Dr. Cohen, local leaders discuss NC health care
Dr. Mandy Cohen makes opening remarks at the fourth meeting of The North Carolina Council on Health Care Coverage.
say something at the outset, and then hopefully Mark can get his audio fix. Go ahead, Mandy. Well, thanks, Tommy. And, uh, welcome. Thio are Zoom World. Uh, you're on you. I can't connect, but I, um first, I just wanted Thio. This is our last official convening of the coverage council. It's been four incredible. Uh, sessions. I'm including today because I know it's gonna be incredible. Um, but I just want to say truly thank you. Think that this council has been one of the most engaged I have participated on, Not just during the meetings, but in between working sessions and trying to come to a place where the open mind to come to some consensus around principles, I think has been really helpful. Andi, I think we've looked at a wide range of types of policies. We're gonna hear mawr today about what other states are doing. Um, and we really tried to keep focused on coverage. Andi thinking about Well, what are the things that we we can see our way forward to? So thank you for that. That deep engagement for particularly those who who don't live in the healthcare space all the time. particularly our business colleagues who are joining, um, those of us in hospital insurance. Uh, doctor, Nurse world. We live in it all the time and thank you as well to all of you. But I'm particularly thankful to to those who are diving into some of these details with us to really try to find our way forward as a state of North Carolina. I know it's been a hard year for everyone with Cove it on top of everything else, but I think that's all the more reason why this this council is so important. So just a thank you. I know the governor is going to join us, um, at at noon to sort of, you know, I'm sure at his own thanks and remarks about where we go from here. But I'm looking forward to a really good discussion further refining those principles and coming out of, uh here with with that, with those principles to get to guide or further work. All right. Thanks. Amy Onda. Secretary Cohen. I think I may be audible now s I'll be very brief is Well, it's been a zany said it's been impressive for us. Toe. See the willingness of people who are really busy with a lot of other things in the pandemic response to take timeto think about how we can work together on making coverage more affordable and available in North Carolina, There have been a lot of good ideas have come up. I think potentially can come together in some very effective steps. We're gonna have another constructive discussion about those today. I'm sure that some further ideas will come out of this to, you know, by by no means is the whole work on making progress on affordable coverage gonna be done today. But it really is, ah, strong foundation that has come out of these past three meetings. We're gonna try and emphasize today the, uh the opportunities for you all toe work together in smaller groups that seem to be very productive. Last time toe refine the principles and to think about combinations of approaches that may work here. And while this is the last meeting of the Council, this is an area where we obviously want to be a supportive as possible. Toe all of your efforts, Thio improve health and health care on the state. So thanks again for joining us today. We're going to turn now, toe going through some of the follow up from the topics that you all raised in our last meeting in terms of other variety of approaches for, uh, improving and expanding coverage on and then going toe break out discussions around the finalization of the principles and some potential further ideas for where to go from here. So thanks again. Looking forward, Toa today's discussions and hey me with I'd like to turn back to you. Okay. Um well, good to see everybody. Um, Mark mentioned what we're going to be doing today, and I wanted to, as always, encourage you to be the active participants that you've been throughout the series of meetings. Um um you know, we always try Thio calling you when we see you. And you are very active in the chat. So, please, you know, raise your questions. Thoughts. That's what this session is really designed to do is really make sure that you will have the opportunity to engage eyes Mark mentioned. Um, we're just gonna take a couple of minutes at the beginning of the meeting. Um, you should have received yesterday a response to some of the questions that were raised in the third meeting. Um, I have to give credit to Elaine, she and who's here with me today from Duke Margolis. She really did incredible job pulling together some responses to those questions that we wouldn't really wanted to have for you. So we're going to just take a couple minutes to review what's in there. I won't go through a lot of detail, but just wanted to make sure you were aware. And if there are any follow ups from that, that we're able to answer that for you either here today or following up afterwards. Um, after that, we're going to hear from a little bit more about Georgia's experience, what they got approved from CMS and where they are in their planning. And so again for that session. Please bring your questions. I think we do want that to be an interactive section, and then we're going to get to what I hopefully is going to be the fun part of the meeting where we get to go into breakouts again. I really thought those those went really well last time and we wanted to repeat them. You will be in the same groups. Um, just