the case. [Speaker Changes] Representative, so [Speaker Changes] Mr. Sherrman I would like to ask Representative Dollar a question [Speaker Changes] Representative Dollar, to you [Speaker Changes] Representative Dollar, you said that the State shouldn't take responsibility for these 500 thousand people that we would be covering by Medicare. Who should take responsibility for them? Who should? Who should? Who? Are these people that are working, but can't afford medical care, who have preexisting conditions and can't get medical care, medical insurance. Who should? Who is responsible? [Speaker Changes] Well, it's some for all of the above. I mean, some studies show that a substantial number of these folks are currently insured, and would be moving off of their, because of the cost to employers, the way this system works that employers might choose to dump folks and say "okay, you go pick yourself up on Medicaid" But what can't, but what I don't think any and I'm not gonna pick on you Representative ?? but I don't think there's any member of this committee that can actually sit here today and lay out all of the cost numbers for us. Now, if somebody can do that, great. Then maybe we should consider moving forward at this point, but I don't think we're there yet. We may get there, and the question I had asked earlier of Representative Burr, this is not a decision for all time, this is a decision for where we are today but, I would think that everyone and some of the question Representative Lewis was raising and others have raised. I think we'll need to continue to monitor this, see where the numbers are and make a decision down the road when we have greater clarity from the Federal level and from the State level on exactly what the cost and impacts are. [Speaker Change] Representative Farmer Butterfield [Speaker Change] Thank you. I just wanted to comment that rejecting the Medicaid expansion will indeed, possibly risk people from having jobs in the healthcare profession. Some people are gonna lose jobs because you're talking about cuts in Medicare, if you don't want to increase Medicaid funding by the federal government. In addition, every year that we delay in North Carolina implementing the Medicaid expansion program means that those dollars are going to go to other states

and bolster their economy. [SPEAKER CHANGES] Representative Burr [SPEAKER CHANGES] Again, Mr. Chair I just ask members to oppose representative Insko amendment at this time. The point being I've looked at the occupation list of all of the members of the general assembly. There's no fortune teller on the list. We don't know what's gonna to happen in the future. We simply don't know, there's to many unknowns. And we shouldn't put future general assemblies at risk to bear the burden of having to take more money from taxpayers, to take more money out of education, to take more money out of transportation, to take more money out of the taxpayers wallets at this time. We simply are going to move forward with what I think is the best option for our state with so may unknowns. [SPEAKER CHANGES] May I call for the show of hands again please? [SPEAKER CHANGES] Ok. Representative Insko moves for adoption of the amendment. The vote will be by show of hands. Those in favor of the amendment will raise their hand. Thank you. Those opposed to the amendment will raise your hand. Thank you. 7 aye's 14 no's, the amendment fails. Back to the bill, anymore comments on the bill itself? Representative Insko [SPEAKER CHANGES] I'll defer my comments to you in just a minute. [SPEAKER CHANGES] Ok, representative Earle [SPEAKER CHANGES] Thank you Mr. Chair. I've been around here long enough to know that this train is on the track and it's going to run me and some other folk right on over but I just want to say that I certainly would think that North Carolina would be more concerned about it's citizens than what's been displayed and what will be displayed and the explanation that has been given for why we are pushing through with this. I was kind of optimistic thinking that maybe we would not after the governor asked for a little delay, so I really was kind of optimistic that we would not continue down this road. But the explanation that's been given to me, it's not valid to me when you talk about the fact that we owe money to the federal government. Every since I've been here DHHS has always had to pay back money for one reason or another and this has been under republican and democratic secretaries so that's nothing new. I would think that we ought to be able to chew gum and walk at the same time and be able to do and focus on more than one thing at a time. I would like to say to that we've got a lot of new members and I just would like to appeal to you to look at what this would do to your constituents. I'm sure that democrats are not the only members that have poor people or people that would need this expansion. So like I say I know this train is going down the track and it's gonna be passed. I can just look around at the faces and look around at the folk that are here and know exactly in the numbers that it's already a done deal. I just want to again, I don't want to rehash everything that's been said cause a lot has been said and I really don't think that anything can justify the fact that we do not take this federal money and cover people that are not insured. We would have a healthier population for this state and I just think that it's the right thing to do. [SPEAKER CHANGES] Representative Fulghum. [SPEAKER CHANGES] For those of you who know me know that I've had some comments to make about being conflicted on this because I'm a physician.

