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MEDICAID
AND THE NGA RESOLUTION:
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DISCUSSION POIN\
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Status Update On: Meetings with the Governors/Congre~sional Hearings n
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Administration Proposal and Commonground with the NGA Resolution:
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(1)
The establishment of a new financing mechanism th~t links and constrains\
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federal financing to enrollment;
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The repeal of the Boren amendment; and
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The liberation of states from the waiver process.
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Outstanding Issues Relat~d to NGA Res~lution:
(1)
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Second Tier. But Critical Issues; and
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The "quarantee;"
The Title XIX Debate.
The NGA Resolutfion and the Guarantee:
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Financing;
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Eligibility;
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Benefits; and
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Enforcement
Congressional and Interest Group Response to the NGA ResoBution
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Discussion of Medicaid Negotiating Positioning/Strat,egy
PHOTOCOPY
PRESERVATiON
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THE WHITE HOUSE
WASH INGTON
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MEMORANDUM FOR THE PRESIDENT
FROM:
Carol Rasco, Laura Tyson and Alice Rivlin
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,SUBJECT:
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National Governors' Associatipn Medjcaid
Resolut~on
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'nismemo highlights 'our major conCerns with,the Na~ional GoVernors' Association (NGA)
'Medicaid resolution. It summarizes these concerns, outlines our current positiQn with regard
to each issue, suggests some possible fall-back positions, and p}ovides you with a reading of
, .the Democratic Governors' positions on' each of these issues. Iti also includes a summary of
the Hill and Interest Group reaction to the resolution. We thought you' might find this to be
uscful'backgro~nd information for our Medicaid meeting with you tomorrow morning:
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Background
The six Governors will also meet fo~ three hours tomorrow evening to prepare for their
,Wednesday hearing., The Democratic GovernorS want to con~inue to work closely with us
and will meet withus tomorrow before meeting with the Rep'ublican Governors. TheY,rightly
believe they achieved a significant victory by getting. the Republicans to agree to a new
financing mechanism that ensures. that "dollars follow, people:",' They also believe that there
ar~ a number of provisions that were vaguely drafted, whic1i!have been interpreted by many
as extremely problematic (such as the NGA benefits section), that can be ~'clarified" through
the nornial NGA policy .development process. Having said this, the Democratic Governors
also acknowledge th(it they are a number of signifiCant flaws in the NGA agreement that
should be addressed.
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Where W e Agree with NGA
Before outlining our differences and cOncerns with the NGA resolution" it is important to
summarize~brieflywhere we have significant agreement.' Your Medicaid refonns include at
Jeast 12 NGA-endorsed flexibility recommendations,inCluding arguably the three most
important structural changes:
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The establishment of a new financing mechanism that: Iinks,and constrains
federal financing to, enrollment through Jhe use of an open-ended "umbrella"
that assures that "dollars follow people" ~d that states ~e protected from
, economic downturns;
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(2)
The repeal of. the Boren amendment and other federal' provider'
reim~ursement requirements; a n d '
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The liberation of states from the waiver process for: •
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Managed care',
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Home and community-based care '
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Coverage expansions up to 150 percent
of poverty
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Outstanding Iss,ues Related toNGA Resolution
There are three sets of issues that will be debat~d in ,the, legislative' p~ocess: (1) the
"gu~antee"; (2) second tier issues; and (3) the Title XIX de,bat,e.
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The "Guarantee." Those issues that are directly related to the Medicaidnguarantee"
(financing, eligibility, benefits' and enforc~ment) will: demand ,most of your attention,
and are the focus of this memo.
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Second Tier, But Critical Issues. There are "second tier" 'is~ues, such, as nursing
home standard enforcement, financial pr<stections for, families (like spousal
impoverishment), and managed care quality assuraIlCe, that
require Administration
attention should negotiations progress., These issues helped us perSonalize the
Republican Medicaid cuts and they are view.ed as, critical by:mosfDemQcrats.
(For example~ Senator pryor feels ,strongly about the nursing home enforcement issue.)
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Th~ Title XIX
Debate.' Finally, the Republican desire to repeal title XIX and
substitute a new Medi~aid title raises a host of conCerns; D~ftinga brand new title
for Medicaid in the limited time we have left in this Congress' would inevitably lead to
unforeseen legal, policy and political consequences. This wbuld inClude having to,
detennine how to, deal with case law' --,- such as what is the: definition of "medical
, necessity" --that has developed over the past 30 years. Per.haps, most ~mportantly,
, ,taking this route would place us in an untenable bargaining position; we would have to
,give "chits" just to "reinstate" provisions that are current law.
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THE NGA' RESOLUTION AND
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THE GUARANTEE:· ADMINISTRATIONPOSITIONS
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_There are four elements that make up the Medicaid guarantee: financing" eligibility, benefits,
and enforcement. Each of ~hese elements is inextricably linked to the orhers and changes to
anyone of them must be carefull y ~onstructed to avoid undermining' the. foundation of the
guarantee and the program. The following outlines the primary conceIl!s'we have with the
proposal and' summariz~s current and possible fall-back' Administration, positions on these
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(1)
Financing Concerns:
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The NGA proposal uses a financing mechanism that is different; from ours but that
also assures that dollars follow increases in enrollment. Howev,er, it has the following
problems:
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states are guaranteed their base formula allotment even it they choose 'to
reduce coverage. This provision ._.... drafted for states like Michigan~..,. is a ..
significant departure; from the historical Medieaid federaVstate partnerShip,
. where federal financing support rises and falls with changes in coverage.
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Many states can reduce their state Medicaid matchi~g requirement•
This provisio~ -- hastily inserted .for Govem<;>r Pataki. i- would signifiCantly
decrease overall Medicaid spending OR sign~ficantly increase Federal spending.
. It would reduce the m~imumstate"match fr~m 50 percent to 40 percent. If
., federal spending is capped and alLstates matched at their minimum levels. the
, matching rate change wouid reduce total Medicaid spending by an additional
$140 billion over seven years (on top of. the already asSumed $85 billion iiI ..
federal savings and $65 billion 'in state savings). ThtS could.:/ead to'large
estimates of coverage loss unless the major eligibility and. benefit protections
mentioned later in' this memo are assured. If federal spendirig were not
capped, the cost-shift resulting from the lower state match would totally offset
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the $85 billion in federal savings.
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States could substitute state tax dollars with revenue raised through·
, provider taxes and donations. Since this is "borrow~d!lmoney. it W9uld
effectively reduce states' real spending on Medicaid. :Because this would make
it~ier to raise state matching doHars, CBO (and OMB) would 'likely conclude
that this provision 'would also significantly reduce Federal savings.
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Administration Position: 'Our CB9-scored per capita cap ~pproach to Medicaid cost
containment has a "dollars follow peopl~" mechanism that is more direct than the, ,
NGA umbrella and does not include any of the problems mentioned above:, We would
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keep the current matching formula, but propose th(it a nation,al commission be
established to make recommendations on how to addre,ss pe~ceived' inequities. '
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Possible Fall-B~ck Position: The RepubliCan- Governors are li~elY to refiIse an
Administration-like per capita cap fina'ncing mechanism. 'We may be able to live with
a NGA-like, fina~cing approach if, as the Democratic Governors; intended, it truly
allows dollars to follow people and. if the state matching reduction and the provider
ta,x/donation provisions 'are. fixed. Govetno~ Chiles, Romer, apd Miller all have
:' indicated they share our concerns with these provisions and support our position.
an fact, the six. "Medicaid," Governors never discussed the ~rovider tax and state
matching reduction isSues; they were added as last second amendments to-.the .
. resolution.)
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(2)
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Eligibility Concerns: ,
, '1 Repeals current law that phases-in coverage for 1.S ~iIIion poor children '
i \betWeen the ages of 13 and 18.0MB estimates a maXimum of $6 billion in .
: \federal savings if all states do not phase-in coverage. (This would overturn a
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Allows states to define. disability, subject to HHS approval, instead of
,requiring all states to meet a minimum federal definition. This proposal .
. could result in widespread variation in eligibility dete~inations among, states:
and could threaten the eligibility guarantee for people with.disabilities.
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Administration Position:' We retain the kids phase':"in and u~ the welfare reform'S ,
a~pr~ach to address the Gqvernors' concern about di~ability ,eVgibility 'abuse. This
~y '(. <-gIves Governo.rs the option not to designate as "disabled" those persons who ~re
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alcoholics and chemical· ~nd substance abusers, as well as tigl;Itens the eligibility
~' « ~, definition for children under S S I . . .
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Possible Fall-Back Position: No, fall-back for the, kids covf!rage expansion. On
disability. we could limit eligibility for other groups if the G9vernors can' demonstrate'
that there have been eligi~ility abuses. If this compromise is still not acceptab~e,we
could consider allowing states to define disability, but with much stricter criteria that
the Secretary must use'to e~aluate designations. (This latier!approach needs to be
politically vetted.) The Democratic Governors :would probably be fine with either
of these, positions, although Governor, ~omer thi,nks, the states should not be
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defining disability eligibility."
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Benefit Concerns:
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" Eliminates the current "'adequacy"' requirement for benefits and gives
, states unlimited discretion to determine tbe amount, duration and scope of
: I services within benefit categories.,' Under, these provisions, the HHS
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benefit, was insufficient to. m~et the federal re'quirenient for a hospital benefit.
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'May repeal the statewideness and compar~bility requirements for, " '
mandatory benefits., Ift,hiS is the case, states could offer 5 months of hospital
services for children and 2 weeks for, the disabled. '
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Repeals current statewideness and comparability requirements for optional
benefits. Without these p~ovisiC:>ns, states could offer different' benefits to
different groups of recipients or provide different, benefitsiil different areas of
the state, ' For example, states could decide topro~ide a nOf":deductible/no c;lp
. prescription drug benefit for a disabled person who had ~ stroke, and a drug
,benefit with a $500' deductible and a $1,000 cap for (i'person with MDS:
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Redefines the
treat~ent portion of EPSDT ~arlY a~d Periodic Screenin~, ,
Di~gnosis an~ Treatme?t) so that ~tates nee,d not, cover all Medi~id '
optional serv.ces Cor children.