because we thought it would make sense to continue conversations. And we hope those can provide a forum for you all toe like to take a look at the guiding principles. We change those, and I'll go through those a little bit before we break out to show you kind of the big changes that we need. Um, based on your feedback in the third meeting and then we go into these briquettes where you can talk about that a little bit more, provide your thoughts, um, considerations as we get to the finalizing of the principles which we hope to do pretty much by the end of this session. And then we'll send out a copy for you all to review next week, and then we will be We will be done with that with that really Herculean task. And again, I just have to thank you for all of the active participation. I really think we came up with a really strong foundations, that of principles. And then after that, we'll talk about next steps. Where do we go from here? I think a number of you brought up last meeting and we'll talk about this today about how the principles, you know, put out, you know, high level foundational ideas. But where does North Carolina really want to go with respect to specific strategy. So we can talk a little bit about that. And you know how the work that we do here in this council, you know, during this last meeting and how that connects been beyond, So that would be a really good time to share, You know, everything that happened in the breakout sessions and talk a little bit about looking forward. And that is Mandy. As Secretary Cohen mentioned, we'll we'll hear from the governor and his thoughts on how this can all fit together and looking into the future. So I think it's gonna be a great um, next About two hours. So keep up the enthusiasm and the energy, and we will keep going. So Okay, next slide, please. All right, so I'm gonna talk a little bit about, So as I mentioned in your emails, you got a response that Elaine pulled together with help from the North Carolina DHHS team. After that really great presentation, we had last meeting on some of the follow up questions. One of the questions that you all had was, you know, what are the differences between small group markets back to coverage requirements, So just wanted to I won't read everything on this slide, but just wanted to share with you. Um, that, you know, the Affordable Care Act did impose different sets of requirements for these different groups for the small groups, which they the they say defines as less than or equal to 50 full time employees. They're guaranteed group coverage. You can have premium set based on geography, ages of enrollees in tobacco use. And then they impose some additional standards where, you know, these plans have to actually cover essential health benefits and benchmark plans. Um, etcetera. I won't read everything on there, but just wanted to be sure. You are aware that that's in in your written response and something that we were just gonna touch on today. The large group market has a slightly different set of requirements. It's, um, you know, 51 employees and greater there. That group is not guaranteed group coverage and premiums are typically set based on past plans. The negotiation they have slightly different standards for, um, media needing to need a minimum essential coverage. So you can't have plans that air just dental or just vision, etcetera. And 85% of premium must be spent on health care services. Okay, next slide, please. Um, wanted to talk a little bit about There was a question around. What's the difference in cost between small and group markets? Um, for out of pocket. And so this is just a snapshot again, I won't read everything on the side. I just wanted to make you aware that, you know, we did include that in the response of the range of costs. And this is specific to North Carolina, based on the agency for healthcare research and quality data. Eso any fall questions there? Let us know. But this is something actually, Julia pulled from the publicly available information. That's that Has the cost projection so great, um, wanted to talk a little bit about association health plans. There was a pretty robust discussion and last meeting about association health plans and and some questions around how those could be structured and what are the different pieces? So I will just spend a little bit more time on this one s o. You know, basically, there are two pathways for association health plans. Pathway one existed before the Affordable Care Act before the rule that was put up by the Bush Trump administration. Um, and it's basically, um, under the a c A. Association health plans have to meet the individual and small market plan rules, which I mentioned in the earlier slide around like including essential health benefits and health premiums are set so they have to meet those requirements. There is a limited exception, um, for association health plans that are covering small employers, like which is less than or equal to 50 employees. But those groups have to be bound by common interests such as common trade, business or profession, and effectively operate as one employer controlling the association. So, you know, there is some some pretty clear definitional pieces that to allow exemption from those otherwise applicable A C requirements. Um, one of the things that we heard about I think it was in the second meeting about association health plans were that, you know, the benefits would include allowing, you know, small employers to band together to purchase insurance leverage, economies of