 Hello, everybody, and welcome. I'm Susan Collins, the Joan and Sanford Wildean here at the Gerald R. Ford School of Public Policy. And I'm delighted that you could join us for what I'm sure you agree is a very important conversation about the Healthy Michigan Plan that is now one year old. Today's program would not have been possible without general support from the Gilbert S. Omen and Martha A. Darling Health Policy Fund. And so we very much appreciate that support. In a moment, Dr. Matt Davis will introduce today's panel more formally. But before we begin, I wanted to say just a few words about Matt. Well, in addition to teaching appointments at the University of Michigan's health system and also here at the Ford School, in fact, he just came straight from teaching a class here at the Ford School. Matt serves as the chief medical executive for the State of Michigan. In this role, Matt provides the Michigan Department of Community Health with professional medical expertise on public health issues and development for related policy. That really is a critical public service role and that perspective is particularly valuable for the citizens of Michigan and also for the conversation that we will have here this afternoon. And today's event really is his brainchild. And so I just wanted to really express my gratitude and appreciation for putting together a phenomenal group to talk about this important set of issues. So thank you. But I have a couple of other things I wanted to say. Today's panel includes representatives from multiple perspectives and I will just list them. They will be introduced in just a few moments. And so please don't applaud right now, although of course they're all very worthy of applause. So first we have Ken Sikama, who is a Michigan alum and senior policy fellow at the Public Center for Sector of Consultants. He is a former long-term member of the Michigan Congress. Next to him we have Rob Fowler, who was president and CEO of the Small Business Association of Michigan. Then we have Erin Knott, who is Michigan State Director for Enroll America. Next to her we have Laura Aka, another Michigan alumna who is senior vice president for strategic initiatives at the Michigan Health and Hospital Association. And then we have him Sibilski, who also studied the University of Michigan and is the CEO of the Michigan Primary Care Association. Last but not least, here who will be joining us shortly, we have Dr. John Ayanian, who will moderate this very impressive panel. John is director of the University's Institute for Health Policy and Innovation, as well as a faculty member both in medical school and here at the Ford School. So please join me first in a warm welcome to all of our discussions. Just a very brief word about today's format before we begin. First, Matt Davis will provide us with an update about the one-year Healthy Michigan plan. And then next, Dr. John Ayanian will introduce our panelists and have some individual opening remarks and then moderate a discussion. We'll save about half an hour for questions from the audience and I do encourage you to share your questions with us. If you have a question, please write it on a card. You should have received cards when you entered the room. And Ford School volunteers will be circulating around 440 and they will continue to do so to gather the cards. If you are watching online, please tweet your questions to us using the hashtag policy talks. Our Masters of Public Policy students, Megan Foster-Friedman and Ruth McDonald will read the questions later. And so I welcome them here as well. With no further ado, Matt, the floor is yours. Again, welcome. Thank you, Susan and good afternoon, everyone. Good afternoon to those of you here in the room and to those of you watching on the web. I'm particularly grateful to all of you who have dedicated the time this afternoon and to the members of our panel to talk about a very celebrated birthday. I won't have us all sing happy birthday, but reaching one year of age in many cultures around the world is a reason for a lot of celebration. We're here to ask today about the Healthy Michigan Plan as it reaches its first birthday and what that means for the health, healthcare and health policy in our state. I have the privilege of providing some background remarks today so that we're all on the same page with regard to what the Healthy Michigan Plan means and where it currently stands. Before I go any farther, I want to acknowledge something that Dean Collins just mentioned, which is that I have a couple of different roles. I'm a faculty member here at the university, which is the primary role I have today behind the microphone. I also serve as the chief medical executive for the state of Michigan, and any remarks that I make today should not be interpreted as the official stance of the Department of Community Health or of Governor Snyder. If I am asked to respond to a question as a member of the Department of Community Health, I will officially make a gesture like this, putting on a hat of that role, but otherwise I'm speaking as a faculty member here today. To understand where we are, we need to understand a bit where we've been. So let me take us back 50 years to when Medicaid was born, and we have here President Johnson signing Title XIX of the Social Security Act with Lady Bird Johnson to his right and to his left, former President Harry Truman and Best Trude. That was a milestone that today we almost take for granted in our system that Medicaid is a foundational bedrock of the government role in our healthcare system. But as a foundational bedrock, we have continued to have subsequent policies that have tried to do different things with Medicaid. And so five years ago, the Patient Protection and Affordable Care Act was born, and when President Obama signed the ACA, there was perhaps first and foremost, but certainly among the major goals, expansion of Medicaid. You see him surrounded in a very different signing ceremony, not by previous presidents and spouses, but by the Democratic leadership, which indicated the polemic nature of political support at the time this act was signed. Three years ago, so it went from 50 years ago to five years ago to three years ago, the Supreme Court upheld the ACA in one decision, but in a partner decision just a few minutes later, permitted states to choose whether to expand Medicaid, and there began a cleaving of the support for Medicaid across different states and by state boundaries. And so states, when given the permission to differ, as they tend to, did differ. And we have here on the left the 2012 presidential election map separated out in the usual blue and red distribution, and then on the right, the current status of state Medicaid expansion decisions. You don't have to be an artist to recognize the similarities here, and that is a common story we have about Medicaid expansion under the Affordable Care Act, that it has strongly followed political lines in terms of the leadership at the state level and the governor's mansion and the state legislatures. In February 2013, so less than two years, or about two years ago, Governor Sider announced his support for Medicaid expansion in Michigan at the time, saying that Medicaid expansion was a way to improve health and save money in our state, to provide greater access to care and lower business costs among beneficiaries. These are the themes that you'll hear from our panelists today. Has the Elven Michigan plan delivered all those promises? And what have we seen as expansion of Medicaid has occurred in our state? You'll notice I circled here in the first paragraph that the estimate of benefit was to about 320,000 residents in the first year. Keep that number in mind. Just a few months later, May 2013, represented as Lori Picholka were the first to sponsor House Bill 4714, which later became the Healthy Michigan Act. This was clearly a connection to Title 19, which I circled here on your slide, Title 19 of Social Security Act, which had been the original Medicaid program. But there was a definite effort to not talk so much about Medicaid expansion, but rather fashion a different approach to expansion in Michigan, something that was gonna lead to a healthier population. Let's talk a bit now about the navigation and negotiations that occurred during the summer of 2013 to take the bill 4714 and help it become a public act a few months later. The advantages that were put forth were to cover uninsured Michiganders, to reduce uncompensated care, meaning the care that providers would provide and would not have been paid for by uninsured individuals, to control healthcare costs, which Michigan is no different, have been rising in the private markets and the public markets, and to have our managed care plans, which have been a big part of the Medicare story in our state, a big positive part, help be