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Clinton Library
DOCUMENT NO.
AND TYPE
DATE
SUBJECTfflTLE
RESTRICTION
001. memo
Chris Jennings to Distribution
Re: Upcoming CBO Reports (2 pages)
4/15/93
P5
002. memo
Chris Jennings to Hillary Clinton
Re: Tomorrow's Finance Committee Meeting (19 pages)
4/19/93
P5
003. memo
Chris Jennings, Steve Edelstein to Hillary Clinton
Re: Legislative/Congressional Distribution List (2 pages)
4/20193
P5
COLLECTION:
Clinton Presidential Records
Domestic Policy Council
Chris Jennings (Health Security Act)
OAlBox Number: 23754
FOLDER TITLE:
April 1993 HSA [2]
gf77
RESTRICTION CODES
Presidential Records Act - 144 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
PI
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b(l) National security classified information [(b)(l) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
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b(3) Release would violate a Federal statute (b)(3) of the FotA)
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FotA)
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RR. Document will be reviewed upon request.
�."
13 April 1993
To: Judy Feder and Ira Magaziner
From: Robert Valdez
Subject: Impact on Local communities - Immigration &
Health Care Reform
Copies: Latino Work Group Members
i
FEDERAL POLICY IN THE 1980s WILL INCREASF!: AND DIVERSIFY
IMMIGRATION STREAM IN THE 1990S AND EARLY 2000
The 1980s was marked by a wave of immigriition nearly equal to the
peak number who arrived in the first decade of the century. With
an acceleration of immigration since the!: 1960s, the proportion of
immigrants in the total population has reached 8 percent in 1990.
Nearly one of every two foreign born persons now residing in the'
country entered within the last decade. I They account for 40
percent of the 22 million 1980~1990 popuiation growth in the
nation and for more than half of the growth. if the U.S.-born
children of immigrants are included.
During the last decade we witnessed a comprehensive redesign of
.
.
11
the U.S. policy towards 'refugees, undocumented immigrants,
temporary immigrants, and those gaining permanent immigrant
status. Three new statutes - the Refuge;, Act of 1980, the
Immigration Control and Reform Act of 1986 (IRCA), and. the
Immigration Act of 1990.- are the most important components of
this redesign.
Together they will increase the number of
immigrants - documented and undocumented! - coming to the United
States. The key expansionary provisions, include:
I
*
number of documented immigrants allowea entry increased from
500,000 to 675,000 or more.
,
I,
*
Refugees and asylees will remain outsiia.e the limit.
Conservatively they can be expected to a.:dd 150,000 to 200,000
entries every'year, up from about 100,000 in the 1980s.
In light of the profound international geopolitical changes and
growing incidence of regional conflicts'!throughout the world, we
can expect· increased pressures to admit refugees and asylees.
(In June 1993, the President must decide the fate of the
Salvadorean immigrant community because itheir temporary status
expires again. Many Salvadoreans live ~h the D.C~ area. and many
have lived in the United States for over; 10 years and raised
their children here.)
,
.
I
IMMIGRATION IS MORE THAN A BORDER ISSUE Ii
In addition the new laws provide for four new categories of
immigrants that will profoundly affect t:he size and composition
�of immigration in the United States. First, the largest amnesty
program for undocumented immigrants will;. move more than 3 million
from the underground to the mainstream of American life. The
'
majority of applicants were Mexicans (75~) ,living in four states
along the U.S.-Mexico border. As amnestied immigrants become
permanent residents and citizens'they will ·be able to sponsor
additional family members. Second, each country's quota for
documented immigrants increased from 20,000 to 47,000. Countries
most likely to benefit are those with long waiting lists,
including the Philippines, Mexico, 'India.~ China, Korea, and
Vietnam. Third, creation of a diversity;;visa (55,000 annually)
to be granted to nationals from counties: sending few documented
immigrants to the U.S •. This is likely to increase immigration
from.some European countries·(e.g., Ireland and Eastern Europe)
and Africa. Lastly, establishment of a "temporary protected
immigration status" for a selected group!of undocumented
immigrants provides beneficiaries protect.ion ,against deportation'
and authorization to work. Currently tw~ groups are so covered:
spouses and children of the amnestied immigrants and nationals
from El Salvador and a few other counties.
L
MANY IMMIGRANTS CAN PARTICIPATE IN SOCIAL, PROGRAMS
Because immigration is expected to continue at peak levels
throughout the 1990s, the local effects of immigration and the
fiscal capacity of local areas and of individual communities to
integrate successive waves of immigrants ,has emerged as a
significant policy issue. Considerable qonfusion exists
regarding what programs and services are available to immigrants
- documented and undocumented.
(This distinction is not very
useful from a practical point of view, particularly at the local
level.
It is virtually impossible to separate out the document
from the undocumented. Families are oft$n composed of a complex
mixture of immigration'statuses - citizens, residents,
undocumented.) The following chart provides a quick look at the'
.
,.
status quo.
:
"
Program
LPR
AFDC
SSI
UNEMPLOY
MEDICAID
Y
Y
Y
Y
FOOD STAMP Y
Y
WIC
SCHOOL
LUNCH
Y
Refugee
PRUCOL
y,
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
PRE-82
sAw
Family
-5 YR WAIT FROM '86Y
Y
~
Y
Y
Y
-CHILD/ELDERS FULL
OTHERS EMERGENCY
for 5yrs from '86
-5 YR WAIT FROM '86Y
Y
Y
Y
Y.
i'
Y
TPS
Undoc
N
N
N
N
N
Y
MCH&Preg
Emergency
N
Y
N
Y
Y
Y
(LPR - Legal permanent resident;-PRUCOL ~ Permanently Residing
Under the Color of Law; SAW - Special Agricultural Worker; TPS
,
Temporary Protected Status)
�I
P
As you can see there are'numerous Federally funded programs that
do not discriminate immigrants based on their immigration status.
It is important to note that the PRUCOL are technically
undocumented immigrants who have established themselves as if
they are documented residents. This can', be done in a variety of
ways including filing a regular tax form: 1040 rather than a form
for non-permanent residents.
;
!,
~
FEDERAL POLICIES GREATLY STRESS LOCAL CO$,MUNITIES ALREADY
Immigration affects most of the countrie~ major cities and local
communities. The twenty-five largest communities in the country
have experienced large growth in their immigrant communities.
Local communities with large immigrant populations were promised
federal financial assistance with IRCA but SLIAG funds were never
made available because they were politically vulnerable as set
aside funds.
'
CONCENTRATION-OF IMMIGRANTS IS INCREASING
Between 1980 and 1990, 8.7 million new i~migrants (documented and
undocumented) entered and remained in the'country. Most (71%)
reside 'in just five states: California, ~ew York, Illinois,
Florida, and Texas. The remaining quart~r are spread throughout
but generally in specific local communities.
RELATIVE CONCENTRATION INCREASES AS SIZE!OF JURISDICTION
DECREASES
r
o
Increased diversity of metropolitan area consumers creates
demand for culturally competent health care delivery systems
I
-
'
,
o Creates a two-tiered system if immigrants left, 'out
Increased needs for public health and ,community development
and health promotion perspectives that' go beyond medical care
delivery reform
o
"
o Tremendous fiscal/stress on local communities due to Federal
policies.
"
j:
o System could collapse in major metropolitan areas under weight
of the transition to 'the new system and rapid population
growth.
�HOUSE JURISDICTION ISSUES
I
I
I
Attached is an analysis of juri~dictional issues raised
surrounding the health reform legislation. This analysis was
prepared for the House Majority Lead~r's office and was given to
me by Andie King. It provides basic!background information that
may be helpful for your meeting tomorrow.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. memo
SUBJECTffITLE
DATE
RESTRICTION
Chris Jennings to Distribution
Re: Upcoming CBO Reports (2 pages)
4/15/93
P5
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For a complete list of items withdra,,:,n from this folder, see the
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I
COLLECTION:
Clinton Presidential Records
Domestic Policy Council
Chris Jennings (Health Security Act)
OAiBox Number: 23754
FOLDER TITLE:
April 1993 HSA [2]
gf77
RESTRICTION CODES
Presidential Records Act -(44 U.S.c. 2204(a)]
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.
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I
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�I
'
16 April 1993
\
TO: Judy Feder and
FROM: Robert Valdez, Henry Montez,·
Elena Rios
SUBJECT: Options for defining
Ci~o
Sumaya, Richard Veloz,
:
,
UNIVERS~L
COVERAGE
I
In response to your request we have P4t together the following
options for defining univera1 coverage that address several
issues regarding the treatment of immIgrants and visitors.
Valdez's 13 April memo provided backgiound information for
reconsidering the publicly stated pos~tion by you and Mrs.
Clinton that only citizens and permanent residents would be
included in the new system. The implications of defining
univeral coverage in this way in the ~ake of a comprehensive
redesign of U.S. immigration policy during the 1980s may not be
readily apparent. The major implicat~ons include:
.