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, Administration Position:, The Adm'inistration maintains that these concerns m~st be
addressed or the national' guarantee to benefits.is legitimately, ~lled into question.
Your proposal retains the current 'benefit, package and protections., On EPSDT, it
clarifies that benefits provided to children llnder the treatment' requirement need not 1.;Ie
given to, any other population (under the cOmparability requirements.)
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Possible' F~II-Back Position: M~intain the b~nefits adequacy standard. ,Maintain, '
\ current protections for mandatory benefits, but negotiate significant changes'in the
'I \ requirements on t~~ optional ben~fits, Includi,ng elIminating o~'significantly li?eral~ng
l \ current comparablhty and statewldeness requIrements. Negotlatefurther m<?dlficatlOns
1\ \ to the "treatment" requirement within EPSDT, including that; the requirem,ent need not
, \extend beyond a certain age group OR the possibility that the benefits provided need
, \not exceed the states', optional packag~", (These are "hot-btit~on" options that would no
rolled out
The Democratic Governors.~
I Idoubt have to be'carefully "adequ~cy if pursued.) but --' like theN-GA, ~- have not
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standard,"
lyet finalized their position on the other benefit issues. I.
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. Enforcement Concerns:
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Eliminates any federal, cause of action under Medicaid by ·beneficiaries,
health care,providers and health plans. ',Claims brought by, individuals to
enforce their rights under ~edicaid ~ould be limited to state courts and state
law. Only the Secretary of Health and Human Services could bring an action
in ,federal court on behalf of Medicaid beneficiaries', '
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There are four maj~r concerns with this proposal. :First, the ~ligibility w~uld
vary betwe~n states pecausestate courts would interpret the ,law differently; ,
the same person 'could be covered in one'state but not in another. Second,
fewer remedies would be available under state law: than under federal law.
, Third, Medicaid would be' the only federal statute ihat, confers individual rights
that could not be enforced in federal courts by its .'intended beneficiaries.
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Finally, the HHS Secretary would be unable to 'litigate adequately on behalf of
individuals because there would be significant new administrative burdens
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placed on the Departmept and because the Qnly remedy aviailable to the
Secretary ~ould be the withdrawal of funds to the state. .'
Administration Position: We repeal the Boren amendment arid :make it clear that
providers have no right to sue over payment rates. We retain current law for
eligibility .and benefit claims brought by individuals.
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Amendment, .we could also eliminate the private right of action by providers and'
health plans completely (so that they could no longer sue over provider qualifications
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On causes of action brought by recipients, we could follow up on a suggestion made
by Governor Chil'es and propose separating eligibility Claims, frdm some benefit
claims. Under this approach:
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' There would, be no. suits by providerS health plans over I '
reimbursement rates or
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any other issue:
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' Ev'eryone filing a claim would be required to ~xhaust a~ministrative remedies.
A recent survey of state Medicaid agencies 'found that in the 40 states that
. responded, less than 5% of fair hearing decisions were 'appealed to a court. In
California, for example. 4,600 fair lieanngs were held and less than 1% were
appealed.. In Wisconsin, 376 fair hearings were held,'¥1d 8 (2%) were
appealed. (Texas Legal Services Center; 1994.)
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. Most disputes over benefits w0l!ld be heard 'in state court. Benefits claims, .
would only ,be heard in federal court if there :were an allegation that the state'
plan or a contract betWeen the state and a provider viqlated federal law.
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aaims brought by individuals over eligibility. would be heard in federal court.
Across the country, there were 6 reported cases ov~r eligibility in 1994, 8
in· 1993, 6 in 1992 and 8.in 1991; (Nation~l Health t,.aw Program, Inc., 1995.)
This is not ~' high 'priority issue. for the Demo~ratic Govetnors, and we believe '
that they would support our approach. However, th~y h~ve reported that the
Republican Governors have a philosophical aversion to any Federal right of,
action. What is clear from our conversations with the NGA staff, though" is that'
the Governors have not focus.ed on this issue in ~any grea!t detail.
Conclusion "
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We hope this information is helpful to'you in deciding hciw the Administration should
position itself on. the Medicaid front. Attached is a. background document'on the
congressio~al and, interest group response to the NGA pr~posal. .
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�CONGRESSIONAL AND INTEREST GROUP RESPONSE TO NGA
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Hill Response to the,NGA Resolution: Most .Republicans, through the B,NC and
comments by the Speaker, are strongly embracing the NGA proposal.' They claim' ,
that it is a virtual mirtor"':image'o(their Medigrant, proposal. Th~ RNCis literally
passing out paper declaring "victory." ' The only exception to a bomplete endorsement
from the Republicans is related to their perception of the financing mechanism. They
.are sending signals that they oppose the open-ended nature of it; and are suggesting ,
that they may push for some type of cap." (The Democratic Governors have already ,
indicated that they would "walk" 'from the deal if .this occuI'!ed.),
Republicans appear to want to push a "bipartisanly-s~pp0l1ed t-fGA" bill out and dare
us to criticize it. It is for this'reason that they hav~,so quickly scheduled hearings for
this Wednesday and Thursday, and have invited'Secre~ary Shal~la to testify next week
before the Finance Committee. Having said this, they·are reportedly being responsive
to NGA calls to not prematurely unveil a Republican '''NGA Medicaid~' bill and risk a '
meltdown of the bipartiSan agreement. There is no question, ,however, that they are "
,(behind the scenes)draftiriglegislatio~ and attempting to get cao to scoreit an~ it is '
not inconceivable that they may' introduce something prior' to Secretary Shalala's '
, testimony.
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The Republican reaction has f\leled the suspicions of the Democrats and; with
extremely few exceptions, there has been a generally: negative reaction to the NGA
proposal. The "base" Democrats, like HenryWaxm~n, have ~een extremely criticai 'of
the proposal antI' have, charged that it offers no guarantee and may, even be a block
grant in sheep's clothing.'
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Congressman Stenholm and cingres~manDingell were apparbiltly quite disappointed
in the lack of state accountability, the reduction lq state ma~ch, and raised concerns
about 'the adequacy of the legal enforcement provisions.' They argue that it is not
unreasonable,to expect a federally-~nforced, national eligibili:ty and standards floor in
return for a large federalinvestment. To back up their pointi theirstaffs have been
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circulating chart that shows' how the coalitio~ proposal wo~ld provide $840 billion to
state Medicaid' programs, 'at :the ,same time the states aretryiIig to, sigriificantly
, decrease their, ~edi2aid expenditures. '
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On the Senat~ side, Senator Breaux' distanced himself a bit and called for hearings so
he could fully understand the implications of the proposal. ' ins staff reports that'
, Senator J?reaux thought the Democratic Qovernors'weregoi~g to be able to "cut a
better deal than they did~", On the moderate Republican sid~ ,of the ~isle. Senator, ,
Chafee privately raised concerns about the proposal and suggested it appeared to be
something akin 'to a federal maintenance of effprt with too little account~bility.
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�Clearly, h~wever, ~th Senators' Breaux and Cliafee want'to keep the Medicaid
discussions alive for the sake of a 'budg~t deal and 'wilL continue to avoid being overly',
critical in public. According to Senator Bre~ux's,staff, ,the prim~ry authors of any'
,alternative, Medicaid bill will likely be Senator Chafee and Senato~ Graham. Lastly,
there ,are also reports'that'Senator Roth's staff'is working with the House Commerce
Committee to draft 'up their own version of the "NGAresolution." Since,t"hey have
fairly "green" Medicaid staff who have previously worked at the House COmmerce
COmmittee, it is likely that their bill will largely m,irror the House Republican. bill.
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. ' interest Group Response to the NGA R.esolution: We have received only
negative reactions from the groups, includirig the unions, 'the Alnerican Hospital'
Association, the American Academy of Pediatri~, the' Childre~'s Defense Fund, the "
Alzheime~' Association and the ,Consortium for Citiiens with Disabilities: The groups,
particularly those' who represent children a~d the 'disabled, feel that enactment of a
proposalli.ke the Governors' resolution would significantly increase the number, of
unirisured and renege on what they believe is a jointly":"lield commitment with the
Administration to expand,or at least not reduce,the number qf insured. The AIDS
groups are particuiarly'concernedbecause they greatly fear the benefit changes and the
, s~ate-by-state definition of disability provision. ,"
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The other inter~st groups are largely staying quiet and waitin~ to see how we respond
to the likely IIclarifying" changes expected to emerge, from the NGA over the next
week or so. Some of them are taking this position because, they do not want to
undermine our position. Others are holding off because they,' want to be perceived as
IIplayers" in the upcoming n~gotiation.
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, The Office ofPublic Liaison believes that your strong stand, on Medicaid has b~jlt
.bridges that extend far beyond the traditional Medicaid constituencies. ,Public liaison
believes that siinificant changes' from 'these groups' perq!ption of our past Medicaid'
position may damag~ this strong alliance and may.I be difficult to repair.
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�CONCERNS/OUTSTANDING ,QU'ESTIONS
ABOUT THE NGA MEDICAID RESOLUTION.
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Eligibility concerns include: '. The repeal of the cum:nt law's phase-in for coverage of
about 3 million children age 13-17 and the devolution o~ the "disability" definition to
the states.
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Benefit concerns include: The total discretion given to i states to alter the
amount/duration/scope of services; the repeal of the current law's comparability and
statewideness requirement that ensure that recipients in particular' groups or locations
are not discriminated against; the apparent elimination of any defined benefit package
for currently optional populations; and the vague redefinition of the treatment
requirements under the Early, Periodic, Screening, Diagitosis and Treatment (EPSDT)
children's health benefit.
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Enforcement conCerns include: The state-based right of action process advocated.
by the Governors (and whether it will work to effectively ensure the guarantee).