part of the Healthy Michigan Plan by having all enrollees in the Healthy Michigan Plan be enrolled in managed care plans. They perceived disadvantages by opponents of the Healthy Michigan Act were that this was really unnecessary government spending. It wasn't a wider way to spend otherwise scarce dollars, and the worries were expressed that the federal government through the Affordable Care Act might not sustain this enhanced match, meaning the federal government is gonna cover the full cost of the program for the first three years and a slightly decreased amount of the latter two, but that may not actually be how it plays out. That will leave Michigan vulnerable in terms of its overall budget and a plan that perhaps wasn't prepared to pay for. This combination of advantages and disadvantages led to some focused compromises. The first was cost sharing by beneficiaries, because if you're trying to create a less vulnerable program, you need to have the beneficiaries with more role in that program to pay for its costs. This cost sharing, however, is unusual for Medicaid and therefore required two different waivers. Waiver one was for people over 100% of the federal poverty level up to the limit of 133% to share up to 5% of their income on the order of a few hundred dollars per year. And then waiver two, which is currently in preparation is for individuals with over 100% of a federal poverty level income to share up to 7% of their income after being in the program for 48 months. There was also emphasis on healthy behaviors, trying to focus on the fact that individuals in Michigan, and we know this from population health measures, tend to be less healthy than in some other states when you try to reduce our levels of obesity, reduce our levels of tobacco use, et cetera. There was an idea to implement health risk appraisals to encourage a conversation between patients and their physicians about how to try to improve their behaviors overall. The legislature asked that opportunity health to set up something new called a my health account for individuals in the healthy Michigan plan to help them understand how dollars from the state government and federal government were being spent on their behalf in the healthcare system. And finally, there were specific triggers for program termination written into the act that said if this happens or if this does not happen, then that will be the end of the healthy Michigan plan. With those compromises, on September 16, 2013, Governor Snyder signed the Healthy Michigan Act here in yet another signing ceremony. And with only one person in common between the signing ceremony of the ACA and the signing ceremony of the Healthy Michigan Plan, that being Representative Dingles, Chairman Dingles. Who, although last time I checked, wasn't directly responsible for state policy, we all know. He is out there. That leaves us then on April 21st, 2014, to the Healthy Michigan Program launching. And on April 1st, 2015, a Healthy Michigan Program that is providing coverage not to 320,000 individuals, not to 400,000 individuals, or even 500,000 individuals, but more than 570,000 Michiganders, ages 19 to 64. Far more enrollees than were anticipated, even over a five-year rollout of the program. You can see here the different age groups that are involved and their different composition of the overall Healthy Michigan Beneficiary Group. So when you have a program that was passed through a contentious debate leading to some focus compromises, and then it's subscribed to by over 50% more individuals than were expected, what do we have then in terms of questions going forward? That's what we have the pleasure of hearing about from our panelists today. Our distinguished panelists, and for that discussion, which I'm looking forward to, I hope as much as you are, I turn to John, I'm trying to hand in to give us some more formal introductions, thank you. So I'd like to join Dean Collins and Dr. Davis in welcoming our panel and all of you to our session today and look forward to a lively discussion, as Dean Collins mentioned. Each of our panelists moving from your left to right will have an opportunity to speak for about five minutes, sharing their opening perspective on where we stand at the one-year anniversary of the Healthy Michigan Plan. And then we will open it up for questions from the audience for about 40 minutes. And as mentioned, those questions can be passed down to our students here in the front and then presented to the panel for their input. So with no further ado, I'd like to introduce our first speaker, which is Mr. Ten Sikoma, a senior policy fellow at public sector consultants, where he focuses on public finance, environment, and energy policy. And prior to joining the firm, he served in the Michigan House of Representatives for six terms and in the Michigan Senate for two terms. And in the House, he served as the Republican leader from 1997 to 98. And in the Senate, he served as the majority leader from 2002 through 2006. Mr. Sikoma. Thank you very much. Thank you. And thanks for the Ford School for hosting this. Thanks for the invitation. I'm going to make three just very quick observations first about what I think this achievement is, fairly, a very remarkable achievement in terms of the politics, why it happened from my point of view and then a note about the future. But I think I want to start with a caveat. Unlike a lot of people that are actually on this panel, I wasn't involved in the day-to-day trench warfare of getting this passed. I watched it and observed it close up at times. But because of that, there's a plus and a minus to that. I might actually get something wrong about what actually happened. And I would urge my fellow panelists to correct me if I do now. It would be our pleasure. Well, and I was just going to say that I've worked with a couple of these people in the past and they've never needed encouragement from me to correct me. So, but with that disclaimer, let me just make three observations. From a political perspective, this should not have happened. I don't mean it's a bad idea. I'm just saying, given the very bitter and really visceral politics of the Affordable Care Act, from the beginning, I'm glad that Matt had these slides about President Johnson signing Medicaid in 1965 and President Obama signing the Affordable Care Act in 2010. The Affordable Care Act passed with no single Republican vote. No, zero. Medicaid in 1965, almost half of the Republicans serving in the U.S. Senate and the Congress voted for both Medicaid and Medicare. So from the beginning, the politics of the Affordable Care Act have been very bitter and they've just gotten worse since. Really, if there's any kind of hint of association with the Affordable Care Act on a Republican side, it's almost like you're Republican and your conservative credentials are being questioned. So from that point of view, the fact that any red state, and I think there's 10, maybe 10 of them, that have Republican governors have expanded Medicaid, but from that standpoint, the fact that any red state expanded Medicaid because it's connected to the Affordable Care Act, that's a remarkable political achievement. So that's my first comment. My second comment is, well, okay, why did this happen? And first of all, I think some people that are on this panel and others have to take credit for the work they did in getting it passed, but I really don't think that's kind of what got Medicaid expansion over the top here in Michigan. I would say and suggest that it goes back to a very specific event where the Speaker of the House, Jace Bolger, asked then-Representative Mike Scherke a very ideologically conservative, almost Tea Party legislator in the House to take a look at this issue and render his opinion as to whether it ought to pass or not. And it was Mike Scherke, and sort of what I would call some like-minded, very conservative legislators that said, you know, this really does make sense for Michigan, and we ought to pass this. And I think if it worked for that, the embracement of this expansion by Mike Scherke, who's now in the State Senate and chairs of the Health Committee on the State Senate, I don't think it would have passed. Now, you know, can't prove a negative, but maybe it would have, maybe it wouldn't. But he gave it the conservative credential it needed here in Michigan. Now, if he were sitting here, as opposed to me, and you asked him, why'd you do it? You know, why did you come to this conclusion? I think he would say the following. First of all, he would probably start by saying, from his standpoint, it was a lesser of two evils. Not wild about the Affordable Care Act, but from his standpoint, kind of three things stood out. One is sort of, it's like the stages of grief. He accepted the fact that the Affordable Care Act wasn't going to mysteriously and magically disappear. And