[Speaker changes.]...and I wanted to slow this down to where we could think about it...how we could do it better. That doesn't mean I'm gonna vote against this bill because I do think that we should do it better. The audit demonstrated there was money being wasted. Profligate waste. This Observer article used the term "rats' nest". We owe our constituents and owe our taxpayers a better fiduciary oversight on how this money's being spent. Most of all, the patients deserve it. People who we're tryin' to help aren't gettin' helped like they should be, whether it's mental health or general health conditions. This category of people who, the new eligibles in this bill, between 19 and 65, childless adults...500,000...they were left out of the original Medicaid coverage, probably because they were the least people the feds worried about makin' eligible. That doesn't mean they're least deserving. That means that we've got to figure out a way to do this better. If we have time, and I think we do over the next year, 2-3 years...how ever long it takes to get this done right. With the auditor's help, Ms. ????????'s help, who's kind to help us on the Medicaid program here...and the new administration. The Medical Society letter that Nelson Dollar referenced mentioned that we support full exploration if...of financing options and we believe expansion should occur only if stable financing is available. It was also echoed to some degree by the hospital association's ??????????? that they recognize expansion can occur only if built on solid foundation. And look forward to working with the state to improve the current Medicaid program...that's what we need to do...improve the current Medicaid program. And make sure that we're doin' the right job by our citizens and the working poor...so I'm gonna vote to try to stay the course with improving our oversight. I'm not gonna approve this expansion. I just don't think it's good...I think it's a house of cards and trying to build more stuff on top of a house of cards will soon collapse because the federal debt will not support it. Thank you. [Speaker changes.] Just a minute, Representative Insko. I would like to hear from anyone in...that are guests of the committee. I received notes earlier that someone may wanna speak? Raise your hand if you're a guest of the committee that would like to speak. OK..please come to the microphone and identify yourself. [Speaker changes.] Thank you, Mister Chairman. My name is James A. Wall, Sr. I am the Volunteer State President for AARP North Carolina and, first of all, I'd like to say that AARP is certainly strongly supports the expansion of the Medicare for services to those who are currently uninsured. I would just acknowledge that Representative Insko and a number of the other committee members, including Representative Baskerville and others, have made a number of the points that I was prepared to make in terms of support of this bill but I just wanna highlight just a coupla' points if I may and that is when you talk about 500,000 people that are uninsured, we don't talk about the fact that about 100,000 of those people are people aged 50 to 64 and who are..have been without employment or for some chronic illness that they have encountered unfortunately. The other point that I wanna make and I'll just mention the fact that I'm a retired hospital administrator, I spent some 37 years in the field and when we talk about uncompensated care, it certainly does have a major impact on our rural hospitals. And what does that do? It increased the uncompensated care but it also increased the highest cost by people having to go to the emergency rooms for care. So I think that has been made but I just wanted to underscore that point. And the other point that I quickly wanna make is clearly there's been a number of reports that say this is a job creator and I know that has been a high priority for the members of this.... [Speaker changes.] [Speaker changes.] [Speaker changes.] [Speaker changes.] [Speaker changes.]