I
o A large number of U.S. residents remain "uninsured," especially
in·the large and rapidly growing Latino and Asian communities
across the country. Dr. Valdez's February 17 JAMA article
documents the extraordinary increase in the number of uninsured
in these communities despite their extremely high rate of
participation in the labor force.
i
I
o A two-tiered system for citizens and "second-c1ass tl immigrants
will be created, especially if the reforms must be phased in
over a number of years. Uncompensated care for catastrophic
events and the wasteful use of emergency rooms for non-life
threatening care will continue the pattern of costly care we
wish to eliminate. Eligible chi1dr~n may not fully participate
in the system because their parentsl' fear deportation.
i
I
o Cities and counties will bear an unusually heavy fiscal
burden in maintaining personal hea1th care services for a large
1
number of immigrants and other disenfranchised individuals.
Maintence of effort funds for the dew system may not be
available as result of these demands.
o Numerous states, especially Califo~nia, Texas, New York,
Florida, Illinois, New Jersey, Connecticut, Washington, and
Michigan, will bear the brunt of f~deral policies on health
care reform and immigration policy.!
i
Among the 37 million or so uninsured residents of the United
States (Mrs. Clinton apparently does ,not know that our estimates
of the uninsured include non-citizens and citizens alike.),
include about 6 million blacks and about 7.1 million Latinos.
It
is ,;important to keep in mind that noimatter what strategy the
President chooses Latinos may sti11~ace major health care access
difficulties. Ensuring adequate medical care services to the
Latino community and immigrant commurtities requires attention to
I
�,
.
both the financing mechanisms and the structure of the medical
care and public health delivery systems. Even Latinos who are
currently covered by health insurance cannot find an adequate
supply of providers in their communities.
EXPECTED: 10 MILLION IMMIGRANTS IN THE 1990s
Current statutes assure the expansion of opportunities for
immigration and undocumented immigration is likely to continue
unchecked. As a consequence, we can expect immigration to reach
one million a year or more during the 1990s. For more than a
century, formulating and enforcing immigrant policy have been the
exclusive prerogative of the Congress and the federal executive
branch. But today, as in the past, the effects of immigration
policy are felt mainly at the local level, a fact that has yet to
be fully recognized by Congress, by immigration advocacy groups,
or even by analysts. The largest demands on local jurisdictions
are for education and health care. Two recent Supreme Court
rulings have broadened state/local responsibility in the area of
education, first by mandating equal access to K-12 education for
the children of undocumented immigrants (Plyler v. Doe,1982) and
second by requiring greater state and local attention to
language-minority students (Lau v. Nichols, 1974). These rulings
and the extension of Medicaid coverage under state option to
immigrants, documented and undocumented require a careful
examination of how "universal coverage" will be defined.
OPTION 1: DEFINE ELIGIBLES BASED ON ESTABLISHED RESIDENCY
Many programs currently define eligibles based on residency
rather than citizenship. These programs have largely followed
the basic American principle, "justice and liberty for all."
Under the Equal Protection Clause of the Fourteenth Amendment as
set forth in Plyer v. Doe, 1982 the Supreme Court said that
undocumented students have a right to a public education. A
permanent injunction by the U.S. Court of Appeals in California
in Crespin v. Coye specifically stated that county welfare
departments and others are enjoined from denying Medicaid
coverage upon verification of immigration status.
The major objection to defining eligibility by residency reflects
fear of immigrants and the notion that some individuals espouse
that immigrants are a drain on the public coffers. Numerous
Presidential Blue ribbon panels and policy analyses including
those by Dr. Valdez have demonstrated that nationally immigrants
add to the economic and social fabric of American society. The
negative effects, as Dr. Valdez points out fallon local
jurisdictions largely in the form of demands on the education and
health care systems.
Provisions for the many populations who do not fit the narrow
definition of citizen or permanent resident must be given renewed
consideration if adopted. These populations include, many
categories of immigrants, foreign students and other visitors who
�live in the U.S. for extended periods of time, and guest workers.
OPTION 2: RESIDENTS PARTICIPATE BUT ONLY CITIZENS AND PERMANENT
RESIDENTS ARE ELIGIBLE FOR FEDERAL SUBSIDIES
Residency could be used to define eligibility to participate in
the new system. However, a more severe test such as citizenship
could be used to establish elibility for the range of subsidies
funded by the federal government. States could choose to provide
these subsidies for special populations such as immigrants or
visitors.
OPTION 3: REMAIN SILENT ON PARTICIPATION REQUIREMENTS
A number of program statutes are silent with regard to
citizenship or residency. States vary in how they determine who
is or is not included in their programs.
In general, groups with
legitimate claims excluded from the programs have pressed their
case in the courts. Program eligibility reflects the individual
community values and concerns.
Programs funded in large by federal monies have largely included
citizens, permanent residents, and other residents (many of whom
are technically undocumented immigrants). Others individuals are
included in medical care programs on an emergency basis.
OPTION 4: INCLUDE SET ASIDE FUNDS FOR SPECIAL POPULATIONS,
SUCH AS IMMIGRANTS, STUDENTS, TOURISTS, AND OTHERS
Set asides are extremely vulnerable to political whim. For
example, a set aside for states with large numbers of newly
documented immigrants under the Immigration Control and Reform
Act of 1986 with the exception of the first year has never been
funded by Congress.
If such a set aside were to be developed it is extremely
important that major metropolitan areas directly be identified
for funds as well as providing state level relief.
After your presentations and Mrs. Clinton's recent meeting with
Latino health care professionals in which it was stated that the
undocumented would not be included in the new system, we have
received indications that Congressional leaders, state
legislators, and local county officials are extremely concerned.
We look forward to working with you in finding a workable
resolution to this and the related issues. Defining who is part
of the universe under "universal coverage" is a key parameter in
the reform initiative.
We should probably meet to discuss how best to address this issue
and to consider how best to respond to the concerns of the
national, state, and local representatives.
�-=
CHRIS - WE'VE DONE THE BEST WE COULD WITH YOURS, LARRY AND LYNN'S
NOTES - THIS INCLUDES STEVE'S INTERPRETATIONS
PLEASE FILL IN BLANKS IF YOU ,.CAN - MAUREEN'
I
NOTES FROM SENATE RETREAT APRIL 15-17, 1994
BAUCUS: wants' distribution tables, to see how it effects
businesses. Liked Modell more than Model 2, size and types.
Percentage of permanent versus temporary employees.
Impact of model 1 (~utoff 1000; individual wage cap) on
businesses of different sizes.
Commends you for keeping concept of universal coverage. Jury
is still out on this. Uwe Reinhart .talks about pursuing shared
ethics. Given these structures I tend to prefer Model 1 because
it hits concerns I hear at home (small business and retail
business)
Do we have distribution tables for Model 1 -- how it effects
different sizes of firms and households? Size and types of firms.
A percentage of permanent vs. temporary employees. 30,000 (perm)
vs. 10,000 (temp)
BIDEN: Present insurance plans are allover the board. Can you
generalize what the payment is for an average plan currently in
the marketplace? Not withstanding tpe 8% inflation rate.
Distribution tables of current household spending. What major
blue chip -- ego average DuPont employee pays. Copayment is
relatively scary notion, but if copayment is looked at in terms
of what people have or don't have today. E.g. people don't have
drug coverage now. Wouldn't be that hard a sell.
Distribution for percentage of Americans with coverage who
have had to spend one day or more in. the hospital. I have an
embarrassing high percent of uninsured in my state. Translate
this to the average person. Raising copays wouldn't seem too
bad, relative to the current system~
I
Can you generalize? wants numbers -- re: individual plan.
Benefit reduction may not be so bad.: Distribution for % of those
who have utilized services.
<'
(Exxon): Benefits: looking at premiums payments and out of pocket
payments, describe impact on familie~ofbenefit package
family payments today, under HSA, under HSA minus 5%.
Discussion focused on tradeoff between premiums and copays
- Do we want to show anything that distinguishes users from
general population (e.g. x for the y percent who don't get sick;
�z for the others?)
Later: compare premiums today and under reform to major
employer in each state (by employer name?)
What are copayments now in comparison?
BINGAMAN: Wants more of other options to reduce value of benefit
package. Wants to see menu of benefits reductions (likes copays
as deterrent on services use) Raised now at SO/50 but customs
very for individuals. Much more interested in legislating
something affordable for benefits. You suggest there were three
changes to reduce value of benefits package by 5%. I think
that's useful. The more you can do to raise copay, the more you
place individual responsibility. I'd like to see menu of other
reductions.
Raised issues of impact of alliance size change; of 50-50 on
families (MOE raised in Ira's response)
What do we lose by taking threshold from 5,000 to 1,000. My
understanding was that premiums for firms inside alliance would
go up.
Model 3: My understanding is that HSA caps household
payments at 3.9 percent to 40K.
55% of my employers don't provide insurance. I'm more
interested in affordability than level of benefits.