I think that's, he made a departure from his conservative colleagues in that sense. He sort of accepted the fact it was here to stay, at least in the near term. Secondly, from a conservative fiscal standpoint, it just kind of made sense. I mean, the federal government's gonna pick up 100% of the cost for the first few years, and then promises to pick up 90% after that. And so from his standpoint, and sort of a conservative political standpoint, fiscal standpoint, it doesn't make sense for Michigan to forego those dollars. I mean, we're sending our tax dollars to Washington. There's probably taxes associated with the Affordable Care Act. Some people claim it's two billion coming out of Michigan. I don't know if that's right or not. But from his standpoint is, if we're sending that money to Washington, why should it just go to other states? Why not recoup some of that? So the stages of grief, acceptance, fiscal argument, it made sense. But finally, and this is, I think, the clincher, is Republican legislators in Michigan looked upon this as a chance to reform Medicaid. That's how they saw this. And so they basically took the approach of, we're gonna do this on our terms. We're not gonna just accept the traditional Medicaid program. We're gonna create an alternative. So they put in provisions that emphasized individual personal responsibility and ownership of this, the copays, the premiums, and the health savings account approach. So that was a big piece of this. Kind of personal ownership, personal responsibility, which required federal waiver, which was granted. The second big piece is they insisted that this not be a lifetime program. They didn't want this to be another lifetime entitlement. And so Michigan has a 48 month limit and after which various provisions kick in and the federal government has not yet approved that waiver or that approach or that provision. And I think you'll hear from others that on the panel that that's a pretty iffy proposition as to whether they'll approve it or not. And then finally, I think they looked at it from almost being able to create a Michigan specific program, reforming Medicaid. They also wanted to look at it from a taxpayer standpoint. And what's the return on investment if we do this? And there are various studies that are gonna be happened and done, that are gonna be done over time. There's gonna be a big study that comes out in September, I think of this year about, is this really working? What changes maybe Michigan, what changes ought to take place to make this work for Michigan and make sense from a taxpayer standpoint? Now, there were other arguments, but I wanna kind of bring my comments to a close. The future, well, you got the second federal waiver that's kind of sitting out there that if Michigan doesn't get, according to the statute that expanded Medicaid, the program stops within 90 days. I think that's an example of sort of the larger issue that is gonna play out over time, and that is how much flexibility is a specific state like Michigan gonna have to craft the program they think will work over time? I think that's gonna be one of the factors that people ought to watch, even beyond the second federal waiver, because from a Republican standpoint, one of the sore parts about Medicaid is the limitations on crafting a state-specific program. And they looked on this as an opportunity to do that. And if that gets taken away over time, I think there's gonna be a dramatic lack of enthusiasm to continue it. Thank you. Thanks. So our next speaker, Rob Fowler, is the president and CEO of the Small Business Association of Michigan, a role he's had since 2003. And the Small Business Association serves over 23,000 member companies from all of Michigan's 83 counties, promoting entrepreneurship, leveraging buying power, and engaging in political advocacy. He also serves as the chairman of the Michigan Health Endowment Fund. Please welcome Mr. Fowler. Thank you. Great analysis. You did good. Thank you. Thank you. The other shoe about the drive there. No, no, no. So maybe just a little bit about the Small Business Association of Michigan, maybe even where we come at this a little perspective on where we typically are in this debate. In fact, I remember a press conference at the very beginning when the governor actually sort of invited himself to a press conference that was already going to take place the hospital association at Sparrow Hospital. And we had already had a conversation with the governor's office and expressed to them that we would be supportive of Medicaid expansion. And so I was also invited to that press conference. And I remember standing there with the traditional press conference, all these people standing up behind all the supporters of Medicaid expansion. Standing in a hospital, it was maybe appropriate to remember when I was growing up, sitting in a waiting room in a doctor's office, there was always a magazine called Highlights. You'll remember Highlights Magazine. One of the puzzles was to look at a picture and figure out what doesn't belong. Well, I figured it was me at that press conference. The business voice in this group of supporters of Medicaid expansion actually was either me or Republican governor. And in many ways, I think a role that we have played throughout this whole thing has been a unique voice, an unusual argument in what is otherwise a group of people who are advocating for either the poor or the healthcare system in general. Again, I should also say we did not support the Affordable Care Act. I'm on the board of our national association. I started all of my testimony with we didn't support the Affordable Care Act, gave me a little bit of credibility, I think, with conservative legislators. So, and I often say, I think people would think of us as a kind of right-leaning organization. We are strategically bipartisan, an important element. I think even in this debate, I think it gave us entree to both sides of the aisle that maybe other business organizations don't have. But I speak Tea Party fluently. Except for the crazy dialect, I don't really have that down past. But we tend to be an organization that relates to conservative policy makers. I would add, we had a partner in this, the State Chamber of Commerce also came along and supported two business organizations, again, that would traditionally be aligned with sort of conservative politics. I think that's important as we think about how this played out. But again, I think it's important to understand our interest in this issue. And much like then representative Mike Scherke, we had to come to the sort of reality that the Affordable Care Act is the law of the land. And what we needed to do is figure out how to best play it out in the state of Michigan for our members and for others. So you may be aware of this. There is something that's been happening. If you're an advocate for small business in Michigan, we have been worried about the cost of healthcare for a very long time. It's rising at a rate, we simply can't sustain it. The cost of health insurance is how it manifests itself to our members as rising at a rate faster than any other business expense they have. And they're trying to hold on to that benefit so they can attract and retain good employees, but it's become so, so expensive. So we've been talking about cost for a very long time. In fact, we've been a student of what are the things that drive the cost of healthcare up? And what we know is one of those things is the phenomenon of cost shifting. People show up in our healthcare system and if they don't have coverage, they get care. And that care is actually sort of absorbed by the healthcare system and passed along to paying customers. I've joked with my friends at the hospital association all the time, they talk about charity care. Well, hospitals don't go out of business. They literally pass it along. This doesn't happen because it's the public policy. Nobody said hospitals, you can pass along so much to your paying customers, it's happened by default. It's the only place when you squeeze this thing, it can come out. So one of the drivers of the cost of health insurance today is uncompensated care that gets passed along paying customers. According to Kaiser Family Foundation, at least when this debate was going on, it was about 14% of current premium are the result of uncompensated care or under compensated care. So we knew this was a big issue. And so if people were able to show up into our healthcare system with coverage, then we believe that those costs will not be passed along. Now that's a big bet. And frankly, we have taken that bet. But maybe more importantly, and I wanna be careful about taking too much credit, I think we had an influence on Mike Scherke in that whole debate. I think Mike Scherke was a former hospital board member and he understood this issue of cost