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DOCUMENT NO.
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SUBJECTfflTLE
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COLLECTION:
Clinton Presidential Records
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Carol Rasco (Meetings, Trips, Events)
ONBox Number: 7677
FOLDER TITLE:
Families' USA Medicaid Coalition Meeting March 5, 1996
2010-0198-S
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�March 4, 1996
MEMORANDUM TO CAROL RASCO
. FROM:
MARILYN YAGER
RE:
FAMILIES USA MEDICAID COALITION MEETING
CC:
JENNIFER KLEIN AND CHRIS JENNINGS
WHAT:
Families, USA coordinates a Medicaid Coalition of about
60 organizations. (only about 30 attending meeting)
whose focus has been to protect the federal mandates on
Medicaid. They asked. for this meeting with you to
reemphasize their concerns about the current NGA
Medicaid proposal (suinmary attached). and to urge the
President to hold firm on these Medicaid i$sues.
PURPOSE: To listen, and where possible, reassure groups that
have been supportive of the President.
DATE/TIME: Tuesday, March 5
1:00pm
LOCATION: Room 180, OEOB
ATTENDEES:List attached.
BACKGROUND: As you may know, we have worked very closely with
both Families, USA, as well as the members of their
Medicaid Coalition.' These folks were instrumental last
summer and fall in helping us to tell the story of the
importance of Medicaid as a family issue and a middle
class issue (nursing home coverage and coverage for
individuals with disabilities) . '
. ,
They have been very appreciative of the President's
leadership on Medicaid ~ndbelieve that he helped turn
the d~bate around ori this issue. However, we have been
careful to make su~e they understand that the President
wants a budget agreement, and therefore we would
continued to pursue a potential compromise with'the
Congress.
'·e·
�For this reason, these groups have gotten increasingly
nervous that we might eventually compromise on issues
. that they believe to be key:
o
o
The importance of keeping Title 19 as the statute
to work any changes off of versus the House desire
to scrap Title 19~
Protecting current l~w on eligibility and a
set of meaningful benefits.'
d~fihed,
o
Protecting the tre~tmentpart of EPSDT (Early and :.
Periodic Screening, Diagnosis ~rid Treatment) .
o
Private right of action.
,
.
.
It is my understand~ng that most of these grbupswere
generally pleased wit~. Sec. Shalala testimony last week
(attached), but were concerned: that she seems. soft on
the EPSDT treatment issue.
ATTACHMENTS:
List·of Attendees
Families USA Critique of NGA Proposal
Administration Critique of ,NGA Proposal. .
Sec. Shalala's Testimony Before Senate Finance Last
Week
�Withdrawal/Redaction Marker
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DOCUMENT NO.
AND TYPE
001. list
SUBJECTfflTLE
DATE
Re: Attendees (partial) (1 page)
03/04/96
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Domestic Policy Council
Carol Rasco (Meetings, Trips, Events)
ONBox Number: 7677
FOLDER TITLE:
Families USA Medicaid Coalition Meeting March 5, 1996
20 10-0 198-S
rylOOI
RESTRICTION CODES
Presidential Records Act - 144 U.S.c. 2204(a)1
Freedom of Information Act - [5 U.S.c. 552(b)1
PI
P2
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P4
b(l) National security classified information [(b)(I) of the FOIAI
b(2) Release would disclose internal personnel rules and practices of
an agency l(b)(2) of the FOIAI
b(3) Release would violate a f"ederal statute I(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information l(b)(4) of the FOIAI
b(6) Rclease would constitute a clearly unwarranted invasion of
personal privacy l(b)(6) of the FOIAI
b(7) Release would disclose information compiled for law enforcement
purposes l(b)(7) of the FOIAI
b(8) Release would disclose information concerning the regulation of
financial institutions l(b)(8) ofthe FOIAI
b(9) Release would disclose geological or geophysical information
concerning wells l(b)(9) of the FOIAI
National Security Classified Information l(a)(I) of the PRA]
Relating to the appointment to f"ederal office l(a)(2) of the PRA]
Release would violate a Federal statute l(a)(3) of the PRA)
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRAI
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors la)(5) of the PRAI
P6 Release would constitute a clearly unwarranted invasion of
personal privacy l(a)(6) of thc PRAI
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal recordmislile defined in accordance with 44 U.S.c.
2201(3).
RR. Document will be reviewed upon request.