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Financing concerns include: The exclusion. of pregn3nt women and children, as 'weIr
as the medically needy, from the Federally-financed. ":umbrella" pool payments; the
inclusion in the base formula of the allowance that states can reduce their matching
Medicaid rate -...:. the result producing an additional $200 billion reduction in state
Medicaid spending over seven yeats, bringing the total FederaVState cut to $290
billion; the allowance for states to, once again, tax he,alth care providers to help
finance their state match; allowing for provider taxes. will likely push up the cost of
the program that CBO scores because it will be easie,r for the State to access Federal
matching funds.
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. Quality concerns include: The adequacy of the qu3.Iity protections for plans under
Medicaid, such as HMOs and other managed care plan; the apparent repeal of the.
Federal-:-based enforcement of Federal nursing home standards. (The difference
between them and us has always come doWn to definition and enforcement.)
Accountability concerns include:
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MEMORANDUM
February 9, 1996
TO:
Carol Rasco and Laura Tyson
FR:
Chris Jennings and Jennifer Klein
RE:
porus Medicaid Memo
Attached is the current draft of the Medicaid memo we promised to get to you. We
attempted to draft it in a way that reflects our best understanding: of the status of the NGA
Resolution, as well as Capitol Hill's and the interest groups' respOnse to it.
It is my understanding through Nancy-Ann Min that Alice Rivlin would probably like
to sign this as well. Do you have a problem with ine sharing utis memo with her and with
making it available for Alice to sign?
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Please feel free to call me 6-5560 with any edits or directions. Thanks.
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February 9, 1996
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MEMORANDUM TO TIlE PRESIDENT
FROM:
Carol RaSco and Laura Tyson
SUBJECf:
The Medicaid "Guarantee" and Issues Rais~di Surro~nding the NGA
Resolution
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The National Governors' Association (NGA) Medicaid resolution passed on Tuesday has
received a great deai of attention from the' media, the Hill, and the health care provider and
advocacy community. As a whole, the "right" has given this proposal Widespread praise and
raised concern only about the resolution's financing provisions. The' "left" ,has been extremely
critical of the proposal, charging that the provisions on benefits, ~ligibility and enforcement
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strip the Medicaid program of its "guarantee."
This memo briefly analyzes theNGA proposal as it relates to the Medicaid "guarantee."
(While there are numerous issues related to the NGA resolution; including how it addresses
quality standards, nursing- home standard enforcement, and spousal h:i1poverishment, we '
thought it was most important to focus on the fundamental structural issues first.) The memo
also describes reactions from the Governors, the Hill and the, interest groups.
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, BACKGROUND
From the beginning of the Medicaid debate, the Administratiori has cOnsistently taken the
position that, it is possible to constrain program growth while' ~till maintaining Medicaid's
guarantee of coverage to the elderly, the disabled,~hildreri arid pregnant women; Your latest
proposal, incorporated into your balanced budget proposal, provides unprecedented flexibility
to the Governors while maintaining the guarantee and saving ~59 billion over seven years.
In response to you and the Republican Leadership, the Governors attempted to hammer out a
compromise Medicaid position to further the budget negotiations. The Democratic Governors
worked tirelessly to move the Republicans from their insistence on a block grant. The
Republicans hesitantly agreed to a new funding forrilUla that .'assures that federal dollars
increase with enrollment increases during 'economic downturns. ,
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The Democratic Gqvemors rightly beiieve that'their success in' gettingi·the Republicans to
agree to a guaranteed funding stream represents 'a significant step fOIWard. To' achieve this
victory, however, the outnumbered Democrats were, apparently forced: togive'in on provisions
that may well undermine other aspects federal guarantee; , , :- . .
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FOUR PARTS OF THE GUARANTEE UNDER MEDICAID
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There are four elements,tha, milke~p the Medicaid guarantee:finan~ing, eligibility, 'benefits,
and enforcement. Since the clebate has so .focused on the "guaranteet i,t is likely that any
compromise will be ,twaluat,ed in this context.· It is with this in mind; that we review the NGA
proposal, understanding that it is somewhat of. a moving target subject to future clarification: '
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Financing Guarantee. As m~ntio~edal?Ove, the NGA prop~sal Seems to achieve the
financing guarantee by eliminating the block grant financing approach and. substituting
a so-called "umbrella" financing mechanism. "This mechanism automatically provides
additional federal support as economic downturns produce erirollmept ~ncreases. Over
the weekend, the Republicans agreed that the umbrella would cover the increased costs
of optional (J.S well as mandatory benefits and populations. This 'was an important
breakthrough' for the Democratic Governors.
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Interestingly, the Democratic Gove'rnors could'only securet~eir recession protection
provision if ,they agreed ,that states (like Michigan and Wisconsin) would be '
guaranteed their base alt'otment even if theycho~e ,to reduce coverage and spending. '
This is a significant departure ·from the historical Medicaid federallstatepartnership,
where federal financing support rises and falls withchaIige~ 'in coverage and state
contributions. Additionally, the reduction of the required state match permitted by the
NGA ,resolution (and inserted at the last second for Governor Pataki) could
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significantly decrease' overall Medicaid spending., In fact, estimates from HHS
indicate that the $85 billion in federal savings would trarisl:ate i'nto $290 billion, in total
spending reductions if all states matched at the minimum level. Lastly, the state. may
be able to substitute, state tax dollarS with revenue raised through provider taxes and
. donations~ Since this is "borrowed" money, it would effectively reduce states' real
spending on Medieaid. ,These provisions may have an impact on how CBO scores this
proposal and, if it does,estlmat~s of fe~eral savings may deCline.
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Eligibility Gua~antee. The NGAproposal, with some notable exceptions, seems to
retain most of,the currently eligib.1e populations. The NGA.proposal repeals
provisions, of the 1990 law, signed by President Bush, that phases-in coverage for
about three million poor children between the ages of 13 :and 18. In addition, the
. proposal allo\vs'states to define disability, subject,to 'federal approval, instead of
,requiring all states' to meet a minimum federal definition,: as is' now the law. As
currently drafted, this proposal has 'potential to result in ~idespread variation in
eligibility'determinations among states and, in the minds ;of some, could threaten the
eligibility guarantee, for people witli, disabilities.
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Benefits (Coverage) GUarantee. The, NGA proposal leaves in place the cUrrent,
nationally defined list of Covered benefits for mandatory coverage groups. ' At first ,
glance, one.might conclude that the benefits guarantee was assured. However, the
proposal seems to eliminate the currentrequii-ement that med~Cally necessary benefits
be provided and gives states unlimited discretion to determine the amount, duration
,and s~pe ofservices within benefit categories. It also 'seems to pennit states to offer
different benefits to different groups of beneficiaries or in di(t'erent areas of the state.
For example, under these provisions, states could limit the number ,of hospital days per
year provided to children, even if a doctor decides that the c3te is medically necessary,
States could also decide to cover five days of hospital services for disabled children
but only two days for people with ArDS. Finally, they could chose ,to cover a
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particular benefit in some' ~eas of the state, but not for exa~ple, on an IIldian
reservation. Although the resolution's language seems fairly: clear, it is hard tO,believe
that the Governors, particularly the Democrats, really intended to go this far on both
mandatory and optional benefits.
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The proposal also redefines the treatment portion of EPSDT; (Early and Pe,riodic
Screening, Diagnosis and Treatment) so that "states need nqt cover all Medicaid
optional services for children." They' have. not yet resolved; what treatment would be,
covered.
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Enforcement of the Guarantee., The NGA proposal dimi'nates a federal Cause of
action by Medicaid beneficiaries. Claims brought by individuals to e~force their :rights
under Medicaid would be limited to state courts and state law. Dilly the Secretary.of
Health and Human SerVices could bring an action in federal court:on behalf of
Medicaid beneficiaries.
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Attached is a more detailed description of the' issues raised, by the NGA, proposal' to
eliminate the federal cause of action. The most significant problem is that, under this
proposal, eligibility will vary between states because state: courts wili interpret the law,
differently. In addition, fewer remedies are' availableund¢r state 'law' than under
f~derallaw. The Secretary of Health and Human SerVice,s will be unable ,to litigate
adequately on behalf of individuals because the significant new administrativeburd~n
. , that will be placed on the Department will likely cause delays and, because the only,
remedy available to the Secretaryisthe,withdI?walof furds (which will make matters,
worse. for the recipients in the state).'
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REACTION TO THE NGA' PROPOSAL
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Governors Position: As
this writing, the 'Governors :are working with NGA staff
to clarify the intent behinq their Medicaid res~lution and to write up the back-up
details.. Based on conversations that we have had with :the Democratic Governors and
their staffs, as well as NGA staff, it is clear that .there are a.great deal' of unanswered
questions regarding the intent and substance behind the resolution. NGA staff will
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work with the 6 Medica~d-designated Gove'~ors(Romer, Chiles, .Miller;Thomps(j~;.,
Engler and Leavitt) in the up-coming two weeks to try to furth~r clarify this issue.
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As with any hastily-~rafted document, we h~ve found that the,re were a number of
provisions that Democratic Governors either did not know abqut or are uncomfortable
with. For example, .Governor Chiles was apparently unaware ;that the resolution'
provided f9r the reinstatement of provider taxes and donation~. Governor Romer has
told us he is uncomfortable with the dIsability langUage. and t~e 'state matching
reduction provision. ,And it seems' that all the Democrats are ;uneasy with dropping the .
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Phase-in o.f the kids.:
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Hill Position: Most Republicans, through the RNC and comments by the Speaker,
are strongly.embracing the NGJ\. proposaL They claim that ~t is' a virtual mirror
image of their Medigrant proposal. TheRNC is literally pas~ing out paper declaring
"victory" and the House Republican staff are drafting up language that they are touting
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will incorporate theNGA recommendations. Repub~icans' appear to want to push a
. bill out and dare us to criticize it. In fact, there, are now rumors that they may attach
their interpretation of the NGA resolut'ion to, th~ debt ceilini bill.