scale to achieve cost savings and customized plans. But one thing just to think about is there also may be a za result higher premiums for older, sicker individuals and groups just because of the way the risk will be allocated. Based on those plans, there is a pathway to that was established through the U. S. Department of Labor. They issued a rule back in 2018 that really expanded the definition of, um, association health plans, in which small groups could be considered a large group and made it a lot more flexible. Frankly, um, to allow folks to come together and constitute ah large group and purchase insurance. But back in March 2019, a federal judge invalidated much of this new rule, saying that it saying that it violated Theresa. And at the moment, it's not currently being implemented in states so and we anticipate that the Biden administration will roll back that rule. So the gist of it is really you know what the future opportunity for association health plans is most likely going to be. Pathway one. Um, we included a reference to Pennsylvania about, you know, they actually added additional standards on top of you know, what was already required with respect to the operation of association health claims that but that pathway would still exists. It's just, you know, frankly, more limited than what was going to be allowed under the 2018 rule the Trump administration put out. I just wanted to clarify that. Okay, next slide. Um, there was a couple of questions around, um, extending Medicaid coverage in for limited populations. And so we really wanted to make sure we share that information with you. And it's again in the written responses that you've got but also wanted to just quickly touch on it now. So this map shows where is covered. Where have state try to extend Medicaid coverage for pregnant women? Last meeting, we talked a little bit about how you know currently under the Medicaid program 60 days, postpartum women lose coverage as you know, as a result of their pregnancy. And that's that's the cases across the country and states. There are several states that have passed legislation to extend postpartum coverage. It's certainly something that's of interest across the country. You'll see here on this map Georgia, Illinois, Indiana, New Jersey and Missouri, Um, have applied for a sectional on 15 demonstration waiver to extend postpartum coverage beyond the 60 days. But the Centers for Medicare and Medicaid Services, or CMS, has not acted on those requests. So those air right now, outstanding and we'll just have to see how the new administration will address those types of requests Now. These include states that have already expanded Medicaid, but they wanted to have AH option for individuals who qualify the pregnant women to have their coverage continue under that category for up to frankly, a year is what most of the mask for. Um, South Carolina is interesting. They had a section 11 15 demonstration approved by CMS, and that approval included 1000 additional snot for coverage where the state can prioritize people who are in need of substance use disorder treatment, and of those 1000 slots of people who need the SUD treatment. That can include women up to 12 months postpartum. So you know it's it's more limited than what these other states are asking for. But there is an option to cover some women if they need substance use disorder treatment. If it fits in those 1000 slots that they're opening up, um California in Texas. Now California, implemented in August 2020 and Texas implemented in September 2020. The big yellows here. These big states, um, they use state only funds to provide 12 months of coverage to a subset of pregnant women. California's extended postpartum coverage is targeted to women diagnosed with the maternal mental health condition, and Texas is limited. Coverage. Extension is for women eligible for the family planning program. So they decided we're going to go ahead and use state funds to provide these limited expansions of coverage for these targeted populations. And then you could see the rest of the blue. Um, there's, you know, an additional 50 states that have related legislation pending so definitely an area of interest. It will be interesting to see how we move along with the new administration and where the opportunities are for state from that. Okay, next slide, please. Um, there was a question about because we talked a little bit about extending Medicaid coverage for parents of Children in foster care. So, you know parents who may be currently eligible for the Medicaid program and then lose their eligibility because their Children go to foster care. Um, you know, we actually did not identify any state that had targeted expansion just for this group. It's pretty small numbers. Um, if if you know, North Carolina was interested in tackling just that group, that would likely require a sexual love between demonstration. But looking across the states generally, states have just included expansion of coverage as a as a broader Medicaid expansion and have included those those folks in those broader, you know, full Medicaid expansion. There's one to clarify that point. Um, okay, Wanted to talk a little bit about extending Medicaid coverage for individuals with substance use disorder. So there there are two states that we identified. The pursuit targeted expansions just for that piece of the pie. Um, Virginia had what's called a gap program before they fully expanded Medicaid. They got approval from CMS to offer a limited physical and behavioral health benefit