�H:30
'U347 2417
joanAlker
Todd Askew
Allan Bergman'
Felidn Brown
ChriStine (;apitoBurch
Patrick COnoyer .
Jeffrey Crowley
Stan Dom
lynne Fagnani
\
,
James Finley
Nicole'Gudzowsky
Gregg HaifleY
Joanne Hustead
Jeff Jacobs
Martha Kendrick
Ann Kolker
Rachel Leahey
John Lewis
Ned McCulioucli
Kathy McGinley
Shelley Mosl(owitz
Trish Nemore .
Peter Nixon
Elizabeth Prewitt
Mark Regan
Gwen Rubinstein
Laura Ann Saul-Edwards .
Karen Sealander
Jeff Singer
. Dong .Suh
Lori Valencia Greene.
Judith G. Waxman
James Weill
'GOV'T l{ELATIONS
....... PUBLIC LIAISON'
Families USA FoUndation
·American Academy of Pediatrics
· United .Cerebral Palsy Associations
iAAR'P ........ .
. '.
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National AssoeiatkirtofPublic'HospftalS, ,
OffM:e 'for Church in Socletyqf. the United ChurchofGhrlst
Na~nal. Associlitlon qf. People with AIO$
.
Children's Defense,Fund
.
National AsSociation of Public Hospitals
National Commun~ Mental Health
Council
National Citiz~ns~liti~llforNurSing Home Reform,
Children's Defense Fund· .
.
Women's Legal Defense Fund
· merican 'Public Health Association
A
~anor. Care
National Women's Law Center
Family Service America.. .
National AssOCiation of Child AdvocateS
Service Employees International Union
eare
TheArc
. ,
Neighbor t9Neighbo.r
.
. NatiOnal Senior'Cnizens Law Center
. Service :EmployeeslntemationalUniOO
'
American CoUege,ofPhysitiiIDs .
Natlon~I'HeaithlJ1w Pr09ralT!
Legal Action,Center .'.
American Academy of Family Physicians
.
.. CounCii Women'S.arid Infant's Spe'cially HospitalS
. National Health Care 10r the Homeless Council'
.
ASian PacifIC ISlimder American HeaHh Forum
.. \·PlannedParenthoodFederatlon01Anlerica·
. .,FamiUesUSA Foundation
Children's De1ens~Fund
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N, D A T I O N
February 21, 1996
Dear Interested Group:
On February 6, 1996. the National Governors' Association (NGA) unanimously approved
a compromise proposal to restructure the Medicaid program.
'
The NGA's description of the proposal posits thatit "guarantees health care to our most·
needy citizens." But a review of the plan belies th,at assertion. Under the Governors' proposal:
• Millions of Americans will be in jeopardy of losing coverage, in particular:
•. children aged 13-18;
,
• senior citizens with incomes above the meager federal Suppleme'ntal Security Income (551)
level;
,
• those with high medical bills;
• some parents who receive Aid to Families with Dependent Children (AFDC); and
• people with disabilities.
• Those who are covered will lose the guarantee they have today to meaningful benefits.
• Low-income and vulnerable Americans can be forced to pay high out-of-pocket charges as a
condition of receiving care.
.
• Existing federal guarantees that high-quality care be provided will be eliminated.
• Federal nursing home quality monitoring will be terminated.
.
.
• Beneficiaries will lose their ability to enforce whatever rights they,still have in federal court.
• Many states will be allowed to reduce their spending on Medicaid beneficiaries, and all states
will be given sufficient flexibility to "game" the matching fund requirement.
Enclosed is an in-depth analysis of specific aspects of this plan. This paper -- entitled "What'
Does the National Governors' Association Proposal Mean for Medicaid Beneficiaries?" ~
attempts to answer crucial questions in order to understand how the. NGA proposal will work for
benefiCiaries.
We hope to continue to work with you as these and other questions are answered.
~o?~.
Ron Pollack
Executive Director
1334 .G STREET, NW • WASHINGTON. DC 20005 .202-628-3030 • FAX 202-347-2417
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What Does the National Governors'
Association, Prop.:»sal Mean,f,or Medicaid
Beneficiaries?
