Today, we are rebroadcasting a recent MultiState virtual client event hosted by Maggie Mick on the budget reconciliation bill which contains President Trump's domestic policy agenda currently moving in the U.S. Senate. In May, the House narrowly passed the "One Big Beautiful Bill Act" — which would cut taxes, increase border and military spending, and notably scale back Medicaid, among other provisions. Maggie alongside two of her PPHC health care policy expert colleagues, Barrett Thornhill with Forbes Tate Partners and Brock Ingmire with MultiState, explored the current disposition and provisions of the legislation, what could come next and its potential impacts to the states.
[00:00:12] First, I want to start with Barrett. At the beginning of this year, there was a lot of chatter on two bills versus one reconciliation budget vehicle. Can you kind of just for all the state folks that are on today's call, can you walk through, you know, the debate between the two and why in this instance it may have been advantageous for one reconciliation path forward? And because this bill contains so much of the president,
[00:00:41] President Trump's domestic policy agenda, can you share kind of his overarching goals with this legislation and what is kind of high level contained in it right now? Sure. And just for a brief background, reconciliation is a special type of legislation that Congress can enact that allows for expedited consideration for budget related matters. So the rules are it has to be related to taxes, mandatory spending and federal debt limits.
[00:01:11] As per the Congressional Budget Act of 1974 that created this process. The real key is that in the Senate, the debate for reconciliation bills is capped at 20 hours and the usual 60 vote threshold to overcome a filibuster doesn't apply either. Other key factor is that there's this, there are these rules called the Byrd rules, which affect what matters can be discussed in this. It limits debate to those that are, that are pertinent to the budgetary
[00:01:41] outcomes of the package. And yes, indeed, while Congress in theory can pass up to three bills per year under reconciliation, they really want to do one. That's politically the most efficient process. You don't want to do a bill just for spending, then one for revenue. That gets a little complicated and it makes people take some bad votes. And obviously the minority party can force these votes on tough topics that you don't want. So Trump, when he says he wants one big, beautiful bill,
[00:02:11] he was agreeing to largely the House strategy because their caucus is so small and their plurality is so small, they don't have the opportunity to pass this multiple times. They want to do this once and be done with it. And frankly, that's now an issue. So they passed their bill out once and now the package is pending the Senate side and whatever the Senate passes has to be repassed by the House. And that is where trouble could come and could delay the enactment of this one big, beautiful,
[00:02:41] package because of the difficulty in numbers, which we talk about. But that's the general sense of it. And Trump wanted to combine it all really for political purposes to show that he's not talking about deficit spending and versus cuts to certain spending. They want to be able to justify the tax cut extensions with some level of offsets and federal outweighs.
[00:03:07] And that's the core goal. And that's the core goal that he came into the year for. But by and large, his major focus is the tax cuts and to make sure that it is not on Medicaid or Medicare or the types of mandatory spending reductions. His focus is on the tax cuts. So hell or high water, those have to be reauthorized and reenacted by the end of this year.
[00:03:29] And that's really his motivation. So you might see some things fall out over time on the health care side because of that core motivation to get the tax cuts enacted this year.
[00:03:41] So in terms of the key kind of conversation drivers in this bill with Medicaid and other component parts, can you kind of walk through what some of those, I would say, categories that stakeholders would be most interested in just for the global context?
[00:04:01] Sure. So on the health care side, it is mostly focused on Medicaid proposals and the bill that came out of the Senate Finance Committee yesterday really hones that down to just Medicaid. So a lot of the provisions that affected the Medicare side of the dial were removed because they wanted to keep it very focused on just on Medicaid, which we can get into.
[00:04:29] So that's one big bucket is on the health care entitlement side is around Medicaid. Obviously, the other side is around taxes. So the other big provisions really is focused on on tax policy. And those are in certain buckets, too. So you have you know, you have international taxes and domestic taxes. There's not too much change on the on the on the personal side.
[00:04:54] But there are a few a few topics that could that could modify things as well. So that's the sort of the large sections of the of the package. You know, Mr. Trump did not want a lot of changes in Medicare and he won out on that on that debate. And I think he'll continue to win out as well.
[00:05:13] But the those are the large sections, you know, when the each committee has to have hit certain numbers attached to attached to their attached to their packages. So it's not just that right now we're talking a lot about the finance committee, you know, language. But each committee had their own language. So the Senate Health Committee has their section of the Medicaid section of the legislation. The Ag Committee has their section as well. Banking and Commerce have sections.