shifting about what happens when people show up in our health system without coverage of any kind. He saw it firsthand that those costs absolutely get passed along. And if we could do anything about it, he was in. And as Ken has said, the opportunity to sort of reform Medicaid at the same time really was what brought him to this table. So we became one of the voices of the coalition and we testified both in the house in a couple of the hearings and in the Senate. We're part of the coalition as it went through. We were at press conferences when the governor was embarrassing Republican state senators for not voting when he was challenging them to take a vote, not a vacation. There was a really tough summer involved in this whole thing. But, and I will tell you the vice president of government affairs for our organization today at the time was the chief of staff for the Senate Majority Leader. And he said, and a former senator and a former house member. And he said it was the toughest issue he's ever, ever been involved in. Now, I only say that to say we want it by one vote in the Senate. The old saying in our businesses, you gotta have 56, 20 and one. You have to have a majority in the house, the Senate and you gotta have a governor who'll sign it. This got 56, 20 and one. And let me just foreshadow something. What I hope we don't have to do is go back to this same legislature, which is more conservative today than it was then. More probably stridently ideological about this issue in particular than it was then. And there are a couple of scenarios where we might actually have to go back to them. So something I hope we'll talk about. Again, I think the hope for us is that it will affect cost. And there's some follow up to be done. If you put a billion and a half dollars to $2 billion into our healthcare system from outside that would have otherwise been uncompensated, it ought to have an effect on the finances of a hospital and the finances of insurance companies. So all providers and insurance companies. We believe that some of that needs to come back upstream to the payers. And that is the hope and the promise and the reason that we got involved in this in the first place. Dr. Ayane's work of measurement of the impact and of the outcomes of the Medicaid expansion is really gonna be important in our ability to sustain it. Let me just say one more thing. And then again, we can talk about this a little bit in the Q and A. Michigan was one of only two states actually that has a Republican House Senate and Republican governor, the past Medicaid expansion. So while this is a blue state and presidential elections this is a red state in local politics. And the other states are watching what goes on here. I was at a meeting of an organization called Grant Makers in Health with my health endowment fund had on and I can tell you that there are a lot of other states are watching us. I've had a chance to talk to business organizations in other states about our arguments, about why we supported it. And I think Michigan really will be a pivotal state in this whole thing. I think if we begin to slide backwards, I see other states going the same way. And that's what's at stake here is really, I think Michigan plays an absolutely critical role in the future of Medicaid expansion. Thank you, so we're off to a great start. So our third speaker is Erin Knott. She's the Michigan State Director for Enroll America which is a national nonprofit organization focused on maximizing the number of Americans who are enrolled in and retain health coverage. She's an accomplished organizer who's dedicated over 15 years to working on legislative, public education and organizing strategies. Thanks. So I was saying to my friend Laura here that I feel like one of us doesn't belong on this panel and it's me because I don't have a stake on the policy side. I mean in a previous career I did but for the last two years almost, I've been the implementer, the boots on the ground in communities across the state of Michigan. And we're here today to talk about healthy Michigan but for Enroll America we just are coming off and still recovering from that second historic open enrollment period which concluded in February. And we're culminating all those lessons learned and applying it to special enrollment periods in healthy Michigan. And so it's been a wild ride and I'd like to step back just to say at the conclusion of that second open enrollment period I think that Enroll America, particularly in Michigan has emerged as a go-to organization that the uninsured, we call them consumers, know that they can go to and eliminate the political rhetoric and just get the facts about their coverage options related to the Affordable Care Act. Republican, Democrat, it doesn't really matter what your political ideology is when you get cancer or when your kid falls in the parking lot and you don't have coverage. And that's kind of how I approach folks across the state when we sit down and talk to them because there is so much baggage still associated with the Affordable Care Act but everybody has a family member, a neighbor, somebody that they worship with that had an unexpected illness and then they dealt with those kind of financial consequences that go along with not having coverage. So again, we're the implementer here at Enroll America and how did we accomplish what we've done to date? We celebrate hundreds of thousands of actual conversations with consumers talking about their options and then linking them to either in-person assistance or to other kind of avenues to obtain that coverage. We've held just over 10,000 outreach and enrollment events here in Michigan. Again, talking about whether it be Marketplace or Healthy Michigan. And we're supported by over 5,600 volunteers right here in Michigan. And those are folks that don't just do one event with us. They're repeated volunteers that run our phone banks at Canvas with us that table in communities. We are a non-partisan, non-profit organization but we run very much like a political campaign utilizing the tactics that you would think about when you think about an electoral campaign. We're very, very focused on data and analytics and I wanna talk briefly about our database real quick. We have a database that uses models and propensity scores that's way out of my pay grade in league that helps us drill down and find the uninsured. And so that helps us focus our work. So instead of just blanketing a community and blindly door knocking, I can pull a list and say based on this propensity score these four homeowners on Grant Street we believe are uninsured. And over two enrollment cycles and lots of work to update the model we now can separate Marketplace uninsured, eligible consumers and Healthy Michigan consumers. Which again helps us focus our efforts. We work with hundreds of partners across the state to get their information, contacts of consumers that they talk to. We have something called a commitment card that people fill out and kind of tell their story. Again, databases is constantly being updated which allows us to trap consumers whether or not they're still uninsured if they enrolled and now as we move forward whether or not they've utilized their coverage. Couple more data points real quick to talk about before I kind of give a little bit of background about our experience. You know I mentioned in-person assistance a few minutes ago. In-person assistors are critical particularly for those hard to reach populations. Folks that have never had health coverage before they don't understand it. Heck I don't understand my coverage that was just recently updated, right? So in-person assistance has been critical for African Americans, Latinos and young adults to kind of cut through again that noise of what this means. And we know that in-person assistance has resulted in consumers twice as likely to enroll when they're meeting with somebody face to face in their community. We also know that repeated contacts with consumers was critical to the success of enrollment whether it be the marketplace or Healthy Michigan. Again, those hard to reach kind of populations African Americans, Latinos and young adults respectively four contacts were needed to drive them out to the marketplace or to Healthy Michigan. The legislature and the governor did they did a great job. We are one of those only red states that have Healthy Michigan or expanded Medicaid but it was a nightmare last year for us particularly of Enroll America because we were knee deep in the first open enrollment period and there was suddenly this appetite for coverage. There was a ton of noise out there people were wanting to enroll and we had to tell people that we believed to be eligible for Market Play or excuse me, Healthy Michigan. You're out a lot come back on April one because the legislature didn't pass immediate effect. And