STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES Of?ce of the General Counsel Jim ustice ()ne Davis Square. Suite East Bill J. Crouch Governor Charleston. West Virginia 2530] Cabinet Secretary Telephone: (304)558-4972 Fax: (304)558-7075 May 16, 2017 Erin Beck, MPH, Staff Writer Charleston Gazette?Mail erin.beck@quazette.com Dear Ms. Beck: On May 10, 2017, the Department of Health and Human Resources received via email your request, pursuant to the Freedom of Information Act Code 298-1?1, et seq, requesting: 0 Any and all correspondence between West Virginia's members of Congress/their staff and DHHR employees regarding the American Health Care Act. If any records of phone calls or in-person conversations were kept, request those records. Your subsequent email to Allison Adler requested guidance about how the bill would affect West Virginia, possibly whether you have urged them to vote one way or another. This office has completed its search for and review of the public records in its custody that fall within the scope of your revised request to Allison. Attached please find copies of the records that are responsive and not otherwise exempt from disclosure under FOIA. The responsibilities of this office with respect to your request are now at an end. You are advised that FOIA affords you the opportunity to seek injunctive or declaratory relief in the Circuit Court of Kanawha County. Sincerely, ynthia H. Dellinger Acting General Counsel CHD/dgg Attachments cc: Allison Adler, Director of Communications a? wEsT d73?." W, il??\g?m n- 51mg~ fig?m?m February 15,2017 The Honorable Ron Wyden The Honorable Thomas Carper The Honorable Maria Cantwell. The Honorable Sherrod Brown The Honorable Robert Menendez The Honorable Michael Bennet The Honorable Benjamin Cardin The Honorable Mark Warner The Honorable Debbie Stabenow The Honorable Robert Casey, Jr. The Honorable Bill Nelson The Honorable Claire McCaskill United States Senate Committee on Finance Washington, DC 20510-6200 Dear Senators Wyden, Cantwell, Menendez, Cardin, Stabenow, Nelson, Carper, Brown, Bennet, Warner, Casey, and McCaskill: As Governor, I appreciate the opportunity to provide input on healthcare reform proposals and the potential impacts to West Virginia?s Medicaid and Children?s Health Insurance Program (CHIP) populations. Below are details on the speci?c questions posed in your January 19, 2016 letter. I. How would a 30 plus percent cut in federal ?nancial participation as seen in Chairman Price ?s?scal year 201 7 budget proposal impact your state Medicaid program? For West Virginia, a 30% reduction in FFP for SFY 2018 approximates to $977 million (23% of current projected expenditures). A reduction in federal funding of this magnitude would require drastic action by the state. These actions include: Elimination of eligibility categories - Medicaid Expansion Reduction of rates - Cut in provider rates across all- provider services Elimination of optional services - Physical therapy, personal care, speech therapy, pharmacy services, and chiropractic services Reduction or elimination of waiver services - Dramatic changes to the Intell'ectually and Developmentally Disabled Waiver, the Aged and Disabled Waiver, and the Traumatic Brain Injury Waiver Dramatic Bene?t Plan Reduction - Limiting number and units of services available State Capitol I 1900 Kanawha Blvd, East, Charleston, WV 25305 (304) 558?2000 .. Page 2 of 5 OFFICE OF THE GOVERNOR West Virginia?s Federal Medical Assistance Percentage (FMAP) is 71.8% (second only to Mississippi). West Virginia Medicaid?s expenditures are predominantly federally funded. Federal funding must be maintained or West Virginia?s healthcare infrastructure will collapse. Decreasing federal funding, whether by means of grant funding, Medicaid matching funds, Advanced Premium Tax Credits, or failing to ful?ll risk adjustment obligations, would immediately reverse all progress made for both our working population and those vulnerable citizens who we are morally obligated to serve. 2. How would repeal of the Medicaid expansion affect health coverage rates in your state? West Virginia has made signi?cant progress toward insuring low income, working adults since the passage of the Affordable Care Act, reducing the uninsured rate in our state from 17% to approximately A repeal of the Medicaid expansion would result in 175,000 West Virginians losing health insurance. In addition, studies have found that as parents obtain health insurance, the probability of their children obtaining health insurance signi?cantly increases. West Virginia?s insured rate for children has grown to over 97%, which is now one of the lowest in the United States. 