[00:05:43] So each each committee has large sections. The Senate Finance Committee has jurisdiction for Medicare and Medicaid. And that's why we're talking about them mostly today. But other other committees also have their have their say in things and we're giving instructions. And that's similar to what the House had. You know, the House has a section on whoopsies, for example, which we talk about today because it does affect folks in the states. But the real health care topics were those focused around, you know, Medicaid.
[00:06:11] Can you and maybe Brock wants to hop in, too. Can you all talk about the proposed provisions and changes to Medicaid? Sure. So, you know, we can talk about this in two two buckets. One are the topics that have already been supported by the House and the Senate basically has endorsed. And then there's also a group of changes that the Senate Finance Committee has has proffered. Now, we should note on the outset, these are just should be viewed as in draft form.
[00:06:41] So we met actually with Senator Crapo this morning and he reiterated this point numerous times that this package is still being modified. There are hundreds and hundreds of ideas. They're still calling through from Republican members to to amend certain topics here. So this should be viewed as a first real draft. It's a solid draft and I wouldn't expect massive changes to it.
[00:07:08] But there are opportunities to change this this package, one, before it goes to the Senate floor and then actually on the Senate floor as well. So this is not final. But the major sort of components around on the Medicaid side, the first release around was known as provider taxes, which are certain.
[00:07:29] I think we were seeing the certain vehicles that that the states and agencies have created over years to allow for a drawing down a larger share of Medicaid dollars from the federal government. And that's a big section. So the U.S. House has a provision that that caps these these provider taxes at six percent starting in fiscal year twenty seven.
[00:07:57] That the Senate bill supports that idea, but also reduces them even further by 50 basis points on annual basis down to three point five percent for those Medicaid expansion states. So it begins to to to carve different policies for those that have or have not expanded Medicaid. The second big thing is around state directed payment limits.
[00:08:21] So the Senate bill grandfathers these to FY 27 as well and limits them to be reduced 10 percent annually until 100 percent or 100 percent of Medicare. This was an idea that actually was that was supported by some conservative think tanks.
[00:08:42] Paragon was the leader of it. And that's an amendment to the to the House bill and a change in how and how HHS was dealt is required to deal with these two SDPs. And that's that's that's sort of a big one as well.
[00:08:57] Another big one that's effects Medicare is that the Senate bill removed the House's Medicare physician payment relief that would have provided update of 75 percent of the medical economic inflation. And after 26 and 10 percent of 27. At 27 percent, a lot of members in the House were supportive of this.
[00:09:21] And really is abandoning that that the Congress deal with this continued abatement of Medicare payments to two providers that was removed entirely. Another big section that was removed was around PBMs. So in the House, the policy prohibited Medicaid spread pricing for PBMs. That was remained in.
[00:09:44] But the other sections were pulled out, including there's Medicare Part B, I'm sorry, Medicare Part D transparency language and also delinking provisions that were removed in the Senate package. There's also a big section on on orphan drugs, which had to deal with how the IRA negotiates prices for these drugs that they have more than one indication. That also was, you know, was was removed.
[00:10:10] And then there was a lot of HSA provisions, including the House bill, that also were dropped out. So, I mean, by and large, you'll see the headlines being that the Senate changes are going to ratchet up the savings from Medicaid and could ratchet up the pressure on hospitals, namely and other sort of providers. There was a bit of a carve out for nursing homes.
[00:10:38] But but by and large, the pressure here is and you'll see a lot of questions here from Republican senators saying, are the additional cuts to the provider taxes and to the SDPs warranted? And should we continue this mission? And so a few things, you know, that the CBO scores are coming out and you'll see the additional savings generated from these policies. And the big question there is, will we need these additional savings?
[00:11:06] Are these valuable to include or do they begin to whittle down the number of senators who are willing to support this package? So if the Senate wants to move forward with this package by next week, which is their goal, there's not a lot of time between now and next week to make these appropriate changes and generate enough support for the bill. Because you're already going to lose some guys like Rand Paul, for example, says he will not support this package because it increases the debt ceiling.
[00:11:35] You have other senators like Senator Hawley, who have advocated to to cool off a bit on these on the Medicaid provisions, particularly around provider taxes, which are viewed as impactful to his rural hospitals. Missouri is also an expansion state. So they're either even further hits to to his states there because of this phase down and provider taxes. But you have senators who who want more, you know, guys like Ron Johnson.