to uninsured adults with serious mental illness who had incomes up to 100% of f pl eso. This again was before they made the decision to fully expand Medicaid, they took a targeted approach where they just expanded coverage to the smaller subset of individuals. Utah. Sort of the same theory. They again before they fully expanded Medicaid, they got approval to cover a cap number of childless adults up to 5% of the federal poverty level who are chronically homeless, involved in the criminal justice system and in need of behavior. Health treatment. So, again, a small number of individuals, um, really focused. Frankly, they had a lot of homeless, um, in Salt Lake City, and they really wanted to target that population. And so this this piece was really targeted to those folks. Um, since then, they have fully expanded in. Those individuals are covered under their full expansion. Um, another piece we just wanted to highlight for you. There is an option not to get too technical, but there's a section 1915 i state plan authority to expand Medicaid eligibility to targeted groups of individuals who are at risk of institutional level of here up to 100% of the federal poverty level. And who would be eligible under the existing home and community based services waiver. So there is an option to expand eligibility. Just with that, with that limited piece. Okay, great. Alright, next slide. Um expanding coverage of 200% of the federal poverty levels, so wanted to just provide a couple of examples of states that have done this again. They haven't policeman and Medicaid, up to 138% of the federal poverty level, which is, you know, what needs to qualify for enhanced match as a As of now, we'll see if there's any changes in that. But that doesn't now. Um, Wisconsin, Georgia in Utah. We're all states that pursue limited expansions, and we're going to hear a little bit more about Georgia, so I won't say much about that now. But Wisconsin back in 2014, they got approval to expand their Medicaid program up Thio 100% for individuals, up 200% of the federal poverty level with the remaining folks than being ableto go to the exchanges and qualify for subsidies on the exchanges. That program is financed at their regular match. They don't qualify for enhanced match, but it is still currently in effect and that is how they're providing coverage for that population. Utah's I mentioned earlier they also received approval from CMS to cover people up to 100% of the federal poverty level and not go up 238%. They wanted enhanced match. They didn't get enhanced match. They got regular match for those people. But the since then because there was a ballot initiative in their state, they went ahead and did full Medicaid expansion for that entire population. Okay, so I want to next move so we can hear a little more about Georgia. But before I do that, does anyone have any follow up questions on any of that? I just want to make sure people had a moment. So to raise their hands if they had anything. Okay, I'm not seeing anyone coming up from you, so feel free to speak if I don't see you. Okay. All right. And if anyone has followed questions after this, you know where to reach us. Um, you can always email, and we're happy to respond to anything. Um, if you want more information or clarification, please just follow up with us, and we're happy to provide that to you. Okay. Um, I want to go ahead and introduce now Dr Kenneth Thorpe. He's a professor and chair of health policy and management at Emory University. And he's going to talk a little bit more about what's happening in Georgia. The doctor. Thorpe, if I could turn it to you now. Yeah, I think you're on mute. Yes. No, no, thank you. It's a pleasure to be with you, Secretary Colin and and Mark, Great to see again is always, uh, congratulations to all of you for pulling this council together, obviously, on a very, very important topic. Um, I'm going to talk a little bit about what Georgia has done, but as you deliberate and think about options, um, with the new administration coming in, uh, Biden administration will have a big focus on expanding health care coverage through a variety of mechanisms, both through insurance and through non insurance mechanisms. Aziz Well, Thio to provide health care coverage. But, um, why don't I go through what? What Georgia did, And let's just skip through to the to the third slide your lien maybe back up one? I think so. Just to give you some context of where this discussion came from, uh, really started in 2015 in 2016 under governor deal and the genesis of it really was from the hospital's, uh, as you can imagine, Georgia has Atlanta and some other large cities, but most of the hospitals are in rural areas. On their primary source of revenue is Medicare, Medicaid and uninsured. On Daz, the economy was kind of stumbling around. The amount of uncompensated care facing these small hospitals was growing and there was increasing interest in finding ways to increase Medicaid coverage, uh, to financially help these rural hospitals out so that they didn't go under. Um, in these communities, these hospitals were the major employer, for the most part on dso finding ways to expand coverage started to get some traction. The challenge was is that in the 2014, 15 16 time period, uh, this is basically when the tea party was still very, very powerful There a lot of fiscal concerns over the cost of expanding Medicaid. Um, the governor made a decision to basically throw the decision making power power to the House and Senate. Eso that, uh, it wasn't gonna be totally