3. How would repeal of the Medicaid expansion impact your state Medicaid budgets? What would be the impact on other state budget priorities such as education? Would your state be able to raise revenues or otherwise compensate for the loss of this federal funding? Repeal of Medicaid expansion would eliminate up to $900 million from West Virginia?s healthcare economy, annually. West Virginia cannot increase state revenues to fund Medicaid expansion beyond the current projected 10% match effective in 2020. The Commonwealth Fund estimates that the loss of? federal dollars ?owing into West Virginia from the ACA couldresult in the loss of 16,000 jobs and $9.1 billion in state economic output (State GDP) in 2019. In West Virginia, under a partial repeal of the ACA, the increased number of uninsured West Virginians could lead to a $500 million annual increase in total uncompensated care sought from providers by 2019, including: West Virginia hospitals would be asked to provide $135 million more Physicians would be asked provide $64 million more Uncompensated prescription drug costs would rise $115 million From 2019 to 2028, the increased number of uninsured West Virginians could lead to a more than $5.8 billion increase in total uncompensated care sought from providers, including: West Virginia hospitals would be asked to provide more than $1.6 billion more Physicians would be asked provide more than $800 million more Uncompensated prescription drug costs would rise to close to $1.3 billion The West Virginia Legislature has been able to reduce approximately $20 million in charity care services due to Medicaid Expansion, aiding in West Virginia?s share for the state?s match for expansion. Page 3 of 5 OFFICE OF THE GOVERNOR According to the West Virginia Center on Budget and Policy, repealing the ACA without an adequate replacement could result in an estimated 16,000 West Virginia jobs lost by 2019 and nearly $350 million lost in tax revenue over ?ve years. SFY2015 Expansion Expenditures Hospital $249,606,654 Prescription Drugs (net of rebate) $108,777,283 Physicians and Other Professional Services $106,613,575 Rural Health Clinic/Federally Quali?ed Health Clinic $30,196,801 Dental $14,949,840 Behavioral Health $42,684,949 Other Services $75,327,456 Total $628,156,558 4. How would these levels of cuts impact your ability to meet the needs of an. aging baby boomer population expected to require more long-term services and supports, including nursing home care and personal cares services? West Virginia?s population ranks second with the oldest average age of all states (average 40.4 years according the U.S. Census). Long-term care and home and community based waivers attribute to 33% of current expenditures. Reductions in FFP would signi?cantly curtail West Virginia?s ability to provide services to our seniors and disabled populations. Elimination of the Aged and Disabled Waiver, reduction in nursing home rates, and elimination of optional personal care services would have a dramatic impact on the elderly population. Furthermore, services provided to older populations also mitigate costs for the Medicare program when Medicaid recipients become eligible for Medicare. 5. How would these levels of cuts impact your ability to combat the opioid epidemic and mental health crisis and meet the needs of those with mental health and substance use disorder needs? West Virginia has the highest drug overdose death rate in the United States. The state also has the highest rate of severe mental illness and poor mental health days in the United States. If budget cuts take place reducing federal funding to the West Virginia Medicaid program, it would have a dramatic impact on substance abuse and mental health services. West Virginia would be unable to fund provider services required to treat the mental health and substance use disorder patients. The state would have to pull back the substance use disorder waiver that was designed to expand substance abuse services for drug addicted mothers, babies with neonatal abstinence and inpatient treatments for addiction recovering adults. 6. How would these levels of cuts impact your ability to invest in innovative changes to your healthcare delivery system? Page 4 of 5 OFFICE OF THE GOVERNOR If these cuts are enacted West Virginia would not be able to invest in any innovative changes to our healthcare delivery system. In fact, the State would ?nd it dif?cult to maintain its current system. 7. How would these levels of cuts impact your ability to respond to public health crises such as the Zika virus or increases in HIV cases? Approximately a third of the State?s population is covered by Medicaid and CHIP. West Virginia?s ability to respond to public health crises in a meaningful way would be severely limited if these cuts are enacted. 8. How would these levels of cuts impact your ability to respond to an economic downturn such as a recession? Unfortunately, many parts of West Virginia are facing depression-level economic stress. If there were to be a compounding economic downturn at this time then West Virginia would suffer greatly and Medicaid would have to look at drastic cuts in order to cover those impacted by the downturn. Many West Virginians who have lost their jobs in recent years, including those who have lost employment as coal miners or jobs related to the energy sector generally, have used Medicaid Expansion as a bridge to address any healthcare issues that develop or to manage chronic conditions until employment opportunities return. 9. How would these levels of cuts impact your ability to respond to new high-cost medical breakthroughs such as Sovaldi and other blockbuster drugs? West Virginia would not be able to respond to new high-cost medical breakthroughs if these cuts are enacted. 