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The Republican reaction has fueled the suspicions of the D¢mocrats ~d, with
extremely few,exceptions,there has been a generally negatlye reaction to the NGA
proposal. The "base" Democrats, like Henry Waxman, hav~' been extremely critical.of
the proposal and 'have charged'thatit offers no guarantee and may even be a Qlock
grant in sheep's clQthing. Congressman Stenholmand Congressman, DingeU 'were
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apparently quite disappointed in 'the lack of state,accountability; the' reduction in 'state
match" and raised concerns about the adequacy:of the 'legal; enforcement provisions. '
They argue that it is not unreasonable to expect,a federally'-enforced, national
eligibility and standards floorjn return for 'a large federal i~vestment. To back up
their point, their staffs have been' circulating a chart that shows how, the 'coalition
proposal would provide $840 billiori to state Medicaid programs, at the same time the
states are trying to signifiCantly decrease their Medicaid expenditures.
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On the Senate side,' Senator Breaux distanced' himself a bit and' called for hearings so
he could fully understand the, implications of the proposalf' On the moderate
'Republican side of the. aisle, Se:nator Chafee raised'significant concerns about the
proposal and suggested it appear~d to be something akin: to a federal maintenance of
effort with little to no accountability. Clearly, however, both Senators' Breaux and
Chafee want to keep the Medicaid.discussions alive for 'the sake of a budget deal and
will continue to avoid being overly critical in public. . "
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Interest Groups:. We have received only negative reactions from the groups~
Including the American Hospital Association; the AmeriCan Academy of Pediatrics, the
Chidren's Defense Fund,.the Alzheimers' AssoCiation and the Consortium for Citizens
with Disabilities. The groups, particularly those who re~resent children and, the
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disabled, fe~l that. enactment' of a proposal like 'the Governors; ,:resoltition' would
significantly, increase the number of uninsured and renege on what they believe is a
'jointly-held commitment with the Administration to expand, drat least not reduce, the
number of insured. The AIDS groups are particularly, concerned because they greatly.
fear a state;"'by-state definition of disability., '
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The Office of Public Liaison believeS that your strong stand on Medicaid has built
bridges that ext~nd far beyond the traditional MediCaid constituencies. Public Liaison
believes that significant changes from the~ gro~ps' perception of 'our 'past Medicaid
position may damage this strong alliance and may. be difficult to repair.
CONCLUSION
This morning, Carol, intergovernmental Affairs and Legislative Affairs met .with Ray
Scheppach to discuss ,the NGA Welfare and Medicaid resolutions and the process to move
forward. We will be following up this meeting ,with ~ briefing by NGA for White House, .
OMB, and DepartmeI,lt staff to seek clarification of the intent behind ,the resolution's language.
We will keep you informed of these discussions and would be happy to meet with you to
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disCuss any of these issues further.
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�PRIVATE RIGHT OF ACTION
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A Federal Private Right of Action is Important to Maintaining the Guarantee. The
NGA proposal (and the Congressional conference report) have eliminated any federal cause of .
action by Medicaid beneficiaries. Claims brought bymdividu~ls ,to enforce their rights under
Medicaid would be limited to state courts and state law. Only the Secretary of Health and
Human Services could bring an action in federal court on behalf; of Medicaid beneficiaries.
Both Republican and Democratic Governors want to reduce the number of Medicaid cases
filed. In addition, they do not want court deCisions from federal courts in other states to have
any effect on how they run their Medicaid programs. While, under their proposal, cases
heard in other states' courts would no longer have precedential i value, it is not like! y that
fewer cases would be filed; they would simply be filed in state court.
Since the inception of 'the Medicaid program, a person eligible for Medicaid has had both' a
guarantee of access to certain services and the right to enforce this commitment. We believe
that preservation of the federal' cause of action for individuals to enforce Medicaid eligibility.
assures this guarantee.
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Consistent Interpretation. Those aspects of the Medicaid program that are common
to all states -- like eligibility -- .should be consisteptly interpreted and administered.
The basic guarantee of who is covered should be uniform ·across the country; without
a federal cause of action, it will not be. For example, under current interpretations, a
woman who has a miscarriage is considered "pregnant" and therefore eligible for
services for complications arising from the miscarriage. Under the NGA proposal, if a
state improperly denied those services, she could no longer go to federal court to
enforce her right. The issue would instead be ,litigated in fifty states; in some states,
she would receive .care while in others she might not.
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Significant Limitation of Remedies. Most state ,laws establish higher hurdles for
plaintiffs and provide less relief than federal law.. Under most state statutes that allow
courts to review administrative actions, there is no de novo review (the record before
the court is limited to information considered by the agency) and relief is granted only
when a claimant can show that the agency action was arbitrary and capricious, not
merely wrong. In addition, most state laws do not allow beneficiaries to recover
attorneys' fees, making it more difficult for theI?1 to afford legal counsel.
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�The NGA proposal (and the conference report) maintains a right to sue in federal court
through the Secretary of Health and Human Services. However, this poses three
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problems: (1) the Secretary can sue only if a state is in "substantial noncompliance"
-- a much higher standard than exists today; (2) the Health Care Financing
Administration will become involved in greater numbers oflawsuits and face
significant new administrative burdens; and (3)' it is unclear what remedies are
available. If the only remedy that the Secretary can seek is the withdrawal of federal
funds, this would cause significant harm to the beneficiaries lthat the Secretary is
supposed to represent (and might even make this remedy unus~ble).
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Departure from Other Federal Statutes. Eliminating the federal cause of action
would single out Medicaid as the one federal. statute that could not be enforced in
federal court by its intended beneficiaries. Such ari unprecedented step would be seen
as a signal of second-class status and would set off a massive reaction· from
beneficiary groups and their allies.
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Elimination of Remedies under Civil Rights Law. Whil~ it is not clear that the
NGA intends to go this' far, the conference agreement precludes the right to enforce
civil rights laws. Protection against discrimination in state' programs has been
established under the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the
Age Discrimination Act of 1975 and the Americans with Qisabilities Act of 1990. If
this is what the Governors intended, the civil rights community is likely to be very
concerned.
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Your Proposal Incl,"eases Flexibility While Maintaining the Guarantee. Under your plan,
you eliminate causes of action by providers over payment rates by repealing the Boren
Amendment. This removes state officials'greatest source of concern over litigation and the
most frequent basis for cases filed in federal court.
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Your proposal maintains current law on private enforcement of beneficiary rights under
Medicaid. You could take steps to address the Governors'. concerns by separating eligibility
claims from some benefits claims. On eligibility issues, which ~re most closely linked to the
concept of a guarantee, individuals would retain their current right to bring suits in federal
court. However, individuals would be required to exhaust a stat¢ administrative process
before filing in court. Most claims involving benefits would be' heard only in state courts. A
benefits claim could be heard in federal court only if there were an allegation that the state
plan or a contract between the state and a provider violated a provision of federal law.
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�M EM.O IlAN DUM
February 7, 1996
TO:
Carol Rasco
FR:
Chris Jennings
RE:
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Medicaid Repeal of Expansion of Kid's Coverage
Attached is the final copy of the memo· we sent to the Pres~dent last Saturday. I have
tabbed and highlighted the section of this memo that mentions the:repeal of phased in
expansion of kid's coverage. I thought you might want to have this reference and perhaps
show it to Leon to inform him that he was also made aware of this provision in this memo.
I hope this information is helpful. Please feel free to call me at 6-5560 with any
questions or comments.
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THE WHITE HOUSE
WASHINGTON "
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Februafy 3, 1996
INFORMATION
MEMORANDUM FOR THE PRESIDENT
FROM:
RE: ' '
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Carol Rasco andLa~ Tyson,
Status of Medicaid discussions
P:URPOSE:
To provide an uPdate on the status of the Meaicaid discussions with t)ieGovemors and the
,Hill, as well as to provide backgroun9 infopnation on,),our Medicaid1reform initiatives. "
BACKGROUND:
Status of Governors Meetings
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'For weeks, in response to reqUl~ts made by the Hill aDd us, the Democratic
and Republican Governors havl~ ,been meetmg to see if they could produce a'
bipartisan agreement on Medicaid.' The lead Governdrs for, the Democrats have '
been R<?mer, Chiles, 'and Miller; for the'Republicans, ;it has been Thompson,
Engler,and Leavitt. To date, :although there is widesPread' agreement on the
need for significant expans~ons in,flexibility, no agreement has 'yet been forged
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on how to structure and financ:e a reformed Memcaid program.
On Thursday evening, and y~;te~day'aftemoon and evening"~ the Governors met
for ,countless hours to review the latest of the Republican Meru.caid.
restructuring propos31s. During their meetings, the RepUbliCans o~tlined their
'new financing (ormula that, f;)r the first time, outlines' how they would allocate
the' downsized '$85 ,billion (fro~ $117 billion) reduction in Federal dollars, " '
amongs~ the states.
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In their new. plan, the Repuhlica~s apparently 'h~ve 1tte~pted to blend their
.blocicgrant with a new contingency fund that is distributed through a per capita
. formula. Their plan would lock·in stat~s; Federal ~~ allotme~ts and grow
them at differential rates. The use of differential rates is meant to address the "
�widespread spending and grO~h I1lte variations between State 'Medicaid
programs. States would be guaranteed thCse.illotnl~nts even If they
signifiCantly decreased the number of Medicaid recipientS tJIeir programs
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served as long as they spent Savin!gs on health care.,'
To address the major policy shortc.oming of a block graxit (no ,
protection), the Republican Go~ernorS have' established a
new contingency poOl of $8 billion that states could apparently tap if they
experienced unexpected enrollment'increases .. Unlike past contingency funds
that have been capped, the Republican ,Governors are claiming that the pool
. " would increase as much as necessary to meet newancl ~eXpected population
growth. If true, this approach could be characterized as a back-up per capita
cap protection. (It is importaDft.o note ~hat we have not been given any ,
statutory.