BOXER: I support deficit reduction. You can do it without too
much pain. Dropping from 5,000 to 1,000 is good. consistent with
what she hears at home. If we base this system on wages, doesn't
this encourage firms to keep wages down? Since this is an
employer based, how can we fix the problem of independent
contractors? Can people still buy additional benefits?
Individual wage cap -- won't it encourage keeping wages
down? (need rhetorical argument)
BREAUX:
Risk defeat from claws of victory if we do too much too
soon.
- All plans have a substantial agreement about what is
needed: a standard benefit package; purchasing coops; insurance
reform; subsidies for poor people; medical malpractice; and anti
trust. We're not giving reform a chance tq work before mandates.
Price controls don't work. Medicare has price controls. The
increase in Medicare alone was higher than all foreign subsidies.
Doesn't want mandates or premium caps'.
�BUMPERS:
(Heflin - does this mean Heflin had same concerns?)
Concern about cliffs (subsidy for firm size) - Would keep him
from hiring that 75th worker if you target higher subsidies to
small firms. (Heflin(?) Allow regulatory flexibility to smooth
subsidies. )
CONRAD: Deficit reduction important. Need charts on the effects
of health care expenditures and subsidizing effects. We're
talking about holding the rate of deficit reduction growth.
Would like to see charts that show how we're changing health care
spending and how we're affecting the actual deficit (i.e.
reducing rate of increase in deficit)
Howard raised the point we're talking about holding down the
amount of deficit increase, not deficit reduction. Net lifetime
tax rates for future generations of 82% if there aren't
sUbstantial reductions. We've got to take action as quickly as
possible. It would be useful to have big charts that show
effects on national health expenditures and federal budget
effects from what we do.
DECONCINI: How verifiable is the feasibility of the tobacco tax.
Black market rise / reduction in compensation etc.
subsidy
too small.
I find troubling that we don't use the word "taxes." Can you
give me background on taxes involved~ $126 B. that CBO scored
included individual taxes, right? How much would be raised with
tobacco tax? If you're looking to increase small business subsidy
without increasing employee contributions or decreasing benefits
package, is there any consideration of other taxes? i.e. liquor
tax or individual income?
We don't want to lower benefits below 50th percentile of
Fortune 500.
DORGAN: Pressure on business
now
of the threat of
reform. What is driving reform is health care costs. Why go
through all of the agony and still increase costs of GOP that
goes from 14 to 18. Why can't we keep around 14-15%.
I've not been surprised at costs moderating -- they're under
direct threat that we're not going to do something about this.
What is driving the demand to do something about this is middle
income families faced with increased costs. BC says spend 14
percent of GOP for health care. We've constructed a plan that
increases 14% to 17.3%. If we go through all of this agony, will
we do anything to address their concerns about increased costs?
Can't we hold health care to 14% of GOP.
All respond to who aren't economists. When we say to them
we've done nothing to address this, I fear that.
EXON:
Any cost to family, rather than just insurance premiums.
�wants total costs.
Modell: Can we talk about average cost of family instead of
premiums? Premiums don't include out of pocket? Need way to judge
premiums and overall costs.
FEINGOLD:
Opposed to liquor and wine tax.
FEINSTEIN: Closer philosophically to Lieberman and Glenn than to
Wellstone. My husband employs 30 people and pays 87-8,000 for
100% of their coverage.
I believe he should be able to continue
to do this. Concerned about how people who now have Cadillac
benefits will stay whole.
Concerned about part-time, temporary employees (The Gap).
We should get people without coverage covered. Illegal
immigrants-- all in CA won't be covered. It's better to cover
those without insurance gradually and then phase in the rest as
we move along. If the average worker earns $28K, are they better
or worse under reform?
In deficit reduction in Models, is it reduction in increase
or is it an actual reduction? How did you select break point of
75 employees?
Providers of last resort--the county hospitals of the bay
area-- are concerned that the money available to compensate
providers won't be sufficient.
GLENN: Our economy depends more and'more on service industries.
I'm not sure I understand subsidy. Size of businesses has little
to do with ability to pay. Profitability would determine ability
to pay. I looked at small companies. 3 out of 5 businesses fail
in the first 18 months. Our economy depends more and more on
service industries. Number of firms between 75 and 5000
employees. Concerned about 500 to 600 range. Was any
consideration given to tying this to profitability and not just
size? Do we have numbers about number of firms and their
contributions to economy under 25 employees and over 5,000.
Maybe link to profitability.
GRAHAM: Early retirees concerns and long-term care. The impact
of tax cap concerns. Regional alliances and their role with
regard to cost containment.
I would suggest continuing this type of analysis for LTC,
early retirees among other things. Consider some nonquantifiable
effects -- as you widen the gap between those covered in HSA and
those outside as I understand it, there will be unrestricted
employer deductibility for 10 years -- what kind of systems are
we bringing people in when you, after 10 years, bring people
closer to a common plan? RE: setting of initial premiums I
thought the negotiation of premium bids would take this into
�account and alliances would take
car~
of this.
HARKIN: Let's not fool ourselves by: reducing the costs of
benefits. It increases out-of-pocket costs.
,
,
Model 1: employer premium goes up/household share goes up.
Model 3: Employer premiums go down, but household payment
,
goes up.
Model 2: Both payments go down, but you have savings. What
is that? (Mitchell response) You're getting less. Reducing the
benefits package.
HEFLIN: What happens to indigent when you reduce benefits?
Impact of higher copayson the indigent. (Kennedy concerned too)
Does this reduce jobs?
will business have to increase administrative burdens on
business?
What about a 1% corporate profit tax instead of a 1%
assessment on payroll?
Won't firms have to increase people to calculate how much
they pay? How will model 1 be reported, monitored, checked and
audited?
'
Does this reduce jobs over the 'long run? How does it effect
500-600 employee size firms? How would businesses fare under 1%
of payroll vs. 1% of income tax?
'
How does overall cost to business on per employee basis
effect firms above threshold as opposed to the smaller firms? If
each of us had our largest employers current payments calculated
and we could show how much they'd pay under reform?
JOHNSTON: Do you have figures about how much employers pay? What
do we do if we're wrong and when do we do it? How about
triggering in expansion as savings come in?
Figures were based on a number of assumptions. What are the
assumptions about prices we have least degree of certainty? What
would we do about this? Isn't there any way to do this gradually
as uncertainty deqreases?
'
Kennedy: Never get federal deficit under control; Gap of people
without insurance growing, especially children -- children are
most vulnerable. For every five people that are hired in Mass.
hospitals, three are administrators.: Every line is going in the
wrong direction; Labor and Human Resources has had 48 hearings.
We should explore downward pressure on wages.
We were looking at 1% payroll tax as a way to finance small
business subsidies.
LAUTERBERG: Wants deficit reductions. wants to be careful about
costs. Don't get too ambitious.
'
If you don't have this characte~ized as deficit containment
or reductions, it'll be impossible to sell. Model 3 -- does not
support this model, but wants to point out do we use increased
assessment from Treasury to mitigate, employee payment? Does
employer pay assessment on wages or total compensation?
�·.
Likes idea of increasing gatekeepers to keep people from
seeing specialists, etc. Doesn't think we can expand coverage
home health, LTC, drugs -- right away. Thinks we should focus on
basic services.
.
LIEBERMAN: Concerned about trying to do too much too soon.
Doesn't want to hurt a good thing -- believes that we have an
extraordinary system in terms of progress made. cited a trip to
Boston to meet with staff at Massachusetts General Hospital about
the impact of new drugs, new technology and the overcapacity due
to shortened stays. More than 50% of people get care through
managed care plans. Health care costs are only rising about 3.3%
a year. Feels that there is a lot of positive stuff going on in
the marketplace now. Politically, the majority of the people
today are satisfied with their health care. The number of
satisfied Americans has risen since we've been talking about
health care reform. Have to be concerned about not making impact
on quality or costs people face. Concerned about the 1996
elections. supports universal coverage, but on a more
evolutionary basis. Concerned that employer mandate will cost
jobs and reduce wages. Believes that people are most concerned
about health security and cost containment and portability.
Thinks we should have managed competition, higher malpractice.
Alliances would allow small businesses and individuals to buy
health care at a lower rate (cost containment). Managed
competition will work for cost containment.
suggests giving
incremental
and then come back to see where things stand
in two or three years. wants a bipartisan approach. Believes
Breaux's bill should be tried first and then come back and see
where we are in two-three years.
I think consumers of health care have said to providers "we
can't continue to pay double digit increases in health care
costs."
Concerned that the first year premium cap administration
is perceived to be too intrusive. Fear that there will be a
reduction in benefits. will there be a MOE for businesses that
offer good plans. Very leery of reducing benefits. It will pay
into the hands of those opposed
LEVIN:
Initial premium will be different region by region. In the
first year there's a requirement to lower the cap. Is the first
year going to work any differently from subsequent years? Is it
any more bureaucratic in the first year?
with the 5% reduction in benefits package it would be at
35th percentile. One of the arguments I hear is that the
President's plan will lead to reduction in current benefits.