"
,',
OVERVIEW
,
' . '
Q
,
,
oi'"
"
,'"
'
n February 6, 1996, the National'Governors' Association (NGA)
,
unanimously approved a compromise proposal to festructure the
,",Medicaid
progr~m. This proposal has
been hailed asa breakthrough
that could breathe new life into the stalled federal budget negotiations between
the President and the Congress. Medicaid reform has been one of the most
e
: , ,contentious issues between congressional leaders and 'the President. Thus, the
compromise 'proposal raised hopes that a
l
feder~1 budget agreement 'is
achievable .
..
•
. . The G~verriors' proposal reflects the ' .,
positions 'of only on'e of the'interest groups in
,
'
All gu.r.ntee~ of
,
the Medica!dprogram controversy-the
Governors. Not surprisingly, the Governors seek,
meaningful coverage
.""III be eliminated
, to maximiz,e federal funding while granting ,
•
themselves the flexibility to cut their' own
Me,dicaid budgets. ,At the same time, the
Governors want much more control over the,
most needy citizens." But a review of the plan
program's operations . .In asserting those'
belies that assertion. Significant numbers. of very
interests, however: the Governors' proposal
'vulnerable g'roups will lose existing or future
significantly weakens the program'shistoric
coverage-including people ,with disabilities,
"
'
"
protections for low- and moderate-income
people who depend on Medicaid lor their health '
e'
DIE CONSUMER VOICE
FOR HEALTH CARE
1334 G Street, NW
Wsshingtpn. DC 20005
public assistance. All guarantees of meaningful
care. It will aisoenable state governments to :
FOUNDATION
seniors. older children, and families receiving
coverage will be eliminated. New and
evade their fiscal obligations under the program,
unaflordable
resljlting in significant cutbacks of se,rvice to
imposed. Federal standards for Quality of health
,
cost~sharing
requirements may be
. care will be nullified. And the ability of program .
program beneficiaries.
beneficiaries to enforce remaining rights will be
, The NGA's description' of the proposal
weakened.
posits the't it -guarantees health care to our
',' .
�GOVERN
Under the Governors' proposal:
• Millions of Americans will be in jeopardy of
Seotlon I
MIDICAID 8INIF.T. COULD 8E
DRAMATICALLY RIDUCED
losing coverage. in particular:
• children aged 13-18;
The Governors' proposal requires states to
• senior citizens with incomes above the
provide the following benefits to groups that are
meager federal Supplemental Security
"guaranteed" Medicaid eligibility (see Section II·
Income (SSI) level;
for list of guaranteed groups):
• those with high medical bills;
inpatient and outpatient hospital
• some parents who receive Aid to
services; physician services; prenatal
. Families with Dependent Children (AFDC);.
care; nursing facility services; home
and
health care; family planning services
• people with disabilities.
and supplies; laboratory and x-ray
,•. Those who are covered will· lose the
services; pediatric and family nurse
guarantee they have today to meaningful
practitioner services; nurse midwife
benefits.
services; and Early and Periodic
Screening. Diagnosis and Treatment
• Low-income and vulnerable Americans can be
forced to pay high out-of-pocket charges as a
condition of receiving care.
• Existing federal guarantees that high-quality
care be provided will be eliminated.
(EPSDT) services (although the
treatment mandate is redefined so that
states need not cover treatment for all
conditions).
This list of benefits approxiniates those
• Federal nursing home quality monitoring will
that states must now provide under Medicaid
be terminated.
law. with the notable exception of services at
• Beneficiaries will lose their ability to enforce
whatever rights they
~till
have in federal court.
federally-qualified health centers and rural health
clinics. However, the list of required benefits is
virtually meaningless because the Governors'
• Many states will be allowed to reduce ·their
spending on Medicaid beneficiaries, and all
proposal gives states total discretion over the
. amount. duration, and scope of such services:
states will be given sufficient flexibility to *game"
For program beneficiaries, this raises the
the matching fund requirement.
following problems:
The following is an in-depth analysis of
specific ·aspects of this Pla~.• This paper attempts
No Quarantee of Sufflolent Benefit.: Under
to answer crucial questions'in order to
current Medicaid law. states are required to
understand how the NGA proposal will work for
. provide Medicaid services ·sufficient in amount.
beneficiaries. The sketchiness of the propoSEd.
duration, or scope of such services to .
however. leaves .many Questions unanswered.
reasonably achieve their purpose.· The
More details must be provided by the Governors
Governors' proposal eliminates this requirement.
before the true impact on beneficiaries can be
Without it •.states can arbitrarily limit the level of
assessed.
services provided. For example. states can
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No Qua~antee of Seneflla All Year Lon.:
saatisfy the hospital services requirement, b)'
.. prC!IDIViding a very limited number of c()vered
There is flO guarantee that a state
:,'
.