,language or accompanyiilg CBO scoring of this concept)
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'~sion/inflation
Upon eloserexamination, however, there appears to be: a numbbr of notable
and potentially quite serious shortcOmings with the contingency fund. First, the
dollars are only available to help' pick up the.costs of'higher than projected ' .
, enrollment of mandatory benefits and populations. Siij.ce over 50 percent of
prograln expenditures are for optional services/populati~ns, this does not
provide'anywhere near the level! of "insurance" protection your per capita cap .
does. Moreover, since'their new pool does not inClu~~ the disabled in their .
, calculation (since they allow the States to define disab,ility), the, recession
'. protection provided is probably clOser to 30-40 perCeht of the program costs
for most states. This lack of protection is totally unabceptable to the
. DemocraticGovemo~, particularly Chiles,· and would be inconsistent with your
current policy.
: In. response to criticisms of tluis shortcoming 'byDe~ocratie Governors, the
,Republican Governors areno~~ saying that they would tJe willing to: consider
the establishment of a separat:;~ contingency fund forfoption~ services.
.. Apparently Ray Scheppach is· trying to develop such; ail option. As of this
writing, we ha~e yet'to see or. hear anything specific, about this proposal. If
~y develops somethihg that is workable and is financed without hurting other,
aspects of their allocatioitformula,sOmeDeniocrati~ Governors may' well be '
quite, interested:
State-by-State Fonnula
By releaSing their new state;-by~stateMediCaid fu~ding distribution yesterday, ,
the Republicans have forced us into releasing ours. We had purposely resisted
'until we saw theirs first and could modify ours to ensure it was better for
almost every state. (Not ev.ery state does better because the Republicans are
closing in on our savings number and beCause we '<;QuId not deVelop a
defensiblepplicy rationale to do '''rifk-shot'' policy fixes:)
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, The revised "draft" formula, which we finished this moinjng, will be handed
out to the Democratic Governors tex!ay. It is attached fo~ your revie'Y and, '
includ~ one additional category aimed to show the adv~tage of a per capita
cap during a projected recession. ',As 'you know, because:of the intense politics
and economics associated with· M(:dicaid, this fO,rmula will', change' countless
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State Flexibility and 'Preservation of Federal Guarantee
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At least as important as the formula is the need t<> get al sense of where the.
Governors stand on the, basic stril.cture of the program. ,Althou&b the
Governors have' yet to take up these issUes' this week, there is no indi~tion that
, the Republicans have, for ex~ple, retracted their insist'ence. that there nQ ., '
longer be a Federal court right of actio~ for enforcement of eligibility and '
benefit guarantees. The DemOCIatic (iovemors tell us that the Republicans
view this issue as their "holy grail" and that they do not believe Republicans
will settle for anything iess than state court enforcement of eligibility and
benefits.
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It is also clear 'that the Republicans will insist on si~ficantly altering the':
Federally-defmed benefit pack<lge,including dropping,the treatment
requirement. from the EPSDT benefit. Moreover, while we have confidentially
, disciIssed with the Democratic Governors the po~ibility of removing the
comparability and stateWideI.less requirements for some optional benefits, the
Republicans Want to drop thes4! protections for all benefits, ,including
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presCription drugs.'
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In response to the Democratic Governors and after reviewing the flexibility
recommendations by the NGA, we have incorpO-rated an unprecedented number
of provisions explicitly aimed at freeing' the' ,Governo~' hands iIi administering
Medicaid. As you will note frolll the, attached summary of your proposal, it is
. an, impressive list' by any me<lSure. ,In 'fact, you sho~ld know th?t your ,
proposal provides for' far mOle flexibility than does the "Blue J:?og" Coalition
proposal. (They haye not repealed Boren, they have not dropped the cost- .
'based reilnbursement requirements for community~ealth centers, etc.)
The Democratic Governors ~!Clmowledgethat we have, come a long way in their
direction on flexibility. They would like to negotiate some'.rnore provisions,
, particUlarly relatiDg to benefitS. flexibility. We believe there is some room to
move, but probably not as IJ,iuch,as they would deSire. Having said this, no
Medicaid reform package that preserves the Federally-enforcedeligipility
guarantee to a nationally-defined set of benefits ~ match a block grant in
terms of flexibility.
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The Corigress , '
The Co~gress is all over the plaa: when' it comes to MediCaid..
In general,
though, the vast majority of the Democrats, including such Members as
Stenholm' and' Exon"stand squardy behind your Medicaid approach and are'
unified in opposition to anything that appears ,to be a blOck grant. There are
exceptions to this getJeralization on the Democradc side and, in the case o.f
" Members like Chafee, there are exCeptions to. the generc¥ly unified support by ,
, Republicans for a block grant and very little Federal oversight.
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, Officially, the o.nly plan that does not have a'per ~pitajcap approach that
, preserves, a, Federally'~efined benefit pack3ge is the Republican package. The
Breaux/Chafee, the Q>alition, the Daschle and yourplap. all include some
.. version of 'your per capita cap proposal.
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Having said this,a number o.f conservative Democrats,; like Breaux, Condit and
Peterson, are much more interested i.iJ. a budget "deal" ~han in complicated
policy implications. That is why they constantly tell the Go.vernors how easily
,they can deliver COngressional !Democrats on a Medicaid deal if the Governors
can delivero.n a bipartisan compromise~ In an effort t~ push this along, these
Members ,have all indicated the:jr interest in the Republican plan' in the last 48
ho.urs. 'Governo.r Engler is using these statements to maccurately suggest that
there is widespread "Blu~:-Dog"Democraticsupport for their revised plan.,
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, Congressmen Sterihohii and most ,of his followers, as well as' Senator Chafee, '
appear to have no. interest in sigiting onto a "cloaked": block-grant approach. '
They, 'as well as Dingell and ~is'followers (DingeU voted for the coalition bill)
have strong' policy concerns about' the direction they ihink the' Republica~ are
headed. The Democratic base. ,anchored by Henry Waxman, are extremely'
nervous ab9ut the Republicans and our position. There is little doubt that vie •
arebeing'do.sely sciUtinized by themore'liberal Democrats (and,by the way,
the press) on thi~ issue.. '
The Advocacy and ,Provider Organizations
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The groups are quite, impress,xl by, and appreciative'o.f, yo.ur defenS¢ of the
Medicaid pro.gram. ,They definitely have problems wit~ our flexibilitypacl'age.
(For exaniple,the advocates illlhate o.ur'provision tQeliminate the wajver
process for man~ged care;' tb~ providers hate our provisio.n to repeal the Boren
Amendment.) Ho.wever, with the exception of perhkps a few hard core,
Medicaid protectio.nists, they probably will live witJioui position if we do not'
stray too far from our current position. If we mov~ too far in the diI:ection o.f '
, the ~epublicans; though, we may well be the target: of sOme hard-hitting
mticisms.
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We have, already received within'the iast 24 hourS a critique of the Republican'
Governors' proposal by the Childn:n's Defense, Fund. They accurately pointout
that the elimination of the, current'law'phase-in,of low ~come kids from 13
through 17 would result in "more than 3 million children" losing "gUaranteed
health coverage" in 2002 alone. A coalition of provider 'groups, including the
American Hospital Association arid the aCademic health penters', also sent a
letter to the Hill yesterday strongly opposing a block ~tapproach and the
elimin(ition of the Federal guarantee for Medicaid eligibfiity.
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Conclusion
Leon is' meeting with the Democratic Governors this afternoon to attempt to
, ensure they don't go in any directi()n you are not cOmfortable with. ' We
continue to update you on major developments with the Governors and the
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Should there be a sudden and unexpected,bipartisan Governors' agreement, we
would recommend that you delayin providing a directJresponse for a short
period of time. A slight ,delay: would give you (and us) some time to get a
sense of what would be the policy/political implications of supporting such a '
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�CONCERNS/OUTSTANDING QUESTIONS'
ABOUT THE NGA'MEDICAID RESOLUTION
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Eligibility concerns include:' Thelrepeal of the cUrrent la~'s phase-in for coverage of
about ~ million children age 13-)$.,and the ievolutLQfl...QUb.e....:.djsabiJj!Y.,"_definition.t0 .
~estates.
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Benefit concerns include: The total discretion given to states to alter"the
amount/duration/scope of services; the repeal of the current law's comparability and .'
statewideness requirement that ensure that recipients in particular' groups or locations
are not discriminated against; the apparent elimination of any defined benefit package
for currently optional populations; and the vague' redefinition of the treatment
requirements under the,Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)
children's health benefit. .
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Enforcement copcerns include: The state-based right Of action 'process advocated
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by ,the Governors (a~d'whether it will 'York to effectively ensure the guarantee).
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Financing concerns include: .The exclusion of pregnant women and children, as well .
as the medically needy, from the Federally-financed "~mbrelb\" pool payments; the
inclusion in the base formula of the allow~nce that sta~es can reduce their matching
Medicaid rate -- .the result prooucing an additional $200 billion reduction 'in state .
Medicaid spending over seven ,years, bringing the total FederaVState cut to $290
billion; the allowance for state:) to, once again, tax healtli care providers to help
. fi~ance their state match; allowing for provider·taxes
likely push up the cost of
the program that CBO scores because it will be. easie,r 'for the State to access Federal
matChing funds.
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Quality concerns include: 1'!1e adequacy of the qu~lity protections for plans under
Medicaid,
s~ch
as HMOs and other managed care plan; the apparent repeal of the.
Federal-ba~ed enforcement of Federal nursing home standards. (The difference
between .them and us has alwaysconie down to definition and enforcement.)
Accountability concerns
in/~Iude:
�.February 6, 1996
The Honorable William J. 'Clinton
Presidentofthe United States
The White House
1600 Pennsylvania Avenue N.W.
Washington, D.C.20500,
Dear.Mr. President,
On behalf of the members ofthe Serv:lce Employees International Union, AFL-CIO,CLC
and the Americ.an Federation ofState, County and Municipal Employees; AFL-CIO, we are
writing to urge you to reject the Medicaid retorm proposal that has been adopted by the National
. Governors Association. It is clear to us that this proposal represents significant step backward
forthe 35 million Americans who depend on Medicaid for their health instmtnce coverage.
