; (4) in paragraph (4)— (A) in the heading, by striking system and inserting systems ; (B) by striking MACPAC shall create and inserting the following: (A) System related to access MACPAC shall create ; and (C) by adding at the end the following new subparagraph: (B) System related to program growth MACPAC shall create an early-warning system to identify challenges with sustaining Federal and State funding for Medicaid during the mid-term and long-term. MACPAC shall include in the annual report required under paragraph (1)(C) a description of such challenges, including challenges posed by budgetary pressures which could lead to increased Federal or State deficits, crowd out discretionary Federal or State spending, or necessitate increases in revenues, and proposed recommendations for addressing such challenges. ; (5) in paragraph (5)— (A) in the heading, by striking and regulations and inserting , regulations, and guidance ; (B) in subparagraph (B), by inserting financing, after quality, ; and (C) by adding at the end the following new subparagraph: (C) CMS guidance MACPAC shall review guidance issued to States by the Centers for Medicare & Medicaid Services with respect to Medicaid or CHIP and shall, not later than the date that is 90 days after the date of such issuance, submit a report to the appropriate committees of Congress and the Secretary on the degree to which such guidance is projected to change Federal or State outlays for Medicaid or CHIP. ; (6) in paragraph (7)— (A) in the heading by inserting and working documents after reports ; (B) by striking MACPAC shall transmit and inserting the following: (A) Reports MACPAC shall submit ; and (C) by adding at the end the following new subparagraph: (B) Working documents MACPAC shall make available to the appropriate committees of Congress copies of draft report chapters, white papers, and other materials distributed among members of MACPAC.