so we tried to help those folks as best we could by capturing their information putting them into a what we call a chase list contact on April one. But it was a really difficult time to navigate your friend got coverage and got financial assistance and has a quality plan now in March but you can't do anything until April one. So when my colleagues across the country took a break on March 31st when open enrollment closed we were ramping up for what was an explosion of another unknown like what's gonna happen what's the demand gonna be for Healthy Michigan. And I gotta say that the state of Michigan really got it right by taking some of the lessons learned from the tragic rollout of the marketplace and putting systems in place on the upfront to troubleshoot to respond to constituents in person assistors groups like Enroll America about some of the snafus. And we didn't see whether it was on the phone or on the web any of those kind of problems that the marketplace experienced particularly in October and November. A couple more just kind of quick points. It's great that we're high five in each other that over 900,000 folks in Michigan have coverage now for the first time through the Affordable Care Act whether it's marketplace or Healthy Michigan but that doesn't necessarily make a community healthy. You know having that health insurance card I got my blue cloth, blue shield card in my pocket but that doesn't make me healthy. So Enroll America particularly the team that I'm organizing here in Michigan we're working with hospitals and other providers to figure out how can we through our scope of service which is again talking to consumers help break down some of the obstacles that still exist to making communities healthy. So there's lots of obstacles that I'm not gonna go into but what I can do is take our field tactics our database our 5,600 volunteers and now start drilling into communities and finding those folks that have coverage and help them access their coverage finding a medical home. We know that it's just under 10% of consumers that have Healthy Michigan plans haven't completed their health risk assessment. So how do we engage them in the process of again establishing a medical home and getting the services that they need so that they're not in the emergency room or that they're not going untreated. And the last point I'll make on that is to be continued we're doing a pilot project particularly in Southeast Michigan where we have kind of two brackets two populations if you will. We have the young adults I'm not sick so why in the world would I go to the doctor and get my health risk assessment, right? And then you have folks that have lived in institutional poverty for decades and there's behaviors and patterns and we need to break those down. So we're doing a pilot project at Enroll America in Southeast Michigan where we're gonna use our database and we're gonna drill down and find those folks those two segments and see if we can produce some outcomes where people are actually getting out of the emergency rooms and establishing medical homes. Thanks. So our next speaker is Laura Appel. She's Senior Vice President for Strategic Initiatives at the Michigan Health and Hospital Association and she focuses on healthcare policy, hospital finance, legislation, governance and communications. At the federal level she represents the interests of Michigan hospitals and health systems in both the legislative and regulatory arenas on key issues including federal healthcare reform and Medicare. Thank you. I wanted to first respond to a couple of things that Ken Sycamore said. I absolutely agree that we needed that conservative Republican lawmaker to help us get healthy Michigan done but I also think that it wouldn't have happened without that Senator Roger Kahn who was also a physician who also nowhere near as conservative but definitely Republican chair of appropriations in the committee in the Senate and a physician and he I think just decided we're doing this and that made a huge difference. The other thing is I should have mentioned I should have put this in my prepared remarks but I'll start with it now which is immediately following the Affordable Care Act which some of my members, my members are pretty much having described to people, well who do you represent? Everybody with an emergency department is my member. So if you've ever been to an emergency room you're probably meant to somebody that's in my membership now. And especially Trinity and Ascension Systems were hugely supportive of the Affordable Care Act. It was extremely important to them from a mission perspective. And about two weeks after the bill was signed into law my policy department prepared a series of statistics and spreadsheets that showed just how much money every hospital was gonna cough up to pay for this which my Catholic members were not too excited about when they saw that in our lawmaker's offices. But over 10 years, the first estimate over 10 years was that Michigan hospitals would forego $7 billion in Medicare reimbursement. So yes, we had already paid at the office and we were very, very excited to get those people covered to perhaps earn some of that back and most importantly to get people better organized about their health. Last month the Center for Healthcare Research and Transformation reported that they saw the number of people without health insurance go down by 50%. We have some very good data about inpatient care. Our data show that in the first two quarters of 14 that we had the plan. So April through October we are seeing 50% fewer people presenting without any form of coverage. So people are coming in with some kind of card even if it's a Medicaid card. It's too early to tell you how this is gonna specifically impact our cost of reimbursement but I will unequivocally say, and my same policy people have run some numbers, this is absolutely reducing the shortfall between Medicaid costs and Medicaid payment for the majority of hospitals. It is raising all boats but some boats were under water to begin with. And the reason for this is that in Michigan to finance Medicaid, we are hugely dependent on provider taxes. Michigan puts about the same, I see Dick Miles is here and he probably tells exactly but we put almost the same amount of money in general fund into our Medicaid program as we did in like the year 2000 or 2002. And we had in the year 2000 or so about a million people covered and now we would have two and a half million people covered. Well how did we do that with the same amount of money? Well certainly there's the federal money to support the expansion but the state doesn't have the match for an awful lot of what we do. So hospitals pay taxes to do that. We put up the state match and that works really well because it generates a lot of federal money. The problem is under federal law that has to be redistributive. Some hospitals must pay more in tax than they get back to Medicaid payments. So for those hospitals they have, they are living on the same amount of money that they had in 2002 or 2003. And they were way under water and kind of continued to be. Of course they're also the ones that had the fewest amount of Medicaid originally. The other thing that I would say is again reiterating this is making a huge difference in hospital finances. The executive budget recommendation this year said, well we see that this is making a difference. Now I can show you our estimate that as close as we're getting to covering costs we're not there yet. So we're still losing money on every patient which makes it hard to make that up for in volume. But the executive budget recommendation this year said, well for fiscal year 2016, since you guys are doing better than you were, we should take $92 million of general fund out of your support. Well it doesn't make a lot of sense to try and get us up to the place where we're gonna help Rob's members and then yank it back down by about 10% of that. And of course we can replace some of that with provider taxes but I just mentioned that whenever I do this on a tax basis I have to make somebody get less money back when they put it. So it's not a great long-term strategy. The other point that I wanna make is, and hospitals know this and we're working on it, we need to work on it. But that is we're not very good at providing enough value for what people are paying. Whether it's a third party payer or a person with a high deductible or a person with a low deductible. Our value needs to improve. And to cover 900,000 people in Michigan but do it all the same way we've done it for the last 35 or 40 years. That is not an improvement. We know there's overutilization in some places. We know there's a lot of preventable harm. We're working really hard to try and identify that and end it. But that really has to be part of what makes healthcare better in Michigan. It's