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The proposal would significantly restrict the. number of individllals who could be
guaranteed health insurance coverage. Mothers receiving AFDC bertefits would no longer be
guaraJ;lteed coverage unless they were pregmmt. States would be able to deVelop their own
definition of disability and deny coverage to those who did not meet the hew standard. Only the
.' elderly wh() met SSI income and resource standards would be covered, putting millions of '
.
elderly beneficiaries at risk.
While the proposal outlines a benefits package of sorts, the categories are quite vague. It
does not appear that .there would be a floor as to amount, duration, and scope of coverage for
various benefits, as there is inthecurrent Medicaid program. An entitlement to coverage means
little if the benefits are ~o sparse as to provide little real protection. :
We are aiso concerned that this proposal would slash $ i 23biliion from' the Medicaiu
program over seven years. While an improvement over the conference agreement, these cuts are
.
still far too large to be abs.orbed by the state:s without significant cutbacks in eligibility and
services, Safety-het providers, who provide the bulk ofcare to the :Medicaid population and the
uninsured, would be at risk of closing their doors, imperiling acces~ in urban and rural areas. We
. are particularly concern~? that the prop,osaJ makes no, mention of the importance bfmaintaining
Disproportionate Share Hospital payments to safety-net hospitals. :
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. Finally, we feel that it is extremely important that beneficiaries be able to enforce their
rights in federal court. Even the limited federal safeguards that do exist in the proposal could
prove meaningless in practice withouuhis basic right. ..
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We are not strongly opposed to thi:, proposal because we ~:elieve that the governors are
necessarily out to hurt Medicaid beneficiaries. But as unions that ~represent state e.mployees
�. across the United. States, we are. well aware ofthe fiscal pressures that :states are under.
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For these reasons, we'urge you to stand by your current propo~al which preserves a .
. federal guarantee of coverage, a federally defined benefit package, adequate federal and state·
providers,
financing, DSH payments to safety:.·net , . , and a' guaranteed federal right of action.
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,Very truly yours,
Richard W. Cordtz
International President
SEIU
International President
AFSCME
RWC:GWM:jpn
opeiu2
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�FEB-07-1996
19:05
FROM
94562878
TO
WHITE HOUSE AIDS ROLICY
P.02
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THE WHITt HOUSE:
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WASHINOTON
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MEKOnANDUM TO CAROL FAS(';O
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NGA Medicaid rroposal
I want to bring to your iuediate ;'Uention 't.he very stroner
conccrns boinq rai~~d by thQ Al~S community to the N.4l1on~1
Governors' ACGocia't.ion proposal to restruceure 1'lCctiCilid. I hAve
attached a copy ora lett:er sene to the President tuUClY by a .
coalition of na't.ional groups; pn-llf.s releases trom the AID:J Action
Council And Hum... n Rights campa1qri on th~1S subject, and ,m..t'.4?rial
provided by Tim Westmoreland o{ Georgetown university Law Center.
As you know, the President has displayed enormous political'
!,:
courage in standing against the tide for dbmantUntj' of Medicaid.
He hac .been particulal'ly t!!ffectlve in communicllt:in9 to the AIDS
cOJllll'lunit.y and. eo the nation as a whole tht:l critical importance of
.Medioaid to Al'nericam'l Hving wi't.h A1DS. For this, the Pl-esiutmt
and his Administra't.ion have 9arnered ~t:lry ~trontj' suppore from the
cOJlllllu:nity for his IId.lons.
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Patsy
SUSJF.CT:
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FROM:
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In that liqht, Lh@ proposal by tho NGA has many in tllt:l commun1.ty
quite alarmed. They have rais~d several key issues:
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)I.4i",•.J.l1' Beody. I3ecAuse of tlu;:lr high m91"1lcal coges, :many
people with AIO~ who are Medicaid boneficiaries are
classifiod. as "medically net!dy." tJnd~r the HGA plan, cuch
individuals c:ould be Cleniecl both mandatory and optianlll
benefit3, includin9 prescription drugs.
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Definition of Dls&bility. By dropping ~o ourrent fcderal
derlnltion of ~isability and allowing stot~~ to decide Who
ie disllbled, the NGA plan could create erel!l.endoue inequities
for. people wit:h lIlV and AIDS. Bec~llse of the high cost of
t:hoir care, people with MTV/AIDS ar,.e an unattraotive
population to cover.
':
8~a~.wi4eae.a of DeDefits.
8y e11mina't.ing requiremcnt3 that
benefIt" :b9 provided stato'Wide 'With comparable Illl['at.lan and.
ccope, the NGA plan would alloW' states to arbitrarily limit
or Rliminate coverage of certain services -- i.@.,
prescription druys -- to certain cate90rioG of beneficiaries
-- i.Q., people with HIV/AIDS.
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FEB-07-1996 , 19 :~
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FROM
WH 1TE HOUSE,' FlI DS POll CY,
94562878
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Right
hava
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of private Action. A!'> you know, people with,HIV/AICS
I:).een and continue to be subject to Mxtraor<.'llnary l.eve1e
of di!;crimination. In fac.t~ AIDs,Srelated. discriminatiun ,i ~
the, lec.d.inq l"'f.:l.ason for biaG investigat-ions' by the HHS
"
'tnspect,or Ceneral. The tiGAplan repl.aces the federal
ght
of private iu.:tion '\l1th a Gtate-ba.sed system., .I:Iy the time '
aueh a c,onvoluted' SyStAl1l ,were completed, a person with ,AIDS
"'i
could very well be dcoCQsed..
•
,Cost-sharing. 'Aqain. because or the hlqh, ooc,t of $c.rvice,s
- eepociallydrugs,-- theimpo3ition of percent~~9 eost
shi'lrlng ,'can be, prohibitively @xpens:1Ve tor peoplew,ith
HIV/AIOS. CUl"n~nt rUles limiting s\.1ch cu::st-f'haring to ,
"nominal" amounts has prot.f:lcted these individuals fl.'oltl thi~
impact. The N~A plan,ho~cveri would 411010' ~or 1~r90r
cl!ar.g es •
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�FEE-07-1996. 19:06
WHITE HOUSE AIDS POLICY
FROM
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94562878
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AIDS 'ACtion Council
1875 Conneoticut Avenue. Nw'Suito 700
WlIihirigton, DC 20009
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.For iiif~r'r:riIition contEt:
,:1. Zuniga. aDZ) 986·1300, EX[, ~.
GO\lUtNORS' MEDICAID REFORM PLAN -UNACCEPTABT.E,'
DOiS NOT PROTECT IIEAT.TH CARE GUARA..Vl'EE FORPWAs
StalemeiJt of Chd~t.i.lle Lubinski
DePu.ry ExeCutive Dira:tor, AIDS AcrIoa CoUDCil
.' .., >
February 6, 1996
, "I
'President Clinton today cxpl'eMCd siJppotr in cornmeala dcli'iered bcfure the N"tional GOvemom
Assioc.l.itioll for i Medieai4n:form 1'181111131, siray' widely ,'com his l'q)ea.ted pro.lllisfls to prole~.t
lbe pa'ruitee to b.ic ~a1th care a.nd life-savlDg 4N;S thi:ltMc:d~4icl has ·come. to repre~.nt to .
al111W>1balt of all.Americans living with HIVIAIDS. While PNiiclent Clinton (Xpr:uti:dan
,interest ia seelnS Itle CongreUion:aJ lludjet 01Ti&:e's aruiiysiS oflhe plan presented 'by a bipartisan .
,rOup ,o( C'JOvemors. he, caUeci the plan 'a step in the j'ig!Jt di~Clloll.· AIDS Action. howc:.vcr,
finds tlla Governors' )¢I'diciici NStrl.l.CtUrillB plan, a pIBl)si1!J.ilar to tile GOP ~'Med.igiamft
prop!)Ml Veined by the President laSe Ial ~. i!a s1ep in the ,vrong direction. lbis ill
coaccived plan is unacceptable 1114 iaise&tivc' particular, COllCems ror peOple., livinS with
HIV/AlDS!
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,,
,'.i:IigIbiWy. The Sraies are ,nmied complete aUthority to cieftrie disability forMedic:aid
eligibility putp05es: In the name of "state: 1'le;dblIlty," peopl.81iving with HIY and AIDS
eit/ler be deemed mcli1i~le for Ixiul!1ils or cOUld be tUgib!e tor completely
. ~Uld
.i:nadeClUaze benefits.
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AIm
for the seate.'
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. • QW&Ji.ty•. StAtes WO~d. be a.tlawedto ~rce' Mediedd' ~nef1cu:nG8 mio,' rnanagcci care
plans w,!l'hoUt federnl overii.!?bt to ensure that qualily pm~ti;~Tlom are in place. With lower,
.paymemi aDd ltls o".l'!liSht, qwit)' of cans will btl: jeDpardb:@d.
-MOllK
...-'-'_.
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• A.1TordabDlty•. The prOposal elitnlnatts federal p~'inrill thAr.,ecst.Ile c:ost;.sharlng
, requirements are nor. Insunnou.ntable barriers to health clre.·Tt' !lures reqUmt co
payments 10 receive St!rviees, people with, HIV could. be foreed to chouSe between
physiciari.yiJjts ana p~ril)li4JlI drujs. at pal cOst totheirovt,;rall health.
... ,
,"'.""