10. How would these levels of cuts impact your ability to respond to natural and other disasters such as Hurricane Katrina, Superstorm Sandy, and the Flint water crisis? Any crisis, be it economic or health-related, will be greatly impacted by the state?s ability to leverage federal Medicaid funds. 11. How would these levels of cuts impact your ability to provide affordable family planning services, including contraceptive coverage to low-income women and families? West Virginia would struggle to continue to provide affordable family planning services which could result in a greater number of babies born to teen and drug addicted mothers. 12. How would these levels of cuts impact hospital and provider payments? What types of increases in uncompensated care would you expected to see in your state given such cuts? If these cuts are made and West Virginia has to close its Medicaid expansion program, uncompensated care costs will return to pre?2014 levels or higher. This would greatly impact our hospitals and other healthcare providers possibly causing them to close their practices. Without expansion, one projection estimates that West Virginia hospitals would be asked to provide $135 million more in uncompensated care annually. The projected uncompensated care amount expected of hospitals from 2019 through 2028 if Medicaid expansion no longer exists represents a more than $1.6 billion increase in total uncompensated care sought ?'om hospitals. Page 5 of 5 OFFICE OF THE GOVERNOR 13. How would these levels of cuts impact localities in your state, such as counties and local jails? If healthcare providers close or decrease their practices, more citizens would be out of jobs, therefore putting more strain on the cities and counties. Also, since many individuals in the expansion population need behavioral health or substance abuse treatment, citizens who bene?t from these services may end up in jail or hospitals as opposed to receiving the treatments they need in their community. 14. What kind of cuts would states have to contemplate under these levels of cuts in federal ?nancing for state Medicaid program? A reduction in federal funding of this magnitude would require drastic action, potentially resulting in: Elimination of eligibility categories - Medicaid Expansion Reduction of rates - Cut in provider rates across all provider services Elimination of optional services Physical therapy, personal care, speech therapy, pharmacy services, and chiropractic services Reduction or elimination of waiver services - Dramatic changes to the Intellectually and Developmentally Disabled Waiver, the Aged and Disabled Waiver, and the Traumatic Brain Injury Waiver Dramatic Bene?t Plan Reduction - Limiting number of services and units available 15. How else would these levels of cuts impact your state? West Virginia?s economy requires a healthy workforce with access to affordable and readily available healthcare services. The drug epidemic has severely impacted the number of employable individuals in the state. West Virginia also has the highest percentage of babies born with neonatal abstinence in the country. These levels of cuts would impact the state?s health and economy for generations. As Governor, I appreciate the opportunity to provide input on healthcare reform proposals and the potential impacts on West Virginians. Sincerely yours, cc: The Honorable Joe Manchin, The Honorable Shelley Moore Capito The Honorable David McKinley The Honorable Alex Mooney The Honorable Evan Jenkins Jim Justice Governor STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES Bill J. Crouch Cabinet Secretary April 14, 201 7 The Honorable Shelley Moore Capito The Honorable Joe Manchin, 111 U. S. Senate U. S. Senate 172 Russell Senate Of?ce Building 306 Hart Senate omce Building Washington, DC 20510 Washington, DC 20510 The Honorable Evan Jenkins The Honorable David McKinley U. S. House of Representatives U. S. House of Representatives 1609 Longworth HOB 2239 Rayburn HOB Washington, DC 20515 Washington, DC 20515 The Honorable Alex X. Mooney U. S. House of Representatives 1232 Longworth HOB Washington, DC 20515 Dear West Virginia Delegation, During the recent consideration of The American Healthcare Act (AHCA), several of you contacted us to get our opinion on the bill. We appreciated the Opportunity to share with you our concerns about the impact that any legislation repealing the A??ordable Care Act (ACA) would have on our state?s citizens. As we shared with you, the AHCA would have eliminated access to health care for 175,000 Medicaid enrollees by June 2021. West Virg?nia?s decision to expand Medicaid coverage under the ACA was predicated on the belief the federal match rate would remain at 90% for years after 2020. As you are considering any further repeal and replace legislation, please consider that any change to the expansion FMAP would create an unsustainable ?nancial obligation for our state. Through the expansion of Medicaid, many West Virginians now have access to health care services, including critical preventive and primary care. We project that in ?scal year 2018, expenditures for expansion mbers will be $941 million. In addition to the danger to the health of our Medicaid population, the ?nancial impact associated with the loss of medical coverage would have a ripple effect