Another negative perception is that it will cost more. Where
there's a supplemental package that has extra cost is going to be
tax deductible. Is there going to be a maintenance of effort so
that employers will have and continue providing current level of
benefits? I'd be leery of reducing benefits package below the
�.,
median.
It'll play into the hands of opponents.
METZENBAUH: Why do we need to get deficit reduction out of
health reform? Why ask businesses, employers and federal
government to pay more for that end? .
Mitchell: Has a slide presentation -- No questions were asked
through slides.
Q&A's after presentation:
Q: Why aren't we giving any attention to the deficit?
A: I feel that increasing changes for employers of
individuals or decrease the benefits will be hard enough. WE
should deemphasize the deficit.
All government programs have cliffs because they're targeted.
If HSA were adopted as proposed, health care costs will rise 7.3
percent per year with covering everyone, but 8.4 percent without
covering anyone else.
Employer subsidy -- every employer gets a subsidy under HSA
depending on size and payroll. 7.9% cap applies to firms,
including those at 500-600 employers. In addition, there's a
lower percent for small firms.
MOYNIHAN: Will start meetings on Tuesday, April 19, to see where
. we are relative to drafting. Physics = Biology now.
Define universality - Thinks Social Security's 95% is about
right.
that's what we got in
fee. Relative
price of personal services increase and there's nothing you can
do about it. That's life. Police, teachers, nurses costs
relative to
will increase.
We have a higher percentage of GOP, now, paying for
education. That's just the way it is for a modern society.
Development of DNA research, pharmaceuticals, etc •• Large
surplus of hospital beds. Sixty percent of surgical procedures
involve one day in hospital now. As progress brings leaves us
confident of future.
PELL: Won't employers
the subsidy system? will there be
bipartisan interaction and a process set up?
Payment - don't subsidies encourage keeping wages low?
ROCKEFELLER:
- Job loss won't be a problem.
Negligible job loss should not get in the way of reform.
15 cents an hour.
Real emphasis at small business in various states.
Individual mandate effect on marginal rates.
Alliance defense -- passionate. Let's make sure that we
design something that is based solely on how it works not how it
�sells.
SARBANES: It's absolutely imperative we pass universal coverage.
Other developed countries have all done this. Need this to make
everything else work. Look at inequities in current system - one
employer wants to do right by his people and provides health
insurance. His competition doesn't. Not only is that not right,
but the responsible employer has to pay for the others employees
when they go to the hospital. The system isn't rational. As a
practical political matter, we have to pass something with
universal coverage because President said he'd veto a bill
without it.
wants real universal coverage. It is the right thing to do
and it won't work without total reform. Look at all the
incentives/rewards we give to irresponsible behavior.
Can you tell us how much of deficit reduction comes from
each policy change?
SIMON: Interested in Board size.
WELLSTONE: Argument we must be concerned about is less choice and
fewer benefits.
- Democrats have made a commitment to coverage.
- We must make certain that benefits are affordable to
businesses.
- Concerned about lowering to a 1,000 firm size.
universal coverage has galvanized people around health
reform. When it comes to families paying more, we need to look
at distribution effects. If it's not affordable, it's not
universal. I worry about companies opting out of community
rating if you go below 1,000 you run risk of risk selection above
1,000. There would be incentives for companies to hire health
people or let people go. Need to be serious about explosion of
costs, but we can't pare down benefits too much.
WOFFORD: Could we have greater state flexibility to address
tradeoffs? Do we have to have same system across states? e.g.
SO/50 in some states; 80/20 in others.
�April 19, 1993
MEMORANDUM FOR
FROM:
SUBJECT:
Chris Jennings for First Lady Hillary Rodham Clinton
Malpractice Reforms at the State Level
As you requested, we are forwarding information on state-level malpractice
reforms. We have briefly summarized the findings of this report below, I hope
this is helpful, and I know Mrs. Clinton is looking forward to working with you on
this and other health reform issues in the weeks and months to come. If you have
any questions regarding this material, please contact me at 456---2645, or
Christine Heenan at 456-2929.
.
The effects of reforms-- background and summary:
Mter four years of relatively flat rates, malpractice premiums and tort costs began
to rise again in 1991 and 1992. Medical malpractice coverage cost jumped from $7
billion in 1991 to an estimated $9.1 billion in 1992, and jury verdict research
found a nationwide increase in the number of jury verdicts exceeding $1 million.
Both the direct and indirect costs of malpractice suits are hotly disputed. While
many analysts (and more doctors) feel that filing rates are unnecessarily high and
litigation too costly, others contend that a very small percentage of medical
negligence-related injuries ever become claims. The indirect costs, or so-called
"defensive medicine", are also in question; tort reform proponents believe defensive
practices-- particularly excessive and redundant testing-- add significantly to
our national health bill. The AMA, for example, estimated the costs of defensive
medicine to be $15.1 billion in 1989. Skeptics claim that doctors hide behind
"defensive medicine" as a reason to do more tests and procedures which raise their
income, and that many "defensive" practices, like keeping more detailed records,
getting more consultations, and telling patients more about risks, are actually
good medicine.
.
Many states have enacted malpractice reforms as part of overall state health care
reform packages, others as more narrow policy targeted toward improving access
to care by limiting provider liability for harm to recipients of reduced-:-cost care.
�-2
This memo focuses on 2 types of malpractice reforms at the state level:
1. ALTERNATIVE DISPUTE RESOLUTION
2. CAPS ON DAMAGES
Main sources of data:
"Medical Malpractice: An Overview of 1992 State Legislative Activity", GWU
Intergovernmental Health Policy Project
"Compendium of State Systems for Resolution of Medical Injury Claims", Agency
for Health Care Polir-y and Research, DHHS
1. Alternative Dispute Resolution
States have enacted statutes authorizing the following four alternatives to
traditional litigation:
A. Arbitration (38 states)1
B. Screening Panels (31 states)
C. No Fault (2 states-- VA and FL-- have compensation pools
for birth-related neurological injuries).
D. Mediation (2 states-- Colorado. and Wisconsin)
A. Arbitration .
Arbitration statutes may apply to disputes generally or to medical malpractice in
particular, and are usually voluntary. Twenty states have statutes based
substantially on the Uniform Arbitration Act. In Nebraska, the arbitration
statute does not apply to personal injury cases; and in Texas, it applies only upon
advice of attorneys from both sides. Few arbitration statutes have been
challenged on constitutional grounds; Michigan's was upheld in 1984.
B. Screening Panels
Use of screening panels are usually mandatory. Colorado requires .screening only
for claims under $50,000. Statutes have been repealed in Illinois and Florida.
Wyoming's Supreme Court struck down its statute on constitutional grounds in
1986; statutes have been challenged and upheld in Massachusetts, Montana, New
1 Based on statutes on the books as of 1991, updated where
possible
�-3
York, Nebraska, and Virginia.
C. No Fault
Under Florida and Virginia's statutes, claims are administered by a designated
organization and, if the injury falls within the program's definitions, the injured
parties receive total coverage for medical and other expenses (i.e. custodial care,
special equipment) for the life of the infant. Physicians who choose to participate
pay an annual $5,000 fee, and all others are assessed a $250 fee.
A no-fault proposal failed in the North Carolina legislature in 1992, but is likely
to be reconsidered in 1993.
ResultslLegal Ramifications
The effectiveness of arbitration and panels is limited by the fact that many of
their decisions are appealed to the courts. However, studies have found that the
existence of screening panels tend to reduce premiums. 2
The lack of accountability of non-judicial decisionmakers also undermines their
credibility and the strength of their decisions, which contributes to the high rate of
appeal.
Washington state's Health Care Commission's Committee on Malpractice rejected
the no-fault concept, particularly for birth-related neurological injuries. It also
rejected the use of mandatory screening panels, concluding that only time, not
money, was saved due to the high costs of preparing for the screening panel.
The Commission did recommend that parties to all claims engage in mediation
and or have at least one settlement conference before trial. It would protect the
information disclosed in mediation from being used at the trial. The Commission
also recommended mandatory collateral source offsets.
The constitutionality of these measures have also been challenged, particularly the
no fault concept. Compensable events can be viewed as unconstitutionally limiting
an individual's access to the courts, since the compensation is substituted for the
right to sue. ·(Virginia's law did survive a challenge in the state supreme court in
1991)
2 "Effects of Tort Reforms on the Value of Closed Medical
Malpractice Claims: A MicroAnalysis"
�-4
2. Caps on Damages
Twenty two states have enacted laws which limit the amount of recoverable
damages in medical malpractice claims. The most common limit is on non;".,
economic damages (pain and suffering, disfigurement, loss of enjoyment of life or
expected lifespan, and loss of companionship) to the range of $250,00 to $400,000.