,, '• .Berieftts.UDder the GOvernors' ptoposal. people Jiving with
who are c~ntly
, tcccivini bencllL'I undermedieall.y needy: provisions. could be deniliri acuess to bom
manda1OQ' (doI:;lUr's viRitS) M4 optional' (presoription clru,s) bCCllllflts. ' People with
ffiV IAlDS ,coulci be denied 0.' liwited access to btneiits titlor4cd other MediQlld
.beneflCi.aries purely bqcause they have a !l~ter need - UltNfore will incur greatcr costs
,
�FEB-12!7-1996
19: 1216
FROM
WH IrE HOUSE A I OS POll CY
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ii AcCOllDtabtllty. MIChsltwns nOw in place that allow eO~ume~arui.providen to hoic1
, " sta'tC~ accmmtable fot obeying tM laW, woul~ be c:lilUinated:Insrea4 of 5uea.ml.ining
Medicaid. enfprcemimt by fitly differem SUite coUrtS with 5(1 differentc,rlreria. ,"'ouId
oreAte a ~jU1alOI'Y qUlIgmile. Tht elimillll.tion of virtJJ.ally .all federal ~ardG
undeni:lirAthe fl.lndallwldal priII:1ple of MeI1icaid ~ an entitlement prosram.
"
A Uttle over cWo inoritba aBo" the AIDS community breathed I collective siab at retid' 2i
President ClImon Vt'lCleGI1 budget reconcili~ion bill thll' Inc:luded (Jevastating cuts and disruptive
stnlcturaJ changes to the Medi~id proeram. The 'AlDS community app!o.udc4 Insident
Clinion's VOW [hen In prmeet Mec1icaic: :md other vital f'ed.erJlL.A1DS progmns frOm thOBe who,
Wc:JUld. b4lance the federal budget on Qlt Dub of this ,nationt':i,nosr ~ulmrable citi2em:. Today.
iii .he appearS ready to take a step in Ille wrong cia;ction. :Wc urge Ihe Presldem tok.ef:1' a,
promiee he
inadc~lO
tIDs
rouillry's 1IlO$f
vulnerable '~i1izcful1)y
~jcct.iJ.@ "'I)'
plan thllt pUts at
. jeOpanly Elle emitlemcClJ aatus of thi~ viral he..alth CaN, piOgI'QRl. Contrary to wl1ltl PRSi4ent
, CliIl10n !D14 thil notion' s Govc~rs earl ier 1Od~ ,he pIaa !isw on the nc,oliatilli table does tJOt
guaram:ee b.ieh~alth oa.re to Ib;'" COJ.littry's lI.lOSt· vulnerable oit~n;. but instead ,il; a
pre.seriptlnn !tIr diS2Stet for which there can be nO/lJuidote.
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AIDS Aaion 'QQUlicU i.t the ()I'll]' ruztio'lIll (l~gtini:rPrjon devoted IDklly If)
'shtiping fetll':ml AmSpiJllry (11uJ 18gistlltion, multo tUivocarillg for itu:rem',.d AIDS jPllullng,
IJJDS Acti<m repllYelll..\ more than 1. 000 r:omM1iit'j-btti«i AlDSsemce ~rZ(llli1J1lioIfS throughnll.!
�FEB-07':"1996
19:06 FROM
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94562878
. WHITE HOUSe:·i=lIDS PoLICY
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Ftlbruary 1. 1998
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The President
''The White HOUle
Washington, DC 20500 .
Dear Mr. President:
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We 818. writing to express our extreme cQncem regarding the National GovernOrs
Asaocllrtlo" (NGA) Medicaid reform propoial. We are appalled at the implication from your
reeent commentS that you may support thi, plan.
" OWlr the past few montns, we haV8 wrttten to you on numerOus QI,;CIJSiDnS fegSrdh10 the .
. aed for .etro"9 federal commitment to protectirig the guarantee to tlighquanty health
m
care for fQW·lriccme Medicaid benefiOiaries-and we have frequently recognized your Strong
leadership 10 lSdvOCi1lng fortnle program. "he NGA plan would b9 devas.tatins to people
with AIDS and other Medicaid beneficiarfes. Th. govem0f'8', plan repeals Title XIX-the
backbOnG ot a meaningful gUlrantee to neaUhcoverage for eligible oenefioiaries--and it
does nOt meet any of the crlWia you.have eetabliahed for acr-.eplab!e Medicaid reform,
The NGA propo&alia nathin9 more thin a block grant. Which you have oppoAAd. d/'eS8@d
up In language maanttc provide assurances cllld guarantees that are, in feet. meaningless.
"yOu we", to auppO" ~18 plar", it would betray thecommib'MmbJ ~u have made to peoplo
witt'! AIDS at your ~mbEtr summIt a~d on sevei'al oth8r ocCasions.
.
We ,b8I1.W that tl10re are three critical questions you mu~t lu&k youreelf in assesstna any ,
refOrm plan:· ~.
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lM10 ja coveie,,?
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'The governors' plan
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f.na. the ~eMfiliiiary becauae It WOLild .al/oW .taUII& to define
. disability f'cr purposes of Medicaid eligibility. The NGA plan contains .assurances that the
· dismbled would'receive coverage. 8y Iltmovlng the aJClstlng federal dl'abifny definition.
· however, current disabled beneficIaries ire yulnerable,:to becomIng Ine1l911)1e. Indeed.
· before we h8d tns cUrrent flaeral dIsability definition there were 9rftAt inequIties in aC~.iI '
to Medicaid IImong the diSabled. It /. easy to ImaAinethat some states would ~k to
dellne dlaaCllity in a way that intentionall)l excludes SCfT18 or all paaple with HIV/AIOS.
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WhBt HMel1i 1m cOyerCd?
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The governors' ,Jan flila the beneficiary bEK.:suse it would "epeal current law provisiOns
related 11;1 atateWldeneG&, comparabilitY and amount. duration and scOpe, It ii not enough
simply to state Chat a spoc::ific b9rieflf will be provided. Beneflta end services mlJst be
prov/deG equally In an parts of Ii state, benP.f'ltsmust be provided equally to on cateGories
of bentftciarfee. and they mutt be s:lrovided in;amounts determlnl!!Cf by, a heal1tt cere
.provider to be effective a"d medleally r:'eeeeesry. Statc~ ohould not i;)e free toarbit.unily
·lImlt a<:eess to services. "
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�FEB-07-1996
19:07
FROM
WHITE HOUSE RIDS POLICY'
94562878
'TO
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. t1bw'r8 jndi¥iduals oo.y¥ gfrecsMng th@ ;gyerage fpr Whleb they gUauta
The DOv.mors' plln fails the ban.flchu., beeause it takes away an individual's private
right of action. Thi&proVisionofthe law Ii absolutely ri~ce88al')' to enlure that individUQI~'
have recourse If a state clo" not I)roVido them with a service for which they qualify. A
guarantee to coverage or beneflla is relatively meaninglessunleis there Is., Ml!lan$ to
en~rCe it. Peoole with AIOS have ueeci,a private riyhl of action to 1Jght diecriminatlor'l and
tn gain Ul811ilmW acoast; to pr8iCription drugs and other services ats ulher MedICaid'
beneficiaries withrn their st.::.tes.· If these provlslone are lost, people with AIOS could find
that, on paper. they are guaranteed access to. Inedlcatlon or a S8NlCG, ~ut inreslity it is
. d9n;~ tathem. .
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It it aaeential that anyrefofm plan be abl. to provide satisfactory anlwGr1. to aUd these
Clueationa. Failina even oRe.lhen'the proposal should be rejected. Medicaid I)ayments
, ntprelent the federal government's largest form 01 financier sllpporllo lnu statas, totaling
nearly $100 billiOn per yelilr, We !'laliev" that you and the Congress awe it to the American
people to 'nsiatthat States are held accountable for the federal money they receive.
W•. urge you t6 stand firm, 88 younaVfJ ClQn,C to ci8te. i~ opposiOg the curtent NGA
MedIcaid proposal and any other plan tHat could threaten' heeM care for millions gf
wlnerable lOw-Income Americans. .
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Sincerely.
'1
ArDS ActIon Council
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AIDS Policy Center for Children, Vo'lIth and Families
Cities AdvOcaiin; fOr E",ergency Ales RilUIf
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Gay McniiHealth Cr~1s
Housins Works
Humsn Riglit!; Campaign
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National Association
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of People with AIDS
National Mlnortty AIDS Council
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ProJe"t, I"fOrm
Sa., FranciSco AIDS FoUndation
Taxas AIDS NetWOrk '
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P.07'
IU~'~ 'NO.UU~ P.U~
�FEB-07-1996
WHITE HOUSE AIDS POLICY
19:07. FROM
.. 82/1)]/9l.. 16UI'.J:i9 . VIA fAX
SEN'r BY;
....
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94562878
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COVDNOIS'MED(CAJ1) PUN PtrTS PEOPLE WITH AIDS AT IUS~
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; .: .rBAIldaUd by IN. 111,. CI.lf"lnc i'edf!nd _da.r:da
shaiJlcl rCtlwn m~ac:e, SIQdt~lbuc Mid.· .
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to
tnewrr milt ..ollid
ir. -cli.Ulcl' itt
_ ..iDia, Medieald f'liJi'/)iliry. H~C c:alled 0.11
l'...ickftc amlDft '" ftic« m;, plan UDJ.. cba .
ptMiIiOll it ft'1IV'I'Iiid.
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people '4IIho
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nprn~i\'c
or poIicil.3!ly
uD~ 6rab~ida, inGrludingAIDS IoIlci HIV. ~
III1d 'WIa!\'" !Ilach~lhrt;. HltC'r RUm t-ldl
pgliq ad.YiX:In:. -1& me Il&I1Ie ofpins 'Il..IJility
m du! 1!'Qcn.' ~~. ~rrlO'llS apprex W'l11i.t~ (0.
enc1.r.Dpt 1M.. '11$ C\IIl'c risk tAt posiItility of~O
4ll1'ereJtr dtSl'I iMAlI ortiimhility."