a governor's decision. They did some estimates of what a full expansion of Medicaid would cost. E think the numbers were a ah little bit high, but they came up with $2.5 billion over 10 years. So on the state side, so facing those those numbers to state decided to take a step back and really not pursue it. At the time Governor Kemp came in Esso in 2019, um, he again brought Medicaid expansion on the table again. There was this tension between the costs of the program for a full expansion. There's also some concerns that legislators had about the design and the effectiveness of Georgia's existing Medicaid program. So ah, lot of people are kind of opposed to what they thought was expanding a program that had many flaws in it. But the compromise view was to find ways to expand coverage, but only to 100% of the poverty line. So next one. So the General Assembly came out with a piece of legislation that prompted the state to move towards a 11 15 waiver. Like Utah, the original proposal was to expand to 100% of poverty, but they're asking for the enhanced 90% match. CMS just recently approved it in October, a modified version of this, but again it's up to 100% of poverty at a lower match. It has not yet started. It doesn't start until July. Um, for a variety of reasons, I'll talk about the minute. It's only estimated in the third or fourth year to cover about 52,000 uninsured. Um, the the proposal had a couple of things in it that were necessary in order to develop a consensus between Republicans and Democrats. One was a work requirement. Um, currently, there are no states that have an active work requirement. There have been other states that have passed it, but they have all been blocked by court rulings that are still pending in Kentucky, Arkansas in New Hampshire. Next. So what the waiver did was expand coverage. Does I mentioned 100% of poverty? Uh, the work requirements You have to demonstrate that you're working engaged in other activities, such as community service, a job training for at least 80 hours per month. Secondly, if you have access to employer coverage, uh, that you had to enroll in it and the state would provide assistance to help you pay your share of the premium and cost sharing. So obviously this is a major departure from other 11 15 waivers that have been passed, Um, by only covering uh individuals up to 100% rather than 138% and also having the work requirements. Um, you'll see in a minute. There's also ah, provision in there that provides essentially sort of ah health savings account type approach to this is well to provide incentives to individuals enrolled in the program to stay healthy on, uh, pursue and stay healthy, cut smoking rates and so on. Yeah, next. So that the estimates are that this a probe. Excuse me. This project cost about 375 year, about $1600 per newly enrolled adult. There are premiums that people pay eso if you're under 50% of poverty, there are no premiums. If you're 50 to 84% there's a $7 per month premium per person in a $3 tobacco surcharge that goes up to $11 per month from 85 to 100% of poverty. Again with the same tobacco surcharge next, there is cost sharing associated with it, so you can see it's it's it's quite quite modest. Uh, I think the good news in this is that there's no cost sharing for primary care. That's gonna be an area of tremendous focus in the bite administration and providing universal primary care services. So Theo idea here is that we want to encourage individuals to seek primary care on, not discouraged them from seeking primary care through having a having cautionary next. The waiver also created what's called this member rewards account. It almost sounds like a something that Hilton or Marriott would put together, Um, but what it is, basically, is the premiums of people pay go into their account on. You can earn additional dollars by completing annual well care visits, complying with diabetes programs. Things like the diabetes Prevention program maintaining ah, body mass index Under 30 which is 30 and above, is considered obese on if you meet those markers. That additional dollars or put into your account on the idea is that those additional dollars then can offset the premiums that people are paying in. They can use the account once it the balance his $100 in its captive 500. So the structure of this was not just and again. This was the compromise. In order to get this passed, the structure was not just to expand coverage, but also to include incentives, toe work and include incentives for healthy behavior. In here, using this member rewards account the next, uh, the benefits are basically the traditional Medicaid benefits that Georgia provides. Uh, the only exception that they put in was for non emergency medical transportation. So what happens next? Obviously, this was an unusual 11 15 waiver that was negotiated between the Republican governor in Georgia and the Trump Administration. Uh, there's a lot of interesting things that went on in the negotiations behind the scene, but it's not clear exactly what's gonna happen going forward to this particular waiver. Um, part of it is that there's the health care team at HHS has not really been put together. There's no CMS administrator as of yet. Uh, you know, the focus really in the bio administration right now is vaccines, vaccines, vaccines as it should be, um, so not clear about what the future is. What I can say is that the health care agenda that he's putting forward, um, is going to focus on tools that would enhance the ability to get coverage through the current