creating crippling economic hardship and service burdens on public and private health care providers throughout the state. For many of our smaller, rural hospitals, the loss of covered patients could be devastating. In addition, in 2016 the Bureau for Public Health received more than $13 million in federal funds tied to the ACA, with more than $10 million directly supporting community based programs and services. These federal programs included a wide range of activities, such as in- home education and services for at-risk pregnant women; tobacco cessation services for uninsured and underinsured populations; diabetes prevention programs in communities; teen pregnancy prevention; immunizations for children; and regional epidemiology investigation support. We remain greatly concerned that as our state continues to wage war on addiction, any legislation repealing the ACA will negatively affect the ability of West Virginians with mental, behavioral health and substance use disorders to access needed services. In 2016, 53,000 West Virginians received treatment at a cost of $60 million. Approximately 20,000 Medicaid expansion members were treated for Substance Use Disorder at a cost of $48 million. Please know, we appreciate your continued service and dedication to the people of our state and stand ready and willing to aid and support you in your efforts. Sincerely, Q5342 a; (LA Bill J. Crouch Cabinet Secretary 4'3? \t?e 53:? STATE or WEST OFFICE OF THE GOVERNOR IQOO KANAWHA BOULEVARD, EAST CHARLESTON. WV 25305 (.304) 558-2000 EARL RAY TOMBLIN GOVERNOR January 9, 2017 The Honorable Kevin McCarthy Majority Leader United States House of Representatives Hv107, US. Capitol Building Washington, DC 20515 Dear Majority Leader McCarthy, West Virginia appreciates that you have reached out to the states for input on the future of health care in our nation. As you are aware, states are at the forefront of health care policy and face unique challenges in ensuring value driven quality health services to our citizens. West Virginia prides itself that our citizens come together to figure out difficult issues. We are of the opinion that great efforts should be made to put partisanship aside and hammer out an agreement that provides long term stability in our health care delivery system. West Virginia has made tremendous strides toward insuring low income, working adults since the passage of the Affordable Care Act. West Virginia has reduced the uninsured rate in our state from 17% to approximately Unfortunately, the overall insurance expense, both premium and out of pocket costs, have continued to significantly increase, making it even more difficult for West Virginia families to afford health insurance. In addition, the ?exibility necessary to operate government funded programs, like Medicaid, to maximize policy goals of effective and efficient care are not always available to states or not available in reasonable timeframes. Generally speaking. West Virginia advocates a three pronged strategy that would facilitate resolution to our many health care challenges. First, Federal funding must be maintained or West Virginia?s health care infrastructure will collapse. Our state faces many challenges in terms of being one of the most rural and oldest in the country. In addition, West Virginia?s population health is similar to that in much of Appalachia, ranking among the worst in the nation. Decreasing federal funding, whether by means of grant funding, Medicaid matching funds, Advanced Premium Tax Credits, or failing to fulfill risk adjustment obligations, would immediately reverse all progress made for both our working population and those vulnerable citizens who we are morally obligated to serve. OFFICE or THE GOVERNOR Second, states should be given maximum ?exibility in determining the best health care policies for their populations. West Virginia has some of the most unique health care challenges in the country and policies that do not take this into consideration often miss the mark in our state. Furthermore, the timeframes established by the Centers for Medicare and Medicaid Services (CMS) are entirely too cumbersome and drawn out. Insurance companies are forced to rely on projections using ?green? data to meet CMS timelines instead of state schedules that are tailored to match market needs using developed data. States should be given broad discretion on how to operate health care programs and, in instances where approval is necessary, should be afforded a streamlined approval process. Third, high?risk pools for individuals with serious health issues need to be part of the healthcare financing system. Focusing care solutions on the major cost drivers in our system will provide greater transparency and opportunity for controls that lead to better outcomes. Risk pools must be actuarially sound, be supported by Federal funding streams, and provide benefits that are viewed as necessary by those procuring the coverage. As Governor, I appreciate the opportunity to provide input on the future of our health care system. Sincerely, Earl Ray Tomblin Governor cc: The Honorable Joe Manchin, Ill The Honorable Shelley Moore Capito The Honorable David McKinley The Honorable Alex Mooney The Honorable Evan Jenkins Secretary Sylvia Burwell