not simply getting people, we can't line everybody up and give them a card and say this is it, it's great now. The same practice patterns or expenditures that we're making on the population that was already insured that did not lead to the best outcomes that we would like to see, we can't just repeat that in this newly covered population. We have to make changes and we have to do better. And we have a long way to go on that. We've come a long way but we still have a long way to go. So that's my comment about the first year. Thanks. So our fifth and final speaker is Kim Sebelski who serves as the Chief Executive Officer of the Michigan Primary Care Association, a role she's had since 1994. In this role she works on state and national health system development planning strategies to improve access to care and working with public and private stakeholders to reduce health disparities in Michigan. Thank you very much. Unlike Erin, I feel like I'm very much this panel. I think I know almost every front of a political geek, kind of not to say that, Mr. Sebelski, but he is pretty political. We're major employers in the communities in which we reside. And so I've always felt a strong alliance to rob a follow-up. Certainly our folks were extremely involved in outreach and enrollment and I'll kind of demonstrate that for you as I get into my prepared remarks. And like Laura and the hospitals, we're deep into provision of care, provision of uncompensated care and have great need actually to make this work, I think. So health centers, as I'm hoping a few of you know, we serve approximately, we're moving towards 700,000 Michiganders today. All of those in health professional shortage areas are medically underserved areas. So as beautiful as these gardens spots are, they're not really usually the most economically viable types of places. So 91.5% of our patients are at 200% of poverty or below. That was 91.5% 200 or below. In the 100 to 200% range, which tends to be our target here, 21.6% of our patients are within that window. Now that's not the exact window we're talking about, but it sort of gets you close to this. These numbers, I have to apologize, are 2013 numbers they don't allow us to illustrate what the impact of year one has allowed us to do. But I think that it will give you a sense of how these folks that we serve are very much in the crosshairs of the work that we're talking about here. 44.7% of our patients prior to the Health Michigan plan were covered by Medicaid, so almost half. 31.4% were uninsured. So in terms of the work that we needed to do as health centers in terms of outreach and enrollment, we actually had a big in-reach job and we projected that we would probably pull about 130,000 people through in-reach. Our sense is we didn't do too poorly with those folks because even I called a number of our members over the past few days to get a little bit of credibility behind my presentation, all is a good idea, I think, as an association member. One of our smaller health centers literally has converted 3,800 of their patients from uninsured into insured. And what we see that being able to do for us is allows us to open up to more of the uninsured that we have not been able to take care of. And that is the dynamic that we believe that we will begin to see more as time rolls on because providers are taking certain numbers of healthy Michigan-planned patients, but our sense is they'll fill their ranks and some of the, they're uninsured, the private providers who have always taken a few. But if they can take Medicaid and sort of not, we believe that that's what we'll begin to see. So right now our uninsured roles tend to be shrinking, but as was the situation in Massachusetts, there, when they were full coverage or as almost as close as you can get, community health centers still had 30 to 35% uninsured folks. The other interesting thing is about 58% of our patients are between the ages of 18 to 64, which kind of has not always been the profile that we have had. And that very much is the demographic that's being reached out to. So uninsured within that age frame, we're kind of like the right folks to do the work in partnership with Erin's group, with Laura's group, the stuff that Rob really cheered us on for in terms of outreach and enrollment in effect to make this, make this grand experiment, if you will, work. We had historic, well, since CHIPRA, actually health centers have been recognized as being very competent in outreach and enrollment. We received national attention for the outreach and enrollment work that we have done. We took that work and we rolled it into the marketplace work, as Erin said. And then we really had impetus to move into Healthy Michigan plan enrollment. At the high point, we had 265 certified application counselors distributed throughout the some 260 sites that we have through in the state of Michigan. At this point in time, we're down to about 230 outreach and enrollment folks, which is extremely exciting for us because one, we've still got work to do in terms of outreach and enrollment. But the work that Erin talked about in terms of person to person advocacy and support, these are people who are very much queued up for the new work that we have before us that focuses on community health workers and moving out into communities and helping to address the social determinants of health. So we're very, very excited about that work. So what are our health centers seeing with these newly insured patients that they have been seeing and with the newly insured patients who have been going to the emergency rooms or not seeking care at all? I think one of the things that Laura said about celebrating the savings of this program, you cannot transform a system and save immediately. And the folks that we're seeing coming to care for chronic conditions that have not been treated. Ever. Or the people who have advanced breast cancer who were not diagnosed originally. Number of my members said some of what we're seeing is really heartbreaking and it sure is not money saving. These are folks that are starting to come to care and there will be a bolus of expenditure. Hopefully at some point in time we'll be able to see that bullet start to level and healthier people and healthier communities. That is certainly what we're looking for. In terms of the objectives for Healthy Michigan plan, I think that it's really, really important from the political side that we recognize that some of the elements baked into these programs aren't bad things. The health risk assessments, wonderful things. Actually helping people to become an even greater part of their own health care team. Looking to have a little bit of, if you will, personal responsibility. I think it's critical for the success of the program one but also the political success of the program that we be able to advocate, support, and tout the victories that we are seeing and will be seeing in people completing those health risk assessments, becoming a part of their own team. And if you will, for our Republican conservative friends and colleagues, enjoying some of the results of that personal responsibility. In terms of the quote unquote skin in the game, I can't speak to that personally. I don't really see that as our health center's personal responsibility. But I do think that we need to be able to speak in terms of successes across the board in order to try to create a political environment to be able to keep this operational. We have people coming to care medical care, dental care, mental health and substance use services that have not received those services historically. We can't help but ultimately see the fruit of all of our labor in healthier communities but that takes time and you don't save money right out of the box. In closing, what I wanna say is that I believe that if we really are going to impact the triple aim, quality, cost, and personal experience, we need to have the vast majority of our public covered. We cannot take a state with 13 to 15% uninsured into a project like the statewide innovations model, plan implementation, SIM, and expect that we're going to start to really create change until we literally have a covered, one covered population, which we're getting off of down close, maybe around 93%. I have mad madding his head so I'm gonna say 93% covered. It's not just the coverage, it's the data though that coverage allows us to start to have access to and only with accessible data that can be turned to information to help to drive change. Well, we see success in a massive undertaking like SIM, 70 million dollars to be expended over four years to help to move Michigan to the triple aim. I really think that we have got to the additional piece beyond skin in the game and personal responsibility not to mention help. I think we need to say that it's critical that we continue on this pathway in