[00:12:05] So we need to have more more hits to to these entitlements because this is the major topic of concern is around deficit spending. And that's a big theme. So yesterday, the Republicans met as a big group. And and the deficit was a major point of discussion. And that's really where they're they're trying to, you know, to make some some big changes and big thoughts is what exactly.
[00:12:30] You know, where where the entitlement reformers need to happen and where they are necessary and where they could need to amend things to to know that these provisions where the House feels very strongly about them. And that's the real the real keys. And then you have the president, you know, the president wants a lot of things. He wants no tax on tips, no tax, Social Security, no tax on overtime, expansion of Medicaid.
[00:12:58] I'm sorry, expansion of manufacturing credits, his baby saving fund. And so there's a lot of topics he wants as well. So the Senate is in a bit of a push pull here. They've got to amend the bill to make the president supportive. They've got to make the change necessary to get their own caucus on the packet where they can pass it with the majority vote. And then they have to make it not so difficult for the House to pass it. And so those are three things they're really trying to focus on and they're doing it all next week.
[00:13:27] So obviously there's a lot of pressure on these folks. And then they have this bigger, larger macro fights around the size of the deficit and the debt ceiling. And that's where these big points are discussed. So it's a lot of changes being made, a lot of sausage making here in this last week. And we'll see if they're able to get over the goal line, you know, by next week.
[00:13:50] And Brock, anything that you'd add in terms of state folks would be particularly concerned with or anything to expand upon that Barrett's already outlined? Yeah, really quickly, just on the provider tax provision. So, I mean, you have seen this in a lot of analysis that I don't want to belabor the point too much. But right, that reduction of 0.5 percentage points for expansion states year over year until 2031. We're talking hundreds of millions of dollars for state Medicaid programs.
[00:14:17] And so there will be expansion states that will obviously be feeling the brunt of that if that provision goes forward. And it's also why it's, you know, Baird Edwards, right? This is why Josh Hawley is so concerned about it is because you have state hospital associations in Missouri. In Kansas with Jerry Moran, in West Virginia with Jim Justice, Susan Collins up in Maine, they have all been really effective to tie provider taxes to rural health care access.
[00:14:40] And so, you know, and I think even if Alaska had a provider tax, which they don't, but if they did, I think Murkowski would be on board with that argument too. And so I do think that's going to be a really pivotal point over the course of the next few weeks as state advocacy organizations really start to weigh in with their federal lawmakers. So you said a few weeks and then Barrett talked about over the next week too.
[00:15:04] So just on paper expectations, the goal is to finalize this by July 4th. Do we think that that is a reality? Or are there enough stakeholders that were impacted by amendments yesterday and enough spend, I guess, starting to ramp up? And other things happening in the world, like Israel and Iran, where this could be drawn out past that July 4th timeline. Sure.
[00:15:33] Yeah, listen, I mean, July 4th, the artificial timeline, it was just, you know, self-imposed. The president thought, you know, you could have this by Liberation Day, for example, which is also coincides with his tariff policy. It's really a made-up date, though. There's no reason you have to have it by next week. And the Senate is not going to pass the bill until they have the votes to pass the bill.
[00:15:55] So I still know what Leader Thune and Chairman Crapo and others are going to do, but that's a major thing they're working towards. I would argue that they are going to meet the deadline until it's proven they won't be able to, and then you'll see a call for a delay. But the real issue, too, is, to Brock's point, the more time the Senate gives people to create opposition, the less helpful it is.
[00:16:24] And so speed is a priority. Yeah, that's a – especially in the House side, too. So the House has three passes, right? And the president may have to make some really hard phone calls to members around, like, the SALT issue, for example, which is a tough one for New England and California members of the House, which is not a big concern in the Senate because they don't have Republicans from New Jersey, Massachusetts, or California by and large.
[00:16:51] So that's an issue for them in the House and not one for the Senate. So there's some tough issues that the House is going to have to go through. The president is going to have to really use his power to get this over the goal line. So it's – the speed is of the essence. It's valuable to have a speedy goal here. So I would – right now, I would bet that the Senate does finish the bill by the end of next week, but it actually could slip, too. There's a lot to go through.
[00:17:20] And that's just on the – and the health care topics are a lot, but Senator Crapo said there's over 200 proposals to change the tax policy that have to be gone through. And so that's important. And the Senate is a body that allows for a lot of member input, and members can really slow things down if they don't get their way here. So here, when you have every single vote counts, it's going to be a tough one to appease everybody.