'
wilt not cut
,
back on benefits if the money runs out in the
halIspitaldays per,year..:..even as little as one day
,
. . , . .
.'
,
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.'
.'
.
middle of the year. If a state runs out of
8:'year. Without. "amoiJnt, duration, and scope" .
prm1ections, be"neficiaries have n? assurance that
· money-because inflation grows m·ore quickly
~f
thee benefits package offered by their state will
than, expected or the mix
services, becomes
be even minimally adequate:
more expensive than initially predicted-the state
. will not be allowed to draw down federal
NCo Quarantee of Equal Treatment:
"umbrella funds· (see Section VI for explanation
•H\mount, duration, and scope" protections also
of the umbrella fun(j). The fear that .states might
emsure that a specific service'will not arbitrarily
run out of funds is legitimate-witness the recent
be reduced because'-of a patient's illness;
discovery by the Medicare program that costs
~r
medical condition .. AU guaranteed
had risen higher than expected due to more
beneficiaries, under current law, must receive "
.inpatient hospital days than predicted. If this
"o::omparable" benefits for comparable medical
situation occurs, states will have either to pay for
meed. This too appears to be repealed, leaving
these services with state dollars or to .stop
s:;cates free to offer various levels of benefits to
providing them.
cfuagnosis,
e.
imdividuals with different
me~ical
,conditions-for
imstance, offering extensive services for someone
No Quarantee of Medical Treatment for
writh cancer.. and few servic~s for someone who
Sick Children: Under current Medicaid law,
· states are required to provide treatment to
hms sickle cell anemia or AIDS.
children for· health conditions identified through·
"'0 Quarantee of Comparable Service.
periodiC screenings, even if the services needed
Wllthln State.: The current requirement that a
are not covered for adults . .The Governors'
smnilar benefits package be offered throughout
proposal eliminates this requirement. As a result,
e!Bch st~te appears to be repealed; This could
'a Medicaid provider could screen a child and
\
result in .rural. counties
ge~ting
fewer services
diagnose a serious illness, .then haye to tell the
family that the state witt not pay fo·r the
. tthan urban counties, for example. States can
~.rovide
necessary treatment.
an expanded benefits package in
. Crounties where the local government is able to
,
c:ontribute to the cost of providing the added
,"Optional" Senem. Threatened: All states
t:iJenefits, so that richer counties can offer more
arecurrentty able 10 offer optional services":" .
tnenefits than poorer counties. Or there could be
incluqing prescription drugs, clinic services,
(fl
"race to the bottom· among counties. It would
prosthetic devices, hearing aids, eyeglasses,
Bven be possible for Governors and state·
€
and dental care-and receive lederal matching
ltegisl~tures: to
funds. Many st.ates are already reducing these
apportion Medicaid funds and
smrvices using inappropriate criteria, such as
. ,
· benefits. In the face of inevitable federal and
,~
plolitical favoritism based on the party loyalties of
state funding cuts (see Section YI), optional
amunty and city officials.
services witt be exceedingly vulnerable.
I&mlll•• USA
1334 G St,••t. NW
W••hln.ton. DC 2000tJ
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12021 828-3030
�GOVERNO
. In sum, the elimination of federal benefits
e
PoorChlldr.n A••d 13·18: Poor children
standards, together with reduced Medicaid
aged 13 through 18 are currently scheduled to
funding, will deny any meaningful guarantee of
be phased in for mandatory Medicaid coverage
health security to those seniors, children, and
from 1996 to 2002: It is estimated that, under
persons with disabilities who retain their right to
the Governors' proposal. over three million
Medicaid services under this proposal. Without a
children will lose this guarantee.'
basic benefits standard, states may fear that a
richer benefits package will attract older and
The' Elderl, Poor: Under current law, low
sicker populations who are more likely to need
income seniors with incomes under 100 percent
. costlier care. This will give states an incentive to
of poverty can rely on Medicaid 'to pay their
. engage in a "race to the bottom ..