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HRC eaUe6 GIl Oiatoft m riud 6n:a _PM '.hi' '
of
~mctJ' p~ ain. hu
spCbA poeldU!ly shOUt dw Mer.all £II:an but 2M
aid he "cecil _~ mil ptoplt·who ~
porQall
currel'ltly eligiMl!f'or Mcdlaid .a.lMtmCII wou(c! '
ItIlialA
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plaA .'WOIIJ,J iii", dlminllR
Ie p'ace.that itoM mnoc
-:-"11lablr r..,r plClVidlnaMcdiaid CClYCnic IS
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,Medialld MU$t Retain A Standard Definition ofDisabUity
'
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,
·-"Flexibility" to defjne'~disabiiity" for Medicaid is just "qUibtlity" to eliminate the Medieaid
safety net Cur people witb disabWties who are currently eligible. There is no other reason for
such flexibility.
'
,
'-Under eurr:ent law, iri order to quality for Medicaid a ~erson with a disability must meet ~
critma:
The perSOn must be poor. ADd.
The person must meet the SSDfiSSJ definition of total disability.
_·the'SSDIISSI standard is bSsi~aUy an inabilitY to work (i.e.• 8 ~on is unable to maintain
substantial gainful activity). but it
developed signitlcant precedents and. refinements.
has
'fhcSSI standard has &eea developed aDd fine-tuned through regulation and precedent
over'the years to addreSs eomplex disability ca., ~uci1 as '
'
~onditjons that are. sometimes disabling
A
and sometimes not (so-called
"intermittent disabllitiesj that may make a. person unemployable but not
rie(;essarily permanently disabled (e.lf-, mu.ltiple sclerosis; epilepsy. asthma);
, ...:disev.ses that ate progressive (e.g. Parkinson's diseaSe, HIV/AlDS);
-disorders ~·ith non-apparent ,symptoms, or effeCts (e.g.• severe f-atigue associated
with lupus or with Lymedisease)j
.
.
.
.
.
,
•..il1nt!sses without standard mediCal profile's or that do not stlow upon Jab tests
. (e.s., high...functioning develop!nental disabilities other m.e~tal and emotional
disablltties);· or
'
.
or
.
,
,
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-diseases that have cliffeteat nianifestations,Jn different groups (c.g., cervical
~ancer in women with iDim.u.n.e deficiencies). i' .
--Without such a well-defined arid uniform Federal standard, people with disabilities will be cut
ontfrom tbe Medi~l1id program aDd~ iQ most Qt.!!es, fromhealtb care altoJether.
,
..
'
States.wiU have in"nttVes to Urbit or eliminate coverage for those people with
dinblUttes who require mOre compl,ex medical care.
-(Note: ,While some' have ...gued 1bat peop~e Iliay fake disabmti~s to claim eligibility for
.Federal cash assistanoe, it wo'Uld be inationaI.for peOple to fake disabilities so'eJy to have those
disabilitiM treated. Even assumins the fraud t..'lkes placo in the pasb programs, cash poSes
incentives tharmtd.ical care does not.)
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PeOple· with intermittent, progressive, .or other ,omph~x disabilities will have no
reliable p~cdent on which to rely and will be forced to re-defiite aDd re-litigate
'their disability for ¥edicai.d; .
states will seek ine.ic:pensive health)'people,to count tOwalu their f~dinls formulae'
and'neglect to find rhdse,With chronic and wstly needs. .
"
WithOut uniform stai:ldards, people with .disabilities will be foreed to m~ve to find State·
.
Medlcaid prolnlD'U that meet their needs.
If some states provide eliaibiiity and ben~fitsand neighboring States dono!,. people
have to move to get neeessaiy health ~.
'
.For eXample. in the early days of the AIDS epidemic, many people ,moved
, . to California to get, access to health care denied them elsewhere.
~iU
This, in turn, will create a "nee to the' bt.ttom~'inwhich no Siate will want to
provide benefits that might attr~ more poor, disabJ~ people their program.
to
This ~6mpetiti~nto provide tbelca.\1wHl
uUim~tel)' JiJidi b~ndiu to people with
, aiiabilities na'ionwide.'
.
WithOut uniform standards, people with disabilities In statesprovidillC care wiD
, "perienee "Medlcaid·loek." similar the job--lock ofemployc,d ,people with insunm<:e.
to
If a person with disabilities is eligible for health care in one Slate and not in
another. theiJersonwiIl not be'~ble t'O move to be with his or het famny~ to seek
appropriate suppOrt Se~'i~ or to retire.
Without uniform standards, people \l,ith disabiJjtie~ ~d their famiJieswill be caught in ,
confwlng bureaueratic delays.
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, The Social Seeurity Act will continue to' have a definition of disability for purposes
, of its Social Security Diubilf~ Insurance and;~upplcinentaISec:urity Income
programs. ,
.
.
In addition, each State
Medicaid.
,
. . . .
,.
will have a'. . , definition ofdisability for p\ipOses of
different
,
People' With ciisabUities and their families will be forced 1.0 u.ndergo duplicative
',. State and Federal tests. processes, arid paperwork--often aHimes wheD they most
. . need immediate belp.
.
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FEB~07-199p 19: 09' FROM. . LJH lTE HOUSE A IDS POll CY
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.... WithOlrtco~eragc under Medicaid, poor pCQpJe witbdis~bilities wnI b" shut out of the health
care 'ayatem altoMether.
8irice Medicaid is currently. by defmition. limited'to people whom poor and who ~ot '
work. if a State finds a person to be ineligible for the new program, that person will have
,no empJoymcnt-relatedinsurariceand no pefsorWl incorne or assets to u~e for health c:are.
'I,'·,
These Ire the pcople wleb'Do place etscto·go•
....The elimination of a Federal definition of "disability" eliminates the gu'arantee
'oChealth care to poor people with disabilities.
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MEDICAID FLEXffiILITY PROPOSAL
Our Medicaid plan: maintains the guarantee of Medicaid coverage for eligible poor women and
children, people with disabilities, and the elderly. while offering states increased flexibility in
meeting the health care needs of these populations. The plan protects states by providing
adequate funding that responds to unexpected increases in need due to recessions or demographic
chattges such as growth in the number of aged or disabled beneficiaries. In addition, the plan
gives states new flexibility by repealing the Boren Amendment and other provider payment laws,
eliminating the waiver process for managed c.are demonstration projects, enabling states to
simplify and expand their health insurance programs without waivers, and removing many
unnecessary and duplicative administrative requirements.
Maintaining the Federal Financial Partnership
Our proposal continues the shared federal/state partnership and controls growth in federal
Medicaid spending without putting states at risk. Under the plan's per capita cap, federal
spending will increase modestly over time, with Jirnits set on a per beneficiary basis, while
federal Medicaid payments will continue to"automatically adjust to a state's enrollment increases.
In this way, the plan limits federal Medicaid spending while maintaining the federal commitment
to protect states in the case of economic downturn, demographic changes, and other
circumstances beyond states' control. The plan also reduces Disproportionate Share Hospital
(DSH) payments while increasing state control by phasing in a new, more targeted payment
program. along with new payment pools to meet special needs. Our plan provides $25 billion
more in federal Medicaid funding to states over seven years, compared to the Republican plan.
While we save $59 billion under Medicaid, the Republicans cut $85 billion in Medicaid funding
to states.
Increasing State Flexibility
The Clinton Administration has already given 12 states the flexibility to develop comprehensive
health care reform demonstration projects through the Medicaid program. Over 657,000
individuals otherwise not covered under Medicaid have been enrolled in the program through
these state demonstrations. By comparison, there were no statewide health care reform projects
approved between the years 1988 and 1992.
Our Medicaid plan builds on the Administration's proven commitment to state flexibility. It
offers states new options in the areas of provider payments, managed care, eligibility and
benefits, and program administration, while giving states continued opportunities to reduce costs
and increase health care coverage.
o
Flexibility to establish provider payment rates. By repealing the Boren amendment,
the plan gives states greater discretion in establishing their provider payment rates. It
also eliminates the requirement that states pay federally-qualified health centers and rural
health centers on a cost basis. In addition, states will be able to set their own payment
standards for obstetricians and pediatricians.
CLINTON LlBP~RY PHOTOCOPY
�•
o
Flexibility to use managed care~ The plan enables states to implement managed care .
programs without the need for. federal waivers. The plan also repeals burdensome
managed care rules, including federal contract approvals, and the requirement that 25 .
percent of all enrollees in a plan be private patients. In addition, states can require HMO
enrollees to pay nominal copayments.
o
. Flexibility in eligibility and benefits. The plan maintains the Medicaid entitlement and
keeps basic Medicaid benefits intact, while giving states· new. options for eligibility
simplification and expansion. States will also be able to provide home and community
based services to the elderly and disabled without having to seek federal waivers.
o
Flexibility in administration: The plan repeals a· number of federal admirilstrative
requirements, including special. minimum qualifications for pediatricians and
obstetricians, federally-mandated administrative requirements for state· personnel
standards and' cooperative agreements with other state programs,. and duplicative
requirements for annual resident review in nursing homes.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Carol Rasco - Issues Series
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Carol Rasco
Issues Series
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="http://clinton.presidentiallibraries.us/items/show/36305" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7763322" target="_blank">National Archives Catalog Description</a>
Identifier
An unambiguous reference to the resource within a given context
2010-0198-S Segment 2
Description
An account of the resource
Carol Rasco's Issues Series collection consists of records relating to affirmative action, health care and reform, Medicare/Medicaid, immigration, disability, children, families and seniors, education, welfare reform, Middle Class Bill of Rights, and state and local economic issues. This collection consists of memos, letters, reports, schedules, itineraries, talking points, copies of legislation, and organizational material such as flyers and pamphlets.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
92 folders in 7 boxes
Text
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Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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NGA/Medicaid [1]
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Carol Rasco
Issues Series
Identifier
An unambiguous reference to the resource within a given context
2010-0198-S Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 125
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2010/2010-0198-S-IssuePapers.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7763322" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Format
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Adobe Acrobat Document
Publisher
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Clinton Presidential Library & Museum
Medium
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Reproduction-Reference
Date Created
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12/4/2013
Source
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2010-0198-Sb-nga-medicaid-1