Hawaii caps pain and suffering alone at $375,000, leaving the value of mental
anguish and disfigurement to the jury. (Soon to be repealed)
New Hampshire would permit recovery of $875,000 for non-economic loss,
Wisconsin $1 million.
Six states place caps on the total amount awarded. This strategy is on weaker
constitutional grounds, due to the argument that it deprives fair compensation to
the most severely injured. Therefore, a number of states provide an "out": for
example, Massachusetts caps total damages at $500,000 unless the jury finds that
elements in the case would make the cap unfair.
Results/ Legal Ramifications
Some analysts believe that placing caps on damages appears to be effective in
lowering or stabilizing malpractice premiums, because it limits the largest awards
and therefore reduces the cyclical increases nec~ssary to maintain the pool.
The constitutionality of caps has been interpreted differently in different parts of
the country. And many states have overrules laws implementing caps on
constitutional grounds.
In late November, 1992, The U.S. Supreme Court refused to hear a case
challenging Missouri's damage cap of $430,000 on non-economic damages. The
Court has consistently declined to consider other, similar caps, such as California's
MICRA, which caps non-economic damages at $250,000 and has been upheld by
the state supreme court. Maryland's cap of $350,000 on non-economic damages
was upheld by the court of appeals in 1992.
Other state courts have judged differently, however:
Overturned:
Alabama $400,000 limit on non-economic damages was overturned on state
constitutional grounds in 1991. The $1 million limit on damages in
wrongful death actions is indexed to inflation.
�,
,
-5
Hawaii
$375,000 limit on "pain and suffering" has been repealed effective
October 1, 1993
Kansas
$250,000 limit on non-economic damages, scheduled to expire on July
1, 1993, was struck down by the state supreme court in 1988.
Minnesota $400,000 limit on intangible loss awards was repealed in 1990
New Hampshire $875,000 limit on non-economic damages overturned on state
constitutional grounds.
Awards Increases:
Nebraska $1 million limit on total damages has been increased to $1,250,000 for
events occurring after December 1, 1992
New Mexico Effective April 1, 1995 limits on damages have been modified to
$600,000 maximum for non-economic and $600,000 for medical care, and
damages for "future medical care" have been prohibited. The maximum
amount for which providers may be liable before recourse to the state
patient compensation fund has been increased to $200,000
�Witlldrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. memo
SUBJECTfflTLE
DATE
Chris Jennings to Hillary Clinton
Re: Tomorrow's Finance Committee Meeting (19 pages)
4119193
RESTRICTION
P5
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For a complete list of items withdrawn from this folder, see the
Withdrawal/Redaction Sheet at the front of the folder.
COLLECTION:
Clinton Presidential Records
Domestic Policy Council
Chris Jennings (Health Security Act)
OAiBox Number: 23754
FOLDER TITLE:
April 1993 HSA [2]
gf77
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�U
-
-
.~
.L
THE UNDOCUMENTED PERSON
'l'
'0
"
IN THE NEW
HEALTH CARE REFORM SYSTEM
Submitted by:
Cluster 1 Task Group 2
Special Issues in Purchasing
Cooperatives for
Underserved Populations
Contact:
Date:
n
Chair:
April 19, 1993
Claudia Baquet
(202) 690-6020
r
�FOR OFFICIAL USE ONLY
THE UNDOCUMENTED PERSON IN THE NEW HEALTH CARE REFORM SYSTEM
~,
RECOMMENDED OPTIONS
OPTION 1.--Given the characteristics of the undocumented, the
easiest option for covering this popUlation within the NEW SYSTEM
would be to acquiesce about any restrictions of coverage due to
citizenship and treat the undocumented as low-income workers or
as homeless people within the HIPC and Plans requirements. For
those worki~g as migrant and seasonal farmworkers, another option
~. may be to eh~-ablish a national purchasing cooperative for mobile
populations.
•
Based on the Omnibus Reconciliation Action of 1989, the
Medicaid program was expanded to include pregnant women with
incomes falling at or below 200% of federal poverty levels
without a test of citizenship. Also, it has been the
general practice of Community and Migrant Health Centers not
to inquire about citizenship for persons seeking care.
Therefore, it is not unprecedented for the U.S. Government
to ignore citizenship requirements when it provides a health
service benefit.
.
•
This OPTION responds to the failure of employer sanctions as
a means of controlling the flow of undocumented persons.
Once a Plan enrolls an employer with a workforce that may
include undocumented persons, it will be difficult for the
Plan to police the citizen status of each worker that is
covered. Also, the employer may be put at-risk if such
workers are uncovered in this process. This is especially
critical for such industries that use "cheap labor" such as
the hospitality industry and agriculture. Depending on what
the risk is to the employer, he may decide to somehow get
around the provisions of the NEW SYSTEM and thus weaken it.
•
Besides economic incentives in promoting this OPTION, there
are also public health reasons for facilitating the
identification of medical conditions to persons living and
working in U.S. communities. Communicable diseases such as
tuberculosis are on the rise and a significant portion of
the new cases are immigrants who come from countries where
TB is highly prevalent. Included in these immigrants could
be and (most likely are) undocumented persons that may be
actively infected with TB or other communicable diseases.
Therefore, to limit the undocumented persons access to the
health delivery systems will drive them to get "underground"
medical services and not allow the public health system to
/
l
STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
�FOR OFFICIAL USE ONLY
work toward eliminating the communicable diseases that may
be present. Given the types of work the undocumented ~.
perform, they could inadvertently expose the general
population to these risks as well. Unfortunately,. this
argument may perpetuate xenophobia and the view that
immigrants are a drain on the U.S. economy.
•
About citizenship, the NEW SYSTEM could avoid the xenophobic
discourse about health care in the U.s. and non-U.S. citizen
that is here "legally" whether they are tourists, students,
or temporary workers can be considered through the HIPC and
Plans t-:a·covered workers or as subsidized populations.
These populations are of significant size to make it
important to facilitate the processes for providing needed
health care.
OPTION 2.--If there are set aside funds for special populations,
then the undocumented population could be included in such
special funding arrangements.
•
This option would need to be Federally administered since
states have a much harder time with the undocumented
populations due to the perspective that the states see the
undocumented as a Federal responsibility. Nevertheless,
since identifying and estimating undocumented person could
be very difficult, it may not be possible to provide the
funding in an informed manner.
•
Experience with the Federal SLIAG program, which was set -up
to reimburse states who have a significant number of IRCA
(Immigration Reform and Control Act) .amnesty person seeking
public services, was non-productive for the states because
the funding mechanism that was established was used by the
Congress for other purposes. Thus, any special fund that
might be considered for the undocumented may be more
vulnerable and would need to have "protection and
guarantees" in order to .be secure for the states to use.
•
within this OPTION special payment subsidies or grants might
be provided to Essential Service Providers (public health
hospitals, local and state health departments, community and
migrant health centers, and other local community clinics,
individual practice providers, and other community based
organization) to assure that services are provided without
the risk of arrest.
(
-2
STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
�,
,
FOR OFFICIAL USE ONLY
(
OPTION 3. -- Establish that enrollment in the New system is 'blind
to immigration status. Establish that the Federal Government
will subsidize costs for those who are not working. Establish
through treaty with Mexico a Binational Border Health commission
and general agreement that Mexico will reimburse the U.S.
Government for at least a portion of costs incurred by providing
subsidized care to undocumented persons. Direct the Binational
Border Health Commission to establish a fair and equitable method
of reimbursement.
•
slnce it would be difficult to identify undocumented
persons, Federal funding might have to be provided to
essential service providers in an uniformed manner, and
subsequent reimbursement by the Mexican government
would be similarly uniformed. Another option is to
have the PC (not the providers) collect immigration
status information and bar them from sharing it with
other agencies.
OPTION 4. - Do not include undocumented workers in health care
reform. If undocumented workers are excluded, the costs
associated with subsidized care that is part of the health care
reform will be reduced, but the following issues need to be
considered:
•
Areas of the United States (Le.,the southwest) will
continue to absorb the costs of uncompensated medical
care for undocumented workers. While some of this care
is provided in publicly funded health centers, care
also is given by private practitioners and
institutions. state premiums/subsidies will need to be
adjusted to absorb dollars spent on the medical care of
these individuals.
•
Families can be composed of legal United states
residents and undocumented workers. How will employer
based insurance cover those member of families who are
undocumented workers? How will undocumented parents of
U.s. citizen children receive treatment?
-3
STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
�".
FOR OFFICIAL USE ONLY
Characteristics of the Undocumented
..
Immigrant status
The Immigration Reform and Control Act (IRCA) divides
immigrants into two categories: "Residents since 1982" and the
"Special Agricultural Workers" who had to demonstrate employment
in agriculture in the U.S. for at least 90 days between May 1,
1985 and May 1, 1986. In addition, other non-IRCA legalization
categories have "numerical limitation" that include nine orders
of "e~erept from li~itations" that have .ten different categories
of exemptions. Non-immigrants who come to the U.S. temporarily
are divided into ten classes. Included in the nonimmigrant group
are "temporary workers and trainees" which include agricultural
workers.