[00:17:46] But right now, they've got to appease enough people to make it acceptable to the majority of the body. So that's where they are. And I'll give you a 60-40 whether they get it done next week. But if it slips, the question is how far back does it slip? Is it a week – how far past the July 4th break do you let it slip? That's a tough one. And then, you know, how fast can you get it back to the house? That's a tough issue. But so is it a week or two?
[00:18:15] Yes, probably at a maximum. But – Were there any questions – or not questions, but surprises yesterday in a big way that you thought may impact its ability to pass or impacts this timeline? Yeah, to Brock's point too. I mean, the ratcheting down on the provider taxes is probably the biggest change.
[00:18:40] And, you know, there was a general feeling that the Senate was going to go easier on the Medicaid bucket than the House did. And that was probably the biggest surprise. And you saw sort of hospital stocks trading, trending down on Monday as news was leaking out. And then they came back in the day, a well-off session lows.
[00:19:06] You know, after sort of the real bill came out and people started to go through it and assess where the impact would be. So, I would say like the 3.5% capital for the expansion states is probably like the high watermark. So, we should assume that's going to improve a little bit, you know, by 50 or 100 basis points or be pushed out even further. But that's a big – that's probably the biggest surprise that I saw.
[00:19:32] And I wasn't too surprised that some of the PBM policies fell out. So, I wasn't too surprised that the state-directed payment programs got a bit more tense because that was one issue where the president has said he's going to act administratively. And so, the Senate goes, well, heck, if he's going to do that, we might as well take the policy ourselves and put the savings on our balance sheet, not really his. And that's a big one for them as well.
[00:20:03] So, that's kind of where we're – you know, where I saw the major change on the healthcare side. There wasn't massive changes on the tax side besides really the SALT issue, which is – which has been a major focus for, you know, for folks. And also making the permanency of some of these tax policy changes as well. That wasn't really a surprise, but it was interesting to see how that's all, you know, shaped down as well.
[00:20:28] And, you know, one of the other things that I think was a little bit of a surprise, but probably honestly not really, but is around work requirements. So, right, when it came out of the House, there was a lot of conversation about, okay, are we going to up the implementation date, right, from 2029 to 2026 or 2027, right? That didn't happen in this version.
[00:20:44] And I think that is probably more so a testament to a lot of Medicaid stakeholders like National Association of Medicaid Directors, Medicaid Health Plans of America, a lot of folks coming in and really talking with federal lawmakers around the administrative complexity of implementing something like this on such a fast timeline. And so, I also don't want to ignore that.
[00:21:04] Like, the administrative implementation of this package after the fact is still this really significant hurdle that I don't think a lot of folks are talking about if you're not, you know, ingrained in the industry itself right now. And we're going to talk more about that here in just a minute. But before we do, one more kind of political or on the advocacy piece.
[00:21:23] We've started to see governors signing letters, a number of organizations as part of the Big Seven, like CSG and NCSL, submitting letters in support of some of the criminal justice funding. Can you just talk about state actors weighing in on this and how that can be influential with Senators Brock?
[00:21:46] Yeah. So, I mean, to your point, Maggie, you've seen a lot of state led organizations that have already started to, you know, chime in with their own letters of, you know, concern about certain provisions within the, you know, both the House Pass package as well as the Senate Finance Committee proposal. It's interesting because you've got, you know, you say the group of seven, there's it's really right now a group of six and it's, you know, CSG and CSL and the local representation bodies that have really come out and said there are significant concerns for state budgets right now as part of this proposal.
[00:22:15] NGA, I will say, has taken a little bit more of a delicate, nuanced approach to where they have more so said, we want a seat at the table to have this conversation, to talk about what this looks like. And I think that is really the baseline for a lot of those state led organizations right now is let's get to the table first and then let's have a conversation around what this actually means for state budgets, for state administrative implementation. And also, how do states respond from a legislative policy perspective that will inevitably have to come out of this as well? Mm hmm. Mm hmm.
[00:22:44] So if, if and when this passes, let's talk a little bit about implementation. Maybe first with CMS and some of the federal agencies, what are they doing now, Barrett, to prepare for, for passage? Well, they are working with the Congress, right? So they've been providing technical assistance all throughout this process to information that can help them score these, these proposals.