order to affect truly meaningful change in quality cost, patient experience, economic health, run for communities, and a healthier state. So I'm writing that down for Senator Schoenke. Thank you. Thank you to all our speakers for the very insightful remarks and now we'll open it up to our students of Master's in Public Policy, Ruth McDonald, and the agreement to introduce the questions that we have from the audience. Thank you. I'm Ruth McDonald and I'm a student here at the Ford School of Public Policy and also a student at the School of Public Health getting a Master's in Public Health. Thanks for being here. Our first question is for those that are facing consumers and patients. What has been your experience communicating with consumers about a cost sharing and healthy by behavior of financial incentives of the non-communicable man? Are there any concerns about affordability for the patients? And we'll start with Kim and there may be any additional comments, thank you. Yeah, my answer will be very brief. Health centers provide health coverage. Health centers create access for folks without insurance by offering the possibility to do a financial review and get sliding fee scale. We had naively assumed that in an expanded coverage world our sliding fee scale would shift to the folks who are uninsured as we have historically. What we are finding is a large number of folks who are underinsured. And as a result, thanks to HRSA and the Department of Health and Human Services they have approved that we can utilize our sliding fee scales for those folks who are insured but cannot and can't cover their own financial participation. To me, that's a sign that we have affordability issues. One of the things that frustrated me greatly during the entire debate about Healthy Michigan was everybody kept throwing up Arkansas and Arkansas great, we love Arkansas. Well, I worked on Medicaid managed care when John Engler decided we were gonna do it in 1996. So when Arkansas started thinking, well, maybe we'll use managed care it's been 17 years since we started it. And we had had co-pays and deductibles for most of that time. We have, I think, a $50 first day inpatient deductible. And I would say that for the most part hospitals just don't collect it. It's not collectible. So it's a, basically it's a rate change for us. But I understand why those people, I mean, these are people just don't really have anything, especially in the population before we got to expansion. Excuse me, just a couple of points. During the first open enrollment period, probably January, maybe early February of 2014, we had Enroll America shipped in our message because we realized folks weren't taking the opportunity to enroll. Again, this is the marketplace because they didn't understand that financial assistance was available. And so all of our talking points was about financial assistance. At the conclusion of the second open enrollment period, we know that 88% of those enrollees received some form of financial assistance and 68% of those folks got it for $100 or less. So a plan for $100 or less. And sometimes you might have seen me in the media talk about, well, that's the cost of my cell phone bill. But I mean, the reality is still $100 is still at times unaffordable for folks. And so there's that point to make. There's also the point that we're seeing after, whether it's Healthy Michigan or two marketplace enrollments, consumers didn't understand what they purchased. And they didn't read through the fine print to see that they have things such as copays or deductibles. And that was a surprise to them. So we're trying to do better as folks renew next year to make sure that they understand what they're signing on to. And a second point to that is, in this time around, we saw substantially, this is focused on the marketplace, but silver plans were no longer the most popular. I'm sorry, that's misleading. Silver plans, we were getting feedback from those that were re-enrolling even with financial assistance weren't determined to be affordable for them. And so they were opting to go with Brown's plans that has $6,000 deductibles and up. And so again, we have to work with folks to understand what the consequences could be to the choices that they're making, trying to balance their monthly, what's coming in and out. Thank you. My name is Maggie Foster, but I'm a first-year master's and public policy student here at the Ford School. I'm interested in women's health and prevention. So I want to thank you all again for all of your wonderful insights. This is a question from the audience talking about just the remarkable enrollment in healthy Michigan. As everyone has said, it's really outpaced expectations. Why was this so successful beyond the predictions that were originally made? Are we capturing much of the hard-to-reach population? If so, where do we go from there? If not, how do we continue to make sure that people don't fall through the cracks? If you brought in Aaron, would you start again? At the risk of sounding very negative, I don't think it's great that we had 600,000 people that could qualify. I mean, we now have 25% of our population qualifies for Medicaid. That's how many people are in that level of an income. When I talked earlier about, we essentially doubled the number of people on Medicaid in roughly 10 years during the year, the 2000s, we made no changes to eligibility. That was all people just getting poorer. And so to have, where are we compared to marketplace about are we at our expected level of the marketplace enrollment or below? I mean, basically we thought people were gonna belong in the marketplace and they belong in Medicaid. So I think that's part of the reason. I'm really glad we have it. I absolutely am glad we have it. I'm kind of disappointed we don't have it a little more balanced. I don't know if you guys want to do something about that. Well, I agree. I described earlier, I felt like this was the commercial where they've just launched a website and they're watching, they get their first hit and then another one and then it looks really great. And then all of a sudden it's like, whoa, that's out of control. And I felt that way a little bit about Healthy Michigan and 605,000 is the number, I think, as of today. And really I feel it's success as it relates to enrollment. But like Laura, I'm not sure that speaks well of the state and our economy. Honestly, my sense is the economy's getting better from where I sit, we're certainly healing. But I think it speaks to a lot of people who sort of dropped out of the economy altogether and this is a way to measure that. That's not good news necessarily on some fronts. For those who supported the passage of the Healthy Michigan Plan for cost reasons, or I think that was one of the reasons of support, what is your plan if the evaluation of Healthy Michigan does not, the evaluation finds that Healthy Michigan Plan did not bend the cost curve? And sort of on a related note, as we heard the status authorized to rescind Medicaid expansion in 2017 if cost savings for the expansion can't be found, do you think the legislature would actually rescind it at this point, or what do you think sort of the realistic options going forward are? I wonder if we could start with Ken with the legislative perspective. He's glad he's not there anymore. Well, yes, one of the, I think, selling points here in Michigan was that we're gonna save money over time and it sort of baked into the statute. You know, they're gonna do these calculations and if that's not true, then we pull a plug. I'm not sure that's what will happen for a couple reasons. One is once you start something and it sort of gets ingrained in government, it's hard to reverse course. I mean, I think that's been my experience. Now that doesn't mean that the people that put that in there aren't well-intentioned and that it is certainly possible. I think over time it's more likely that they'll wanna make changes to this. I mean, just, you know, this happened a year ago or two years ago and maybe it's not gonna work. What do I mean by that? Well, maybe the copays and the premium sharing from recipients, you know, I think the theory is that will help them take ownership and they'll get healthy because they don't wanna spend the copay to go in the hospital or whatever and that'll be an incentive for healthy behaviors. Well, maybe it won't be. So maybe there's a different way to structure Medicaid that will become apparent in three years and they'll wanna make some changes. So I for one, somewhat circumspect about whether or not the lack of measurable cost savings to the Michigan taxpayer will mean the plug gets pulled over time when they will wanna maybe make some other changes and maybe that'll be the reaction. Maybe they'll say, well, if we make changes X, Y, and Z there will be cost savings. So I'm a little bit, like