Medicare premiums. deductibles. and
copayments. These seniors are called Qualified
Section II
MILLIONS OF MEDICAID
BENEFICIARIES COULD LOSE THEIR
.COVERAGE
Medicare Beneficiaries (QMBs). Today, seniors
whose incomes are between 100 and 120
. percent of poverty can rely on Medicaid to pay
their Medicare premiums. These seniors are
known as Specified Low-Income Medicare
The. groups that are guaranteed 'eligibility
under the NGA proposal include:
• Pregnant women with incomes up to
133 percent of poverty ($16,745 for·a
Beneficiaries (SLMBs). The Governors' proposal
e
does require states to continue to pay Medicare
cost-sharing for OMBs, but it is silent on the'
question of premiums for SLMBs, apparently
leaving states free to drop this coverage.
family of three);
The plan allows states to pay lower
• Children through age six whose families
have incomes up to 133 percent of
poverty;
reimbursement rates to providers serving QMBs
than would be paid for other Medicare
beneficiaries. This could result in undesirable
• Children through age 12 whose families
outcomes. Providers could discourage low
have incomes up to 100 percent of poverty
income seniors from using their services.
($12,590 for a family of three);
Alternatively. low-income seniors could be
• People with disabilities (as defined by
required to pay the difference. Current law
the state); and
prohibits this practice, but this protection
.
• Elderly persons who meel SSI eligibility
apparently is eliminated.
,
' , . '
standards ($5640 for a single person or
Elderl, Nuralne Hom. R.aldenta: Ninety
$8460 for a couple).
percent of elderly and disabled persons who
While this list includes many 01 those who are
currently assured coverage, there are a number
01 groups that are no longer guaranteed
coverage:.
receive nursing home care under current law
have incomes above the SSI income standard.
Under the Governors' proposal, states will have
complete flexibility to determine what benefite
these people receive and how long they will
Famlli•• USA·
1334 G
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rweceive them: Currently,
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thEis~
nursing home
• individuals or families who meet currenI'
ar~ covered at th~, option of th~ state;
Ihowever, If the '~tate chooses to cover this
rJesidents
AFDC income, and re~ollrce standards
(however, states with income standa'rds
IQrOup,,'it is required to provide comprehensive
, higher than the national average may lower
!Services all year .I~ng. This wil,l no lon~er be
thos~standards to;the national average);
lTequired under'the Governors' proposal.
or.
The Governors' proposal is silent on a
welfare program'as defined by the state.'
primarily low-income women, and children who
a~ assurance th'~tthe spouse of s'
nursi~g home resident can keep enough
•
are ,13, years or older are like!y to lose, their
coverage, but it is in,possible to estimaie how
.
to live at h'ome (known
','
"
, The Governors' proposal apparently,
, • an assurance that adult children of
.
repeals the current uniform rulesf.or, determining
,
,
, nursing home residents will not have to
what constitutes income (and. presumably,
impoverish'themselves to pay for the'ir
resources, in the case of people witb ','
pare'nts' care; arid
disabilities). Medicaid cu~rently relies on AFDC'
• an assurance that the state will not take
rules for determining income and assets. Without
,
the nursing home resident's house or put a
,
,
'
,
choices, sucn as what income to c;ount, and how
' :
"
'
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there.
,
, to treat income available from other, family ,
.,
,
.
members. As a result, thEr sa.me child could be
"
'
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Dlaabliltlea:
Stat~s will b~able
guaranteed eligibility in one state a'nd not in
est~bliSh their, own definition of di~ability. ,
!Disabled 'perso~s ;"'ho do' not qualify under more'
~estrictive state definitions but curr~ntly 'meet '
,
,
,
, tfederai guidelines will lose guaranteed coverage.
States CQUld decide, for example, that a certain '
,
,
'
Idiagnosis~ such~s AIDS" does r)ot qualify a
, person as disabled. Or stat~s '~ould decide that
,~ 'I
,
'only people who are bedridden qUaliiY',A state
,that wants to reduce expenditure's can do so'
.
~,
~
'
easily by n~rrowing the definition of disability,
.1
Liniform'rules, states will , make their own
lien on it 'if 6ertain family members still live
~th
,
many.
as "spousal impoverishment" protection);
, " Pe~ple
,I"
Und~r either of these scenarios,· many parents,
/population. They include:
and~ssets
'..