ACA rules. Increasing the premium subsidies to purchase coverage. Um, providing a universal primary care package, which is not an insurance based approach but really would cover 70 to 80% of the types of health care services that people need. And a focus on digital therapeutics. That is proven wellness programs that are really inexpensive but really help patients with multiple chronic conditions manage their diseases. So there's gonna be a mix of insurance and non insurance approaches that they will be putting forward. So that is a really brief overview. Did not want to take a whole lot of time, but I'd be happy to answer any questions you may have. Thank you. Thank you so much. Um, wanted to open it up to members of the council to ask any questions you might have. I'm not having some questions. Hey, this is today. Good morning. Um, you know, the comment about uncompensated care was intrigue A because I think that's I don't know, that we've been able to tag, you know, to what degree um, most of the programs would reduce on uncompensated care. I mean, we know it will. I think in North Carolina we have the last numbers I saw was like a $1.3 billion being spent annually on uncompensated care. And if a third of our uninsured here in the state less than 138% of the Fbl, I think that's the number. Um, do we just based on the modeling that was done in Georgia, do they have a sense off by how much or to what degree Uncompensated care would be reduced even with a limited expansion, not even to talk about, ah, full Medicaid expansion? Well, my sense it's a good question. Um, you know, obviously, other states have approached this by doing expansions, but also been having an uncompensated care pool that funds hospitals in order to pay for uncompensated care. Perhaps the New York state historically was probably the best known of that, uh, in terms of how they virtually eliminated uncompensated care in the state. But my sense is in Georgia, if you look at the total amount of uncompensated care, is probably going to reduce about 10 to 20% of it, and it's only because the enrollment numbers our only picking up probably about 10% of the potential now visual uninsured under 138% of poverty. So the work of requirements, uh in particular is something that, in terms that they're modeling, came up with lower enrollment numbers. Then if you have, if you have no requirements, that is, if you just expanded coverage to everybody under 100% of poverty, no requirements at all, so it will make a difference in terms of uncompensated care. But again, I think e talked about there are other approaches that you could couple this with that could have a dramatic impact on health outcomes and uncompensated care in the state. I mentioned just briefly this primary care package that the administration is gonna put forward that would provide a universal primary care targeting people who don't have insurance, and these digital digital therapeutic programs that work through health coaching again and non insurance approach, but proven to be very effective in reducing costs. Uh, Onda generating better outcomes. So I think there's a package of things that you could look at insurance expansions in these other non insurance approaches that could be very effective. Uh huh. Okay, representative Adcock had a question about what was the cost to Georgia of the administration of H s, A type account for those covered up to 100% of F p l. You mentioned a third party administered it. Yeah, so I have not seen that the change. So they made a decision to not use, you know, try to use brokers to provide insurance rather than doing pool through the exchanges. No way, no, the the cost of using brokers is higher. Then sort of a, you know, a pooled approach to this. Um, you know, again, it's a trade off that there are people who want to use their own insurance brokers, uh, on DSO on to get coverage. On the other hand, it probably adds anywhere from 5 to 10% additional costs in terms of administrating, administrating the program boats, right? Other questions. This is representative Cunningham. I wanted him Thio elaborate a little bit on the work requirement data, how they were able to capture the data and the administration costs of capturing that data from the work from people that work well, it's it's got to be self. It's self reported, uh, and so, uh, and that the individuals don't report it thin. They have a time period, a grace period, so to speak, to get the data in. But if they don't report it and provide documentation of it, then, um, over a period of time, they would not be eligible for the benefits. Yes, so it's really itself. It's really documented by the individuals. And so the follow up was the administration caused to the state of Georgia for, you know, even setting up a system for them to document it well, again, we don't It's not clear yet because it doesn't start until July. So they're just kind of doing the planning right now to pull it together. Um, but we'll know more in a couple of months, right trip. And then there's a question that I think this is Senator Robinson. I wanted to know, and I may have missed this. I know Georgia is very rule and their rural hospitals that have taken care of people some you mentioned, uh, you know, suffer well. I may be on the wrong slide, the closure, but what has been the anticipated impact, even though it hasn't begun but in terms of looking at this model. What did you anticipate being the impact on those rural hospitals that suffered mostly from the uninsured populations and lack of revenue? Yeah, well, I