Committee, and also I believe the Governor has spoken to that as well. So it is a job creator. In some estimates, as many as 23,000 jobs will be created. Certainly by expanding Medicaid to the uninsured, it certainly has the potential of having a healthier workforce to respond to these jobs that everyone is working to create. I'm encouraged to hear that members of the Committee are willing to go back and revisit this issue. I'm encouraged by the fact that the Governor indicated that he's certainly willing to go back and revisit this in the future. The stakes are too high for us not to do that for our citizens within the state who are currently without insurance. Thank you, Mr. Chairman, for allowing me to make some brief comments. I look forward to working with you as part of AARP in any way that I can.[SPEAKER CHANGES]Thank you, sir. Anyone else? Yes, sir. [SPEAKER CHANGES]Thank you very much, Mr. Chairman. My name is Adam Searing. I'm the Health Care Director for the North Carolina Justice Center. I think there's been a lot of great debate in this Committee today. I think a lot of great points have been made with both these amendments. I just want to point out one thing for you all. Folks who are saying don't expand Medicaid keep pointing to this audit that says we overspent money in the Medicaid program. Really this shouldn't be as a surprise to anybody who's been in this room for the past several years. I'll just quote and let that be my remarks. Former Republican lawmaker and former DHHS Secretary Lanier Cansler. Back in August 2011 he said, when you all proposed a budget and passed that budget for the Department of Health and Human Services for the Medicaid program, he said to you all, quote, it's really just going to be next to impossible to achieve this budget. And I'm not sure where the Legislature will go with that. The fact that this budget plays into next year means that next year is going to be a difficult year as well. So then we had some more discussion about the budget in Medicaid. And Secretary Cansler, former Republican lawmaker Lanier Cansler, wrote a letter to this General Assembly, again in 2011, saying the aggressive budget cuts mandated by the General Assembly's budget are unreasonable and unattainable. So then we come to this year, and we have an audit that says we went over budget in the Medicaid program. Well, I think we all know why we went over budget. So I don't see that as much of an argument for not expanding Medicaid coverage to our poorest citizens in this state. I think that some of the Representatives made the point most clearly today when they said, how are we going to look our constituents in the eye? And I've been around the state a lot as well. Who are coming to us January 1, 2014, saying, in a majority of the country I can get health care coverage. But here in North Carolina I can't because of a decision made by the General Assembly. So I'll just leave you with that. Thank you very much for allowing me to speak. I appreciate it [SPEAKER CHANGES]Thank you, sir. Anyone else? Yes, ma'am. [SPEAKER CHANGES]I'm Brenda Cleary and I'm a proud North Carolinian. But I was glad to see North Carolina AARP here, because I worked at the AARP Public Policy Institute in Washington for three years looking at the health of our country. In my past practice, my nursing career spanned 40 years. And in my past practice I was a geriatric nurse. In that capacity, all of my patients I served were insured by Medicare. But many of them had over the course of their lifetimes either, unlike most of us in this room, gone without health insurance or had spotty health coverage. And it's almost impossible to do prevention for diabetes and heart disease. It's a life span proposition. So that's why I'm really very concerned about how we're moving forward in North Carolina. Thank you. [SPEAKER CHANGES]Thank you. Yes ma'am. [SPEAKER CHANGES]Hi, my name is Sarah. And I just became a citizen in ?? America. I came from Korea, who has 100% insurance. I never though about ?? who's going to have insurance and who's not going to have insurance. And I don't think you don't care about the poor people. I don't think you don't care about the ?? population. But, like ?? doesn't have a job or

Not paying a lot of money, getting paid a lot of money, and doesn’t have insurance that’s going to be unstable. I had an experience when I was in pregnancy, I couldn’t enroll insurance company because I have to pay $1500 a month to cover my pregnancy tests and everything, and I have to pay $10,000 for entire pregnancy when I was 30. I’m willing to go back to work. I’m willing to be working, but I was not able to work. So if you support a short period of time, I will be so fortunate that I can get support from my state or from my country. And people who are in their 20s or 30s who are healthy, sometime they never check their physicals because they don’t have any insurance. They don’t know they are diabetics. They don’t know they have high blood pressure because they never had a physical exam for ten years. I hope everyone can do the physical at least. I’m an MP student. I’m willing to work for under-served population. I’m willing to let them come into my office and do the physical exam so at least they know what they are and what their blood pressure number is, what blood sugar number is, so that they can check their body at least once a year. They can keep themselves healthy for the future. So for three years support will be good for some people to take the physicals, take their blood sugar. It’s not going to cost a lot of money, but this bill supporting entire state. So thank you for talking here and thank you for Chairman and I support three years. It’s going to be a lot of money to support a lot of people. Thank you. [SPEAKER CHANGES] Thank you, ma’am. Representative Dollar. [SPEAKER CHANGES] Thank you, Mr. Chairman. I appreciate it. I just have to respond to what Mr. ?? said. The fact of the matter is, when we came in majority two years ago, we inherited a hole in the Medicaid