• individuals who are eligible for a new, '
. mumber of protections in curr~nt law for t~is
income
"
another. "
Peopl~'Quall"lng Und.r'IIOptlonal~'~,
C~yerage
",
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-I'
Categorlea:, Under current law, as '
well as in ,the
Governqrs~
proposal,
opt to '~xterid Medicaid'coverage
specified groups
0.1
~tates
may,
t~ cithe~
peopl,e beyond the' ,
"guaranteed" populations, Under'current law, .
these include persons whose medical expenses
are so nigh that they are left with little money for
basic living costs (the "medically needy·);.,
Parents and Older Children on AFDC:
IUnder current law, families who are on AFDC
are automatically eligible, for Medicaid benefits.
The Governors' proposal allows states to choose
to cover either:
pregnant women and children up to age one in
families with incomes up to 185 percent of
poverty; and, in some states that do not have a
medically needy program, nursing home
residents who could not otherwise afford the
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1334 Q St,••t, NW
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costol care. More'than one-sixth of all current
Medicaid beneficiaries, and 90 percent
0" all
. Medicaid nursing home patients, are in these .
c~uld bEi
e
diverted to meet
existing, state responsibilities-by using Medicaid
,
.
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t' ),'
.
fuMs to subsidize health coverage for state
.
optiOnal coverage categories.
,.
Medicaid lunds
'.
'
';,
.
.
'
employees, for example. Such a diversion would
,
If federal dollars are cut and.states are
,
likely result in a loss of benefits for the state's
allowed to reduce their shares significantly"as
current' Medicaid beneficiaries 'sinceiunds would
the proposal recommends, pressure w'ill
have to 'be diverted from
increase to reduce the number of people·
(see Section vi) .
.
"
afinite pot' 01 money
covered by Medicaid: In the' last few'years,
several states (Arkansas, Flori9a, North Carolina,
Vermont, and Wyoming) reduced Medicaid
'eligibility in response to state budgetary
',Section III
' MIG'M COPA~MENis
MAY, PREVENT
POOR FROM ••EKING CARE
, ,'pressur~s. '.'
Over six million optional Medicaid:
benefiCiaries nationally would be at great risk of
. The
Gov~rnors'
proposa!' appears' to repeal
current protections ,en~uring that beneficiaries
losing coverage. More t~an one out of ,four
. ,can afford ~he cqst of medical care. Without
Medicaid beneficiaries· receive optional coverage
" these vital protections, states may ra.ise cost
in fifleeh·states. These states are: .Connectic~t
sharing reqUirements, leaving beneficiaries
(42%); North Dakota (41%); Oreg()n (40%);
unable to afford the care they need.
, P,e'nnsylvania (40%); MassaChusetts,(39%);
Kansas (38%); Arizona (38%); Virginia
(35%)~
, . Hawaii (34%); Mary,iand (33%); illinOis (32%);
UnaHordable Coat4i.arlng
lIa,. ae
Impoaed On, aeneflolarles: Under current
,
, Vermont (30%); Arkansas (28%); Tennessee
(27%); and New York (26%).
,
'e
.
law, Children, pregnant women, persons in
institutions; and those receiving ~mergency
services maynot be charged premiums,
People With Income. Above Poverty Ma,.
copaymehts, or deductlbles. All other
Gain Covarage: Under the ,Governors"
beneficiaiiesmay only be charged n~minal co.st~
proposal, states may cover any individual or
sharing amounts. The Governors' proposal
family (as:defihed by the state) whose income i,s
appears to repeal these protections.
.
1
'
'up to 275 percent of poverty .. This provision,
could help states cover morfi people ,who now
Provider. Ma~ Turn Awa,. aeneflclarle.:
lack access ,to Medicaid or to private insurance,
Under current law, provider~ maY not turn away
sucn asnon-disabled adults. This wo~ld enable
beneficiaries if they do not have the copayment
states toredu'ce the number 01 people who are
at the time services are requested. This
"uriinsured, as some states have already done'
through 'their approved federal Medicaid waivers.
O~ the' other hand, it is possible that federal
1334 0 Sf,eef, NW
protection also appears tO,be repealed by the
Governors". ,
proposal..
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W••hlllflfoll, DC 200011
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Under current law,states must survey
ProvldereCould "Balanc8 BIII",Th.elr
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'ttl.:
Patlen,le: Medicaid curre~tly requires 'health
'nurSing homes annually, using federal
care providers to accept the Medicaid
procedures. These procedures layout the steps
reimtiursement rate (and any required
inspectors must take, such as observing
copayment) as ·payment in fulL·, This protection
residents, talking with family members. reviewing
also appears to be