think e think the view is that they would rather have had a full expansion, the 1 38 with no requirements, because that's going to generate the most new revenue for them. On the other hand, I think that that they're all appreciative of any efforts to expand coverage, even though it's only about 50,000 statewide in the second or third year. Um, because most of these hospitals that exactly right that air in small rural communities, you know their revenue streams are Medicare, which barely if at all covers costs the existing Medicaid program, which probably pays a little bit below cost of treating and uninsured patients, obviously, which pays virtually nothing. So even if you could get some of those uninsured patients up to Medicaid payment rates, that's a that's a win financially eso Well, I'm sure they'll keep working to push, to find ways to continue to expand coverage, either through using insurance or some of these other methods. I talked about these non insurance approaches in order to get revenue flowing into the system, but not as much as they wanted. It was a big compromise, but better than what they had. Okay, right? And there's a follow question, and this may be more directed. Thio North Carolina DHS But there is a question of how Maney North Carolina uninsured would be covered with if if there was a coverage up to 100% of the federal poverty level. Georgia seemed Thio, I think, Dr Thorpe, you said 52,000 for Georgia. But I think they're wondering, What about North Carolina? This is really if you know that Miami this is Julia at North Carolina Medicaid. So what we shared in the last meeting is we're projecting over 300,000 individuals would be covered by the third year if we expanded up to 100% of em. Pl hey, yeah, that's really not that that really not a whole lot different from what would have been covered in Georgia again. Those of those a year three numbers that I was talking about again, they just knocked them down a little bit because of the work. In order to be eligible you had to meet the work requirements. So if there were no requirements and just a pure expansion 100,000 or 100% of the federal poverty line, um, the numbers would have been in the two or 300,000 range. This is representative Adcock again. I just cannot type fast enough. You know, I'm gonna get out of the chat, ask my next question. So, um, if North Carolina has 300,000 of our total uninsured population, that would be covered by extending Medicaid to those who make less than 100% of federally the federal poverty level, what's the cost to the state, though? If the match is 67% versus 90 that's my question, because, I mean, that's that's where you really kind of you. That's a big question to me. So what we What we shared was that that would be about $900 million by the third year to cover those 300,000. That's that's the non federal share. Thank you. Sure. Hey, Julia, this real quick, though. It's 900,000 up to 100 but it's actually less. If we go to 138. I think it was, like 500 million or something because of the 90% federal shame match. So I think that zone important point you make the point. I didn't finish. And I appreciate that. Is that we cover. I mean, 300,000 people. That's not a small number. But when you look at the cost toe ad 300,000, you cover 300,000 people versus the cost of trying to get everybody. It's actually less to get everybody because we have a 90% match instead of a 67% match. Am I missing something? No. That's just what I want to just clarify. Thank you. And to add to that, that number actually doubles. Julie. If I remember, it goes to 600,000. Interestingly enough that we would cover up to 138. Right? We get a bigger we get more juice for the squeeze. Exactly. Oh, okay. Other questions on this just real quick. I don't think any state, though, has actually been able to move forward with work requirements. I mean, Arkansas and I mean, they all tried. Uh, yeah, Arkansas. I think Indiana and Kentucky, if I recall. Right, But just I mean, they're lawsuits. I think right there are all over the place. They're all pending lawsuits, so we'll have to see what happens here in Georgia, right? Yeah, percent of Cunningham. I got one last question on the demographics of that 52,000. Are you? I'm sure you all are able to track it through your system. Is what does the that population look like for that? 52,000 people that special carve out there. Are we looking at that is, in the rule space off Georgia, where that 52,000 additional people would be picked up. Well, im I don't know that they've done a sort of geographic estimates of it. My sense is that probably the bulk of it is going to come out of Atlanta, Columbus in Savannah in terms of where they are. Certainly there's gonna be uninsured affected in some of the more rural communities. But that's for the bulk of the sort of working on insured list. Well, okay. Well, thank you, Dr Thorpe. That was a great, um, quick overview. You did a lot in just a short amount of time. Appreciate you coming to the to the council meeting? Well, thanks. Thanks for having me on. And, uh, I wish you the best with your deliberations Do great things there. And again. Congrats for really focusing on this really important set of issues. Thanks, Ken. All right, great. Okay, um, we're now going to move to the next part of our meeting where we're gonna go into the breakup before we go into the break out. I just wanted to talk a little bit about, um, the revised guiding principles. Um, you all got a copy earlier this week of those principles and wanted to just