[00:23:09] So that's one thing is, you know, they're, they're intimately involved in the day to day at both the White House level and at the CMS level. Implementation is always a difficult road. There's, there's some provisions that, that the Republicans need to speed up to, to get a faster savings, which was a requirement in the House, like around the work requirements, one example that Brock mentioned. So that's going to be difficult.
[00:23:36] I mean, the implementation is not going to be an easy thing. So some of these policies, Medicare and Medicaid have to put out, put out rulemaking for and have to put out, have to change their regs as a part of. So, as you've seen, it's, the CMS is getting up to speed and they're, you know, they're, they're, they're, I'd say they're all their, their folks are in place, but they're still, you know, gaining more, more teams and staff.
[00:24:03] And at the same time, they're going to have to deal with the legislation. They're under a lot of pressure from the president to make their own regulatory changes of cuts and other issues that haven't, are not in this bill. So like drug pricing, for example, is a very large topic or Medicare advantage topics, which are up for debates too. So there's a lot of things that are also dealing with.
[00:24:24] So I think we should expect a, a, a slow and, and plodding kind of implementation for those policies that they have to operate by 27, but it's going to be a, you know, it's going to be a struggle to get them all ready and operational and get all the programs ready to go. But it's a tough one. Yeah. The work requirements alone are, or, or, or cost. Um, those costs are being put back to the states too.
[00:24:51] They've got to have, they have a lot more requirements now on states and on their, their processes and procedures to make sure that, you know, deceased people aren't, aren't getting benefits. For example, there's, there's a lot of different, uh, transparency requirements that are, that are imposed on the state. So there is going to be a cost element associated with this. Verification. Anything to add there. Education. It's, it's a lot of, it's a lot of work. Yeah.
[00:25:17] The only thing that I would add to what Barrett has iterated is that, you know, in the house pass version, there's this provision that authorizes up to a hundred million dollars in grants to state Medicaid agencies to implement work requirements. Right. And I think to some extent that is recognition of the administrative, you know, complexity that there is to implement something like that, especially after we've seen such states like Arkansas back during the first Trump administration implement work requirements. And there was, you know, admittedly some criticism in terms of how that rolled out.
[00:25:44] And so I think that appreciation from CMS recognizing that states are going to need a little bit of support. Um, you know, it's appreciated by state administrators, uh, for the time being, but how that plays out in, you know, reality, I think we're kind of in a wait and see mode right now. And before we talk a little bit more about the administrators at the state level, can we, let's talk about the finances.
[00:26:07] So the, the further and further we got in the spring, the budget uncertainties for so many states started to, to become very, um, present. Can you talk about kind of how governors are positioning and also how we ended a number of state, um, sessions, um, with some, some budget questions, um, knowing that this was looming? Yeah.
[00:26:29] So I want to start off like from a 30,000 foot view of this because the budget implications here impact obviously healthcare stakeholders, but it's also super influential to non healthcare stakeholders and anyone who relies on state revenue for any type of, you know, performance of their, you know, function of their job. Um, you know, on average, it's expected that this bill is going to cut federal Medicaid revenue for states between eight to 11%. For non expansion states, obviously it's lower between two to 5%.
[00:26:56] For expansion states, you're probably looking more closer to 10. And in some states like Washington, you're looking at as close as 18% of federal Medicaid revenue cuts. So the one thing that I want to emphasize with this is that, you know, there are some good case studies out there to understand the magnitude of what that means. Um, the example I always like to use is Illinois. Every year for the past two to three years, they've received 20, uh, about 20 billion in federal revenue funds from the federal government for Medicaid. Right?
[00:27:23] So under this package there, state Medicaid officials and state budget officials there expect that they're going to lose between 2.7 to 3.2 billion. Their rainy day fund in Illinois is 2.2 billion. Right? And so this is going to set up this conundrum of how Illinois is going to have to make policy decisions at the state level. And the questions are twofold, right? It's do we enhance tax revenue to sustain coverage services and reimbursement rates for providers? And if so, what is that new tax? Uh, and what does that look like?
[00:27:52] Because right, we can't use the provider tax anymore. We can't use state directed payment program to increase anymore. We can't use the MCO tax to the full flexibility that we used to. And so states are going to have to start looking at, do we look at sales tax? Do we look at increasing property tax? Or do we siphon off revenue and taxes from other non-healthcare stakeholders to fund healthcare initiatives?