budget that proved to be over $600 million. We didn’t create that. That’s what we were facing and we resolved that hole in the Medicaid budget with no cuts to beds. No beds were eliminated in this state. No optional services were eliminated in the state of North Carolina and we have one of the richer programs. And there were no rate reductions for physicians. So we made sure to keep access up. We did all of those thing and were able to find sufficient savings and, frankly, put the money up to fix that hole. Now that we’re getting additional things that we had to address the following year. Thankfully, they weren’t as much. But a big portion of that was mismanagement from past years, from community supports and other programs, where we had to provide one-time money to fix things that were frankly, off the budget and had never been on the budget. We did those things and I also think that there are great things that have been going on that we’ve tried to move forward. If you look in the last 07-10, actual growth in Medicaid, the actual program itself and get down to the core program, the average for the four years is 3.5 percent. That’s the lowest of any place in the nation. So we have things that we have been working on for two years to fix. We’ve got more to do. I applaud the department for example they released. I think this last week, an RFI requesting additional innovations from folks all around the state to put forth additional ideas. I think this general assembly will be looking forward to looking for additional things to do, innovative things to do with the Medicaid program. We’re on the right track. We have solved out problems. We have more problems we’ve got to solve and then we can take a look at where we are after that in terms of expansion. [SPEAKER CHANGES] We recognize Representative Insko, and then Representative Burr, and then I think we are ready to vote. [SPEAKER CHANGES] Okay. Thank you, Mr. Chair. Aside, I’m really glad to join Representative Dollar in supporting Community Care Network of North Carolina. It is one of the best models in the nation. Our growth rate is 3.5 percent. It has been that low, really a model that other states I hope will endorse. Those of you who have worked with me over the last ten or fifteen years, know that I’ve been heavily involved in Medicaid, mental health care…

There are people with mental health and developmental disabilities, addiction disease. One of the great tragedies I think of our efforts to reform that system was the fact that we didn't make any, that we didn't put any money into our system to care for people who didn't have health insurance. It is very hard to get a provider to provide healthcare, mental health, addiction disease, developmental disabilities if they don't get paid for it. Providers just can't provide free care to very many people. And what we've seen is this huge increase in people going into our jails and prison system and sitting in our emergency rooms, that's because we're not putting money into services for people who don't have any insurance. People who have Medicaid coverage and are fortunate enough to have private sector insurance for mental health care are pretty stable and for the most part not revolving in and out of our system. This expansion of Medicaid would cover a lot of those people and I guess one of my main goals in expanding Medicaid is making sure that those people between the ages of 19 and 64 who have mental illness, currently don't have any insurance, would actually have access to care for the first time in a long time. So I'm going to vote against the bill not to move forward with this, I think it's a bad mistake and I know we can do better and I know our state, this is an option that we should be - this should be an option that we accept and embrace and fix, but we should do it. So I'm going to vote no on the bill. [SPEAKER CHANGES] Representative Burke. [SPEAKER CHANGES] Thank you Mr. Chairman. I just will simply ask for the members support. I will not repeat all the points that have been made, very valid points from Representative Dollar, Representative Avila, Representative Fulgum and others as to why this is the right direction for the state of North Carolina. And I would ask with all the unknowns, with all the uncertainty that quite frankly the federal government created this mess and much of the unknown and still today there are as we talked about, Representative Bakersfield, many unknowns, and we shouldn't put our citizens of this state at risk for those unknowns and future general assemblies and I would ask members to support the legislation. [SPEAKER CHANGES] Mr. Chair could we have a show of hands please? [SPEAKER CHANGES] Okay. The chair will entertain a motion. [SPEAKER CHANGES] Mr. Chairman? [SPEAKER CHANGES] Yes Ma'am. [SPEAKER CHANGES] I would appreciate it if whoever makes a motion would re-refer this bill to the insurance committee, it would give us another place, another group of people to discuss it, another time for more information to come in. Everyday we're getting more information from the press about things we didn't understand, and I think that would really be a benefit to us. [SPEAKER CHANGES] I think - thank you Senator or representative. I think that we can refer to the floor and it would be up to the speaker then to put it to another committee if he wishes. Representative Dollar? [SPEAKER CHANGES] I move for a favorable report for the proposed house committee substitute for senate bill 10 and I believe, excuse me senate bill four, 10 comes later. Senate bill four, and I believing the serial referral to appropriations had already been struck. [SPEAKER CHANGES] Right. Unfavorable to the original? [SPEAKER CHANGES] Unfavorable to the original. [SPEAKER CHANGES] Okay. Show of hands has been asked. All those in favor raise your right hand or any hand. Thank you. Those opposed? 16 aye's, 7 no's, the aye's have it and the motion passes and the bill will be reported to the floor. Thank you all for attending, this meeting is adjourned.