go over very briefly. The changes that we made as a result of the feedback that we got, um, a couple of things we need, Some added some introductory language reflect the purpose of the principles, um, that they should be used as a guide to the development of more specific ideas for how to improve health care coverage in North Carolina. We combined, um, the first two principles to highlight that as health care coverages maximize, it needs to be affordable. That was a comment that we got throughout the discussions in the last meeting. Um, we added two principles. One on ensuring that coverage options air simple to navigate for consumers and providers and another centering, um, around the overall goal of improving the health of North Carolinians. So by, um, on this set of principles health system, sustainability, efficient use of taxpayer dollars and strength in real communities, there's some small word changes, but nothing very significant. So we look fairly similar to what you all saw in the last meeting and then the next, um, group of principles around reducing disparities, expanding access to in coverage of behavior, health services and supporting the business community. We added some background information on behavior, health parity in the footnotes, but really largely these also remain the same as what you all saw last week. And then finally, Theoden all considerations for access. So we added to this list and became more specific, um, involved to request of a number of you talking about lowering the cost of care, strengthening telehealth, infrastructure, workforce development, access to primary care and social determinants of health. So those are some of the additions that we have in this list here. Okay, great. So, um, what? We're going to do next. I actually did want to just asked if if folks can write, make sure their full name is being displayed, um, in their zoom, um, picture because we are going to go to break out sessions. We wanna make sure the right people get to the right places. I think most of you actually have that. But if if you have some, If you don't have your name there, please just add that. So we're not gonna go? We're gonna be automatically sent to our breakout rooms. That will be the same breakout rooms as we had last time. We hear two. Margolis will be the neutral note takers, as we were last time around. And we will keep time and keep everyone going. Um, this will be about 40 minutes or so. Um, is that right? Still, Elaine, we're still on track for that. Okay, um, one member of the group will be asked to report out when we come back together, like we did last time. And really, we wanted to give you just the space to talk in a little bit more detail about the principles as we move towards finalizing them. Are there any other ideas or thoughts that you want to have attitude them wanted to be sure to give you space to do that. We also wanted Thio give you space to talk about, like, How can these translate into specific strategies? So all of that may not be reflected in the written document, but we know some of you want to talk to you. No more specifics on behavior, health and telehealth, and what are some real ideas that can move some of the concepts in the principles forward? Um, there's also, I think, things that you all want to talk about around association health plans or tax credits or other ideas to support businesses targeted, limited Medicaid expansions, licensure and scope of practice changes. So so these breakout sessions, you know, don't feel like you have to stick to what's on the page. This can also be a place to talk about additional ideas, even if they don't got get all reflecting the document itself. We will have a meeting summary where we're going, Thio summarize all of the different conversations happening in these breakout groups. So to the extent that you know, there's lots of other good ideas on Tallahassee and behaviors that emerge from this. We can definitely capture that in the meeting summary, which we will send up to all of you and also made public on our website. Um, the other thing I just wanted to mention we will be recording the small group conversations. Um, just, you know, as we have been doing for the larger group when we're all together, So we will continue to do that, and those will be available, um, for the public after we conclude our sessions. Um, the last thing I will just say here, um, is just to keep in mind as we think about how to move forward. You know, I think there's been a lot of interest on, you know, thinking about different pieces that can can really impact lots of different parts of the population and how to help different aspects of our health care system. So really want to encourage you all to have a very frank discussion about all of that in your breakout groups? Um, you know, again, as I said at the outset, I really feel like this is the beginning of the conversation of, you know, going into 2021. And what could be really helpful and useful for North Carolina? So want what you have to feel like You could use that time to be very frank and open and and have a really good this discussion. Any questions before we break into the groups? Amy, are you going to display those principles thus far for each group is we're discussing. Yes, we will. So you don't have to memorize thumb. Yes, we will have them fund the country. No worries. Yeah. Anything else before we move into our groups? That was a good question. Okay. All right. So we'll be back here together. Um, about 11. 30. So All right. You will shortly. Thank you.