Estimate of undocumented
In a recent report (November 1992) to the Los Angeles county
Board of supervisors on the "Impact of Und9cumented Persons and
other Immigrants onCosts, Revenues,and Services in Los Angeles
County", undocumented persons is defined as, "Foreign-born
persons who are not in the country under a lawful immigration
·tus and who are not permanently residing in the united states
.er color of law ... " The Report uses two different models to
estimate the number of undocumented persons--one results in 1.6
million and the other in 2.1 million. The INS statistics,
estimate between 2.0 million and 3.5 million undocumented persons
in 1990 in the U.S. This is the same range that the Urban
Institute and Rand Corporation estimated in 1980. About 3.0
million undocumented persons were identified under· the IRCA
legalization program between 1981 and 1989. Therefore, the
current INS estimate suggests that the number of undocumented
continues to increase notwithstanding IRCA provision such as
employer sanctions. The November 1992 Report of the Commission
on Agricultural Workers stated, IIA reasonable mid-range estimate
based on these case studies is that 25. percent of the 1991 non
supervisory SAS (seasonal agricultural service) labor force is
made up or unauthorized workers." They estimate about 2.5
million hired agricultural workers in the U.S.
Economic Issues
The L.A. County Report calculated that there were 700,000
undocumented immigrants in the county, 720,0900 persons under
amnesty, 630,000 recent legal immigrants, and 250,000 citizen
-4
(
STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
~
�20 April 1993
I
TO: Judy Feder, Ira Magaziner, Chris Jennings
FROM: Robert Valdez
SUBJECT: OPTIONS FOR DEFINING UNIVERSAL COVERAGE
This memo provides a political and economic analysis of options
for defining universal coverage as outlined in my 16 April memo.
ISSUE: Publically members of the task force have indicated that
citizens and probably permanent residents would be included under
the universal coverage provisions of the reform initiative.
_. Recognition ·<~.f . the need to support current efforts that provide
services to disenfranchised groups such as the undocumented were
vaguely identified in the form of a "set aside" or special fund.
Unfortunately, this narrow definition for participation leaves
out numerous "types" of immigrants that are distinguished by
immigration officials •. Furthermore, it suggests that groups of
individuals currently served by programs would no longer be
eligible for assistance. The political and economic implications
of defining univeral coverage in this way in the wake of a
comprehensive redesign of U.S. immigration policy. during the
1980s may not be readily apparent. The major implications
include:
o Requires a costly and burdensome adminstrative structure to
police participation
o Encourages fraud and abuse at all levels
o Creates financial hardship on states and local communities with
large immigrant populations
o Perpetuates expensive approach to caring for ill individuals
o Reduces or eliminates benefits currently enjoyed by some U.S.
residents
o Some 4 to 6 million u. S. residents remain "uninsured,"
concentrated in the large and rapidly growing Latino and Asian
communities across the country.
These communities are highly concentrated in key mid-term
election states and metropolitan communities.
Several metropolitan areas would experience serve
financial impacts. These communities include Los Angeles,
New York City, Chicago, Houston, and Miami but the effects
are certainly not confined to these large metropolitan
areas. Many smaller communities will also be affected.
These communities, largely composed of immigrants - both
documented and undocumented - have the highest levels of
labor force participation and economic activity in the
�country.
o Complicates system reform in a number of ways
As employers will the disenfranchised be allowed or
required to participate?
,:
If employers do not have to cover some workers such as
undocumented or temporary workers or students then we
create adverse hiring and immigration incentives.
The impact on 'the health care system of defining participation
narrowly include:
o Uncompensated care for catastrophic events and the wasteful use
of emergency rooms for non-life threatening care will continue
unabated.
o Non-participation by large segments of community residents
increases the risk and costs of preventable and communicable
diseases such as tuberculosis.
o Maintence of effort funds for the new system may not be
available as result of local and state demands to care for the
medically disenfranchised.
Current statutes assure the expansion of opportunities for
immigration and undocumented immigration is likely to continue
unchecked. As a consequence, we can expect immigration to reach
one million a year or more during the 1990s.
The largest demands on local jurisdictions are for education and
health care. Two recent Supreme Court rulings have broadened
state/local responsibility in the area of education, first by
mandating equal access to K-12 education for the children of
undocumented immigrants (Plyler v. Doe,1982) and second by
requiring greater state and local attention to language-minority
students (LaU v. Nichols, 1974). Recent U.S. Appeals Court
rulings (i.e., Crespin v. coye) stated that county welfare
departments and others are enjoined from denying Medicaid
coverage upon verification of immigration status. Extension of
Medicaid coverage to immigrants, documented and undocumented
require a careful examination of alternative ways of defining
"universal coverage."
OPTION 1: DEFINE ELIGIBLES BASED ON ESTABLISHED RESIDENCY
PRO: Many programs currently define eligibles based on residency
rather than citizenship.
Creates universal coverage system.
Provides greater control of health care budget.
Reduces financial stress on states and locales.
Reduces political opposition by major states, county, and
city officials, immigrant advocacy groups, and the Latino
and Asian communities.
CON: Perceptions by vpcal minority will oppose and use zenophobic
arguments to arouse deepseated fear in the general public.
�Potentially increases subsidies for lower income populations
(but current data estimates probably already include
immigrants because they are indistinguishable)
OPTION 2: RESIDENTS PARTICIPATE BUT ONLY CITIZENS AND PERMANENT
RESIDENTS ARE ELIGIBLE FOR FEDERAL SUBSIDIES
Residency could be used to define eligibili~y to participate in
the new system. However, a more severe test such as citizenship
or permanent legal residency could be used to establish elibility
for the range of subsidies funded by the federal government.
States could choose to provide these subsidies for special
populations such as immigrants or visitors.
_.PFO: Maintc..i,ns a universal program
Reduces funds needed for federal subsidy
Reduces political opposition by potential allies
CON:
Anti-immigrant groups would not be mollified
Some poor families and individuals would be denied options
within the system because they cannot afford them.
Administrative structure would be required ~o determine
citizenship or perma~ent residence
OPTION 3: REMAIN SILENT ON PARTICIPATION REQUIREMENTS
A number of program statutes are silent with regard to
.
citizenship or residency. states vary in how they determine who
is or is not included in their programs. In general, groups with
legitimate claims excluded from the programs have pressed their
case in the courts.
PRO: Program eligibility reflects the individual community
values and concerns.
Status quo would be maintained for most programs
States would reduce political pressure but not locales
CON: Highly variable state and local approaches
Costly patterns of care and neglect would continue
Less budgetary control
OPTION 4: INCLUDE SET ASIDE FUNDS FOR SPECIAL POPULATIONS,
SUCH AS IMMIGRANTS, STUDENTS, TOURISTS, AND OTHERS
PRO: Provides some certainty that funds will be available.
Maintains role of public health in care of disenfranchised.
CON:
Set asides are extremely vulnerable to political whim.
Difficult to target and budget for funds to high impact
areas.
Anti-immigrant opposition would be voc.al and organize mass
opposition.
Requires safety net provides to continue to provide
personal medical services.
�16 April 1993
TO: Judy Feder and Ira Magaziner
FROM: Robert Valdez, Henry Montez, Ciro Sumaya, Richard Veloz,
Elena Rios
SUBJECT: Options for defining UNIVERSAL COVERAGE
In response to your request we have put together the following
options for defining univeral coverage that address several
issues regarding the treatment of immigrants and visitors.
Valdez's 13 April memo 'provided background information for
reconsidering .the publicly stated position by you and Mrs.
-Clinton that-only citizens and permanent residents would be
included in the new system. The implications of defining
univeral coverage in this way in the wake of a comprehensive
redesign of U.S. immigration policy during the 1980s may not be
readily apparent. The major implications include:
o A large number of U.S. residents remain "uninsured," especially
in the large and rapidly growing Latino and Asian communities
across the country. Dr. Valdez's February 17 JAMA article
documents the. extraordinary increase in the number of uninsured
in these communities despite their extremely high rate of
participation in the labor force.
o A two-tiered system for citizens and "second-class" immigrants
will be created, especially if the reforms must be phased in
over a number of years. Uncompensated care for catastrophic
events and the wasteful use of emergency rooms for non-life
threatening care will continue the pattern of costly care we
wish to eliminate. Eligible children may not fully participate
in the system because their parents' fear deportation.
o Cities and counties will bear an unusually heavy fiscal
burden in maintaining personal health care services for a large
number of immigrants and other disenfranchised individuals.
Maintence of effort funds for the new system may not be
available as result of these demands.
o Numerous states, especially California, Texas, New York,
Florida, Illinois, New Jersey, Connecticut, Washington, and
Michigan, will bear the brunt of federal policies on health
care reform and immigration policy.