[00:28:13] The alternative and the flip side to all of this is, okay, in an election year, do we as state lawmakers come back to the state capitol and make decisions to cut reimbursement, to cut services, and to cut coverage from Medicaid? And I'm not saying that I know which answer is the right answer because these are policy decisions that I think a lot of lawmakers are going to struggle with over the course of the next year. But that's the predicament that a lot of lawmakers are going to find themselves in.
[00:28:38] And rainy day funds at the end of the day aren't going to be enough to cover this over the first year, let alone the next 10 years. So I want to start off with that kind of as this high level. And I think like the Senate Finance Committee proposal obviously just kind of digs into that even further, you know, that this is further going to compound the problem in terms of the provider tax increasing hundreds of billions of dollars across state cuts that we would see over the next 10 years. Now for governors, the one thing that I want to emphasize most of them has been pretty transparent this session.
[00:29:08] They want to, you know, hold the line toe the line when it comes to Medicaid spending, and then they're going to come back for a lot of special sessions would be my guess if they feel like they can't adequately address this during the regular session early on in 2026. So I would not be surprised if you've got about 12 to 15 states come back for special session or do something during veto session if they can kind of amend and course correct their budgets after whatever gets passed gets passed out.
[00:29:37] And you mentioned Illinois, but, and we've addressed the expansion states, but just any other states that you think are particularly vulnerable, either due to their rainy day limitations or the impacts? I mean, yeah, right now, I mentioned this as well, but Washington, I think is particularly vulnerable and that's more so I mean, a very big budget debate over the past, past few months involving new tax revenue in terms of how to generate that.
[00:30:04] And it's going to be states that right are hit by that 10% F MAP cut for Medicaid expansion, you know, individual states who have Medicaid expansion that have to implement work requirements. I want to say non-expansion states, it's not that they're out of the woods on this, but I will say that Congress has done a really good attempt to try to mitigate the impact to their state Medicaid or to their federal Medicaid revenue.
[00:30:27] And I think that really is to limit the exposure that states like Texas and Florida, you know, might have in their own lobbying efforts, because if you were to get those governors involved in lobbying against any type of Medicaid cuts, that would probably play a little bit of influence in terms of the final outcome. All right, and then just diving into the state level administrators in preparation for potential passage. What are they currently up to?
[00:30:57] Yeah, so I think this really becomes a twofold question. And I would say, you know, it's one thing that I mentioned earlier in terms of the administrative onus that I think a lot of these states are going to have to encounter with. And I think some of the key provisions right now that are being considered that are going to create the most onerous administrative burden are going to be issues like work requirements. It's going to be the, you know, Medicaid expansions every six months of eligibility verification checks.
[00:31:22] It's going to be, you know, states trying to implement work requirements on a more frequent basis than just annually. And that's where that Arkansas example comes into play, to where Arkansas, when they passed this or when they got the approval for their 1115 Medicaid waiver back during the first Trump administration, they saw 18,000 enrollees disenrolled over nine months because of concern over administrative churn. And look, when you have administrative churn, here's what happens for staff and administrative responsibilities, right?
[00:31:50] It's not just the matter of processing that, you know, eligibility verification and that work requirement verification. It's then dealing with the appeals process, the resubmission of the verification documentation. And then if they are disenrolled or suspended, they didn't have to resubmit new eligibility documentation to prove that they can get back onto Medicaid. That all adds up to time. The other component just to all of this that I would say are Medicaid enterprise systems, right? And Medicaid information management systems.
[00:32:19] Like, we have a lot of states, more than 20, that are still operating on their legacy-based systems that have been in place for more than, you know, three decades in some cases, right? And so when we talk about how do we transfer in data from trusted, reliable data sources into these systems so that we can conduct verification checks on a more efficient basis, what does that look like, right? That's going to take time for states to be able to implement and integrate those new systems so that they can do that in a more efficient basis.
[00:32:47] And we're talking three, four, five years. And so then the question becomes in that interim, who are the state actors that are going to have to pick up that burden until we get to that technological upgrade standpoint? And it's going to fall on administrative staff. It's going to fall on hiring up contractors. And in some cases, I think they could contract out with Medicaid MCOs to help relieve some of the administrative burden as well. All right.
[00:33:12] Well, before we turn to client questions, and we encourage you to put them into the question, the Q&A box, I'm going to thank our Political Life audience for joining us and go to those Q&As. But before I do, Barrett, Brock, you guys are so smart. I'm so thankful to work with you both. Thank you. Thank you.