I said, circumspect whether that trigger would end the program. I'm a little bit more certain that federal government and I'm gonna say recalcitrants, you know, not approving the second waiver would have a better, bigger impact on having the program end. But that's just my opinion. Yeah, I maybe a slightly different perspective. I did a lot of arm twisting of Republicans during this debate and it was, we tried very hard to stay on message. This is about cost saving, not to the state. That's not who I represent, but to insurance premium payers in our state. The cost of healthcare again manifests itself as premiums for us. And I feel like I'm very much out on a limb and I feel like I've taken some policy makers with me out on that limb. And we've taken a policy bet that this will manifest itself as cost savings, bending the cost curve. I'm not so naive as to think it's really gonna notch down, but in a measurable way, showing that instead of going on this trajectory, it is lower. I think if that doesn't manifest, then there will be some policy makers who are the champions from the conservative side who will rethink their position. So I think absolutely it's very difficult to take away a benefit that's been given, but let me tell you, you'll hear all this. This took on all the arguments of a welfare debate. Really, if you think ending in 48 months, having some skin in the game, personal responsibilities, all of those are arguments about welfare. And so this really became to a lot of conservatives one of the basket of welfare things we provide to citizens. I get that, I actually tend to agree with that, that if it becomes too comfortable to not work, there become incentives to not do so. I wouldn't start with healthcare, however, if I were to pull back some sort of public benefits, the access to healthcare actually becomes the nexus for a lot of other ability to make it to work and take care of your kids and those sort of things. So this isn't the place I would concentrate if I were gonna try to pull back a little bit, but I think this is the most recent thing on the table and therefore it's vulnerable to being pulled back. So people have time for one or two more questions. Excellent, all right, well I think we're gonna pull on from Twitter here. I was speaking with our friends on the internet. This one comes from a Twitter user who wants to talk about, as many of you have mentioned, expanding coverage doesn't mean making people healthier. So expanding coverage isn't always enough. How do we improve, how do we accomplish and improve practice patterns, reduce overutilization and preventable harm? And I think I'd like to tack on that too. How do we encourage healthy behaviors and prevention in the populations that we're serving? Nothing about world peace. That too. That's not it. There are perhaps within the healthcare community and Dr. Davis might want to speak about this. For example, we are, I would say partners on the overuse of opioids. And we have another, this is a collaborative that our hospitals will do the work, I mean table convene, to work on over subscribing or to basically weed out the wrong practices around using opioids as part of an inpatient stay and after surgery. That is, I don't know what number of collaborative we've worked on improving care in the ICU, eliminating urinary tract infections, safer surgeries, safer and better OB, getting people, everybody to term, all kinds of stuff that we've been doing. But there's a lot of fatigue out there among the caregivers. There are 900 measures, collaborative from the MHA, collaborative from, or rules from LeapFrog, Blue Cross has their things. As Dr. Joyce Lee, who is from the University of Michigan said last week during the Detroit Chamber, nobody got up and said I want to be a doctor so I can do really poor sloppy care and maybe people won't feel so good at the end of it. So nobody's got that goal, but certainly bad things are happening to good people in our system and we're really working to improve that. One thing that I commend to everybody because I read it before every time I do all these things is the busted healthcare myths from the spring 2008 findings of the School of, and at UM School of Public Health. Just in case you're interested. You know, a lot of the things that we want to do to improve care, you know, they're not gonna be the answer. I think that with what Rob said earlier, we need people to be in a better place and being in your intersection with the healthcare system is usually very brief. I hope it is. I hope you'll only see your doctor a couple times a year for simple things like a flu shot and a physical maybe. That's even, that's like, wow. Yeah, sure. But the other 363 days you're on your own and that's where the rubber really hits the road in terms of having a healthy population. So yeah, we got a long way to go on preventable harm. Absolutely, among all of those other things that were mentioned, but being healthy goes way beyond whether or not, you're not gonna get healthy by being when you cure people in an inpatient setting but can't keep them healthy because you're getting it out of that in patient time. Thank you. Our final question, and Kim, I think that you might be the first one to tackle this, but several states have clarified that Medicaid expansion also covers transition-related care for transgender residents. What will it take for Michigan to overcome this policy deficit for such a vulnerable population in the state? We should just read that one more time for sure. Several states have clarified that Medicaid also covers transition-related care for transgender residents. What will it take for Michigan to overcome this policy? I got nothing. I want to give this to Sycamore. Really, Dr. Dave? So I don't know what our policy is on that. Well, right. And I mean, it's gonna be a wonderful, wonderful debate because it's my sense that the governor has staked himself out to not sign a religious freedom bill unless there is LGBT language within, and I always hear better the names of those bills, but the- Elliott Larson. Elliott Larson. Thank you very much. At which point I think Mr. Scherke's senator, excuse me, Scherke has said he's going to, he's gonna move it forward. So it's gonna be a wonderful rugby match. I have no strong sense of how it will wrap up, but what I will say is I do not take Senator Scherke lightly. I do not. I have not seen will like his since Governor Angler, and I pulled all the kids up the streets when Angler went out because he knew what he wanted and he would get it done. So I'm not sure that's an answer to that question, but fundamentally speaking, it will be dealt with. I think politically beautiful, it gets dealt with in terms of coverage and care. If I could offer just a observer's answer to the question, when will Michigan do this? I would say no time soon. Again, if you look at the political makeup of our legislature, that is just not on the drawing board in any significant way. I would say Kim has rightly said that the Indiana religious freedom effort and Michigan's expansion of Elliott Larson coming together isn't going to happen any time soon either. I just think the political environment right now will suggest that that doesn't get done. Well, but there's another issue there because as I understand the question, it's using taxpayer dollars, Medicaid, to fund that transition. If I understood the question. And regardless of how the Elliott Larson debate plays out or how the Religious Freedom Restoration Act debate plays out, I can't imagine, I can't imagine this legislature or any legislature in the foreseeable future making the decision to use taxpayer money to fund that procedure. Because that's what you're asked about. And you could, you could add. Does it ever play ever? Exactly. Well, I don't want to get in a debate with you. I'm giving you a political judgment about, I mean, you could add LGBT rights to the Elliott Larson Civil Rights Act. You could not pass the Religious Freedom Restoration Act. And it wouldn't do this. But you still have that remaining issue. So that's why I agree with Rob. I think it's important to put that, that's a wrinkle in that question that needs to be on the table. People need to understand, I think. Well, as we wrap up our policy talk for today, I first want to invite all of you to the reception that the Ford School is hosting right in the Great Hall, outside the Wild Hall here where we're meeting. And we'll begin right after our session today. I want to thank Dean Collins and Dr. Davis and Cliff Martin in the back for hosting us and organizing today's events here at the Ford School. I want to thank our student questioners, from Megan, for the moderating our discussion. And most of all, I want to thank our five guests from across the state for sharing very thoughtful insights into the future of the Healthy Michigan plan.