Among the 37 million or so uninsured residents of the united
states (Mrs. Clinton apparently does not know that our estimates
of the uninsured include non-citizens and citizens alike.),
include about 6 million blacks and about 7.1 million Latinos. It
is important to keep in mind that no matter what strategy the
President chooses Latinos may still face major health care access
difficulties. Ensuring adequate medical care services to the
Latino community and immigrant communities requires attention to
�both the financing mechanisms and the structure of the medical
care and public health delivery systems. Even Latinos who are
currently covered by health insurance cannot find an adequate.
supply of providers in their communities.
~.
EXPECTED: 10 MILLION IMMIGRANTS IN THE 1990s
Current statutes assure the expansion of opportunities for
immigration and undocumented immigration is likely to continue
unchecked. As a consequence, we can expect immigration to reach
one million a year or more during the 1990s. For more than a
century, formulating and enforcing immigrant policy have been the
exclusive prerogative of the Congress and the federal executive
branch. But today, as in the past, the effects of immigration
. policy are felt mainly at the local level, a fact that has yet to
be fully recognized by Congress, by immigration advocacy groups,
or even by analysts. The largest demands on local jurisdictions
are for education and health care. Two recent Supreme Court
rulings have broadened state/local responsibility in the area of
education, first by mandating equal access to K-12 education for
the children of undocumented immigrants (Plyler v. Doe,1982) and
second by requiring greater state and local attention to
language-minority students (LaU v. Nichols, 1974). These rulings
and the extension of Medicaid coverage under state option to
immigrants, documented and undocumented require a careful
examination of how "universal coverage" will be defined.
OPTION 1: DEFINE ELIGIBLES BASED ON ESTABLISHED RESIDENCY
Many programs currently define eligibles based on residency
rather than citizenship. These programs have largely followed
the basic American principle, "justice and liberty for all."
Under the Equal Protection Clause of the Fourteenth Amendment as
set forth in Plyer v. Doe, 1982 the Supreme Court said that
undocumented students have a right to a public education. A
permanent injunction by the U.S. Court of Appeals in California
in Crespin v. Coye specifically stated that county welfare
departments and others are enjoined from denying Medicaid
coverage upon verification of immigration status.
The major objection to defining eligibility by residency reflects
fear of immigrants and the notion that some individuals espouse
that immigrants are a drain on the public coffers. Numerous
Presidential Blue ribbon panels and policy analyses including
those by Dr. Valdez have demonstrated that nationally immigrants
add to the economic and social fabric of American society. The
negative effects, as Dr. Valdez points out fallon local
jurisdictions largely in the form of demands on the education and
health care systems.
Provisions for the many populations who do not fit the narrow
definition of citizen or permanent resident must be given renewed
consideration if adopted. These populations include, many
categories of immigrants, foreign students and other visitors who
�live in the u.s. for extended periods of time, and quest workers.
OPTION 2: RESIDENTS PARTICIPATE BUT ONLY CITIZENS AND PERMANENT
RESIDENTS ARE ELIGIBLE FOR FEDERAL SUBSID~ES
~
Residency could be used to define eligibility to participate in
the new system. However, a more severe test such as citizenship
could be used to establish elibility for the range of subsidies
funded by the federal government. states could choose to provide
these subsidies for special populations such as immigrants or
visitors.
OPTION 3: REMAIN SILENT ON PARTICIPATION REQUIREMENTS
_v.-A.,number of-"~rogram statutes are silent with· regard to
citizenship or residency •. States vary in how they determine who
is or is not included in their programs. In general, groups with
legitimate claims excluded from the programs have pressed their
case in the courts. Program eligibility reflects the individual
community values and concerns.
Programs funded in large by federal monies have largely included
citizens, permanent residents, and other residents (many of whom
are technically undocumented immigrants). Others individuals are
included in medical care programs on an emergency basis.
OPTION 4: INCLUDE SET ASIDE FUNDS FOR SPECIAL POPULATIONS,
SUCH AS IMMIGRANTS, STUDENTS, TOURISTS, AND OTHERS
Set asides are extremely vulnerable to political whim. For
example, a set aside for states with large numbers of newly
documented immigrants under the Immigration Control and Reform
Act of 1986 with the exception of the first year has never been
funded by Congress.
If such a set aside were to be developed it is extremely
important that major metropolitan areas directly be identified
for funds as well as providing state level relief.
After your presentations and Mrs. Clinton's recent meeting with
Latino health care professionals in which it was stated that the
undocumented would not be included in the new system, we have
received indications that Congressional leaders, state
legislators, and local county officials are extremely concerned.
We look forward to working with you in finding a workable
resolution to this and the related issues. Defining who is part
of the universe under "universal coverage" is a key parameter in
the reform initiative.
We should probably meet to discuss how best to address this issue
and to consider how best to respond to the concerns of the
national, state, and local representatives.
�f~
•
..
13 April 1993
To: Judy Feder and Ira Magaziner
From: Robert Valdez
Subject: Impact on Local communi~ies - Immigration &
Health Care Reform
Copies: Latino Work Group Members
FEDERAL POLICY IN THE 1980s WILL INCREASE AND DIVERSIFY
IMMIGRATION STREAM IN THE 1990S AND EARLY 2000
~"
,,~,Tb.e
1980s wb:$'marked by a wave of immigration nearly equal to the
peak number who arrived in the first decade of the century. With
an acceleration of immigration since the 1960s, the proportion of
immigrants in the total population has reached 8 percent in 1990.
Nearly one of every two foreign born persons now residing in the
country entered within the last decade. They account for 40
percent of the 22 million 1980-1990 population growth in the
nation and for more than half of the growth if the U.S.-born
children of immigrants are included.
During the last decade we witnessed a comprehensive redesign of
the U.S. policy towards refugees, undocumented immigrants,
temporary immigrants, and those gaining permanent immigrant
status. Three new statutes - the Refuge Act of 1980, the
Immigration Control and Reform Act of 1986 (IRCA), and the
Immigration Act of 1990.- are the most important components of
this redesign. Together they will increase the number of
immigrants - documented and undocumented - coming to the United
states. The key expansionary provisions include:
* number of documented immigrants allowed entry increased from
500,000 to 675,000 or more.
*
Refugees and asylees will remain outside the limit.
Conservatively they can be expected to add 150,000 to 200,000
entries every year, up from about 100,000 in the 1980s.
In light of the profound international geopolitical changes and
growing incidence of regional conflicts throughout the world, we
can expect increased pressures to admit refugees and asylees.
(In June 1993, the President must decide the fate of the
Salvadorean immigrant community because their temporary status
expires again. Many Salvadoreans live in the D.C. area. and many
have lived in the United States for over 10 years and raised
their children here.)
IMMIGRATION IS MORE THAN A BORDER ISSUE
In addition the new laws provide for four new categories of
immigrants that will profoundly affect the size and composition
�of immigration in the United states. First, the largest amnesty
program for undocumented immigrants will move more than 3 million
from the underground to the mainstream of American life. The
majority of applicants were Mexicans (75%) living in four st~tes
along the U.S.-Mexico border. As amnestied immigrants become
permanent residents and citizens they will be able to sponsor
additional family members. Second, each country's quota for
documented immigrants increased from 20,000 to 47,000. countries
most likely to benefit are those with long waiting lists,
including the Philippines, Mexico, India, China, Korea, and
Vietnam. Third, creation of a diversity visa (55,000 annually)
to be granted to nationals from counties sending few documented
immigrants to the U.s. This is likely to increase immigration
from some E~lropean countries (e.g., Ireland and Eastern Europe)
--and Africa. 'i,astly, establishment of a "temporary protected
immigration status" for a selected group of undocumented
immigrants provides beneficiaries protection against deportation
and authorization to work. CUrrently two groups are so covered:
spouses and children of the amnestied immigrants and nationals
from El Salvador and a few other counties.
MANY IMMIGRANTS CAN PARTICIPATE IN SOCIAL PROGRAMS
Because immigration is expected to continue at peak levels
throughout the 1990s, the local effects of immigration and the
fiscal capacity of local areas and of individual communities to
integrate successive waves of immigrants has emerged as a
significant policy issue. Considerable confusion exists
regarding what programs and services are available to immigrants
- documented and undocumented. (This distinction is not very
useful from a practical point of view, particularly at the local
level. It is virtually impossible to separate out the document
from the undocumented. Families are often composed of a complex
mixture of immigration statuses - citizens, residents,
undocumented.) The following chart provides a quick look at the
status quo.
Program
LPR
AFDC
SSI
UNEMPLOY
MEDICAID
Y
Y
Y
Y
FOOD STAMP Y
WIC
Y
SCHOOL
LUNCH
Y
Refugee
PRUCOL
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
PRE-82
SAW
Family
-5 YR WAIT FROM '86Y
Y
Y
Y
Y
Y
-CHILD/ELDERS FULL
OTHERS EMERGENCY
for 5yrs from '86
-5 YR WAIT FROM '86Y
Y
Y
Y
Y
Y
TPS
Undoc
N
N
N
N
Y
N
MCH&Preg
Emergency
N
N
Y
Y
Y
Y
(LPR - Legal permanent resident; PRUCOL - permanently Residing
Under the Color of Law; SAW - Special Agricultural Worker; TPS
Temporary Protected Status)
�As you can see there are numerous Federally funded programs that
do not discriminate immigrants based on their immigration status.
It is important to note that the PRUCOL are technically
undocumented immigrants who have established themselves 'as if,
they are documented residents. This can be done in 'a variety of
ways including filing a regular tax form 1040 rather than a form
for non-permanent residents.
FEDERAL POLICIES GREATLY STRESS LOCAL COMMUNITIES ALREADY
Immigration affects most of the countries major cities and local
communities. The twenty-five largest communities in the country
have experienced large growth in their immigrant communities.
Local communities with large immigrant populations were promised
federal finL~cial assistance with IRCA but SLIAG funds were never
made available because they were politically vulnerable as set
aside funds.
CONCENTRATION OF IMMIGRANTS IS INCREASING
Between 1980 and 1990, 8.7 million new immigrants (documented and
undocumented) entered and remained in the country. Most (71%)
reside in just five states: California, New York, Illinois,
Florida, and Texas. The remaining quarter are spread throughout
but generally in specific local communities.
RELATIVE CONCENTRATION INCREASES AS SIZE OF JURISDICTION
DECREASES
Within a state, about 80 percent of immigrants concentrated in
the largest metropolitan areas. with the exception of New York
and Chicago, these metropolitan areas have been among the fastest
growing areas of the country, expanding at 2 to 3 times the
national average. In these areas, immigration in the last decade
accounted for 60 to 100 percent of population growth.
IMPLICATIONS FOR HEALTH CARE REFORM
o Increased diversity of metropolitan area consumers creates
demand for culturally competent health care delivery systems
o Creates a two-tiered system if immigrants left out
o Increased needs for public health and community development
and health promotion perspectives that go beyond medical care
delivery reform
o Tremendous fiscal stress on local communities due to Federal
policies.
o System could collapse in major metropolitan areas under weight
of the transition to the new system and rapid population
growth.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. memo
SUBJECTrrlTLE
DATE
Chris Jennings, Steve Edelstein to Hillary Clinton
Re: Legislative/Congressional Distribution List (2 pages)
4/20/93
RESTRICTION
P5
This marker identifies the original location of the withdrawn item listed above.
For a complete list of items withdrawn from this folder, see the
Withdrawal/Redaction Sheet at the front of the folder.
COLLECTION:
Clinton Presidential Records
Domestic Policy Council
Chris Jennings (Health Security Act)
ONBox Number: 23754
FOLDER TITLE:
April 1993 HSA [2]
gf77
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a»)
Freedom of Information Act - [5 U.S.c. 552(b)[
PI
P2
P3
P4
b(l) National security classified information l(b)(I) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency l(b)(2) of the FOIA)
b(3) Release would violate a Federal statute )(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information l(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy l(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes l(b)(7) ofthe FOIAI
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIAI
b(9) Release would disclose geological or geophysical information
concerning wells l(b)(9) of the FOIA)
National Security Classified Information [(a)(I) of the PRA)
Relating to the appointment to Federal office [(a)(2) of the PRA)
Release would violate a Federal statute [(a)(3) of the PRA)
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA)
PS Release would disclose confidential advise between the President
and his advisors, or between such advisors [a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of _
personal privacy [(a)(6) of the PRA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.c.
2201(3).
RR. Document will be reviewed upon request.
�'\
-
.,.
HOUSE LEADERSmp DEMOCRATIC REUABLES
Member
Background Information
ARIZONA:
Coppersmith
English
Education and Labor, Caucus for Women's Issues, Mainstream Forum,
Freshman
Pastor
Hispanic Caucus
ARKANSAS:
Lambert
Energy and Commerce, Caucus for Women's Issues, Rural Health Care
Coalition, Freshman
Thornton
Mainstream Forum
CAliFORNIA:
Fazio
Rural Health Care Coalition
Matsui
Ways and Means
Mineta
Pelosi
Caucus for Women's Issues, McDermott Cosponsor
Stark
Ways and Means, Subcommittee on Health, Chair; Rural Health Care
Coalition; McDermott Cosponsor
Waxman
Energy and Commerce, Subcommittee on Health, Chair
CONNECI1.CUT:
DeLauro
Caucus for Women's 'issues
Gedjenson
McDermott Cosponsor
Kennelly
. Ways and Means, Health Subcommittee; Caucus for Women's Issues
1
�FLORIDA:
Bacchus
Deutsch
Johnston
GEORGIA:
Lewis
Ways and Means, Health Subcommittee; Congressional Black: Caucus;
McDermott Cosponsor
HAWAD:
Abercrombie
McDermott Cosponsor
IDAHO:
laRocco
Rural Health Care Coalition, Mainstream Forum
n..LINOIS:
Collins
Energy and Commerce, Caucus for Women's Issues, Congressional Black
Caucus, McDermott Cosponsor
Costello
Rural Health Care Coalition, Mainstream Forum
Evans
Rural Health Care Coalition, McDermott Cosponsor
Rostenkowski
Ways and Means
INDIANA:
Sharp
Energy and Commerce
KENTUCKY:
Mazzoli
Judiciary
Natcher
MARYLAND:
Cardin
Ways and Means, Subcommittee on Health
Hoyer
2
�MASSACHUSETrS:
Frank
Judiciary, McDermott Cosponsor
Kennedy
McDermott Cosponsor
Markey
Energy and Commerce
Olver
McDermott Cosponsor
Studds
Energy and Commerce, Health Subcommittee; Rural Health Care Coalition,
McDermott Cosponsor
MICHIGAN:
Bonior
Carr
Mainstream Forum, McDermott Cosponsor
Dingell
Energy and Commerce
Ford
Education and Labor
l£vin
Ways and Means, Subcommittee on Health
Kildee
Education and Labor
MINNESOTA:
Sabo
McDermott Cosponsor
MISSOURI:
Danner
Caucus for Women's Issues, Rural Health Care Coalition, Freshman
Gepbardt
Wheat
Rules, Congressional Black Caucus
MONTANA:
Williams
Education and Labor, Rural Health Care Coalition
NEBRASKA:
Hoagland
Ways and Means, Health Subcommittee; Rural Health Care Coalition;
Mainstream Forum
3
�NEW YORK:
Ackennan
McDennott Cosponsor
Engel
Education and Labor, McDennott Cosponsor
Lowey
Caucus for Women's Issues, Mainstream Forum
Manton
Energy and Commerce, McDennott Cosponsor
Schumer
Judiciary, McDennott Cosponsor
Slaughter
Rules, Caucus for Women's Issues, Rural Health Care Coalition, Mainstream
Forum
NORm DAKOTA:
Pomeroy
OHIO:
Brown
Energy and Commerce, Health Subcommittee; Freshman
Sawyer
Education and Labor
Strickland
Education and Labor, Rural Health Care Coalition, Freshman
OKLAHOMA:
Synar
Energy and Commerce, Health Subcommittee; Judiciary, Rural Health Care
Coalition
OREGON:
Kopetski
Ways and Means
Wyden
Energy and Commerce, Health Subcommittee; Rural Health Care Coalition
RHODE ISLAND:
Reed
Education and Labor, Juciciary
SOUTH CAROLINA:
Clyburn
Congressional Black Caucus, Single Payer, Freshman
Derrick
Rural Health Care Coalition
�•
L
•
TEXAS:
Bryant
Energy and Commerce, Health Subcommittee; Judiciary
Frost
Rules
Geren
Mainstream Forum
Lauglin
Rural Health Care Coalition
VIRGINIA:
Byrne
Caucus for Women's Issues, Freshman
Moran
Mainstream Forum
Scott
Education and Labor, Judiciary, Congressional Black Caucus, McDermott
Cosponsor, Freshman
WASmNGTON:
Cantwell
Caucus for Women's Issues, Freshman
Kreidler
Energy and Commerce, Health Subcommittee; Freshman
McDermott
Ways and Means, Health Subcommittee; Rural Health Care Coalition; Sponsor
of Single Payer Bill
Swift
Energy and Commerce, Rural Health Care Coalition
Unsoeld
Education and Labor, Caucus for Women's Issues, Rural Health Care Coalition
WEST VIRGINIA:
Mollohan
Rural Health Care Coalition
Rahall
Rural Health Care Coalition
Wise
Rural Health Care Coalition
WISCONSIN:
Kleczka
Ways and Means, Subcommittee on Health
Obey
Rural Health Care Coalition
5
�
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Chris Jennings
Health Securities Act
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Chris Jennings
Health Securities Act
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Box 38
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/Systematic/JenningsHSA.pdf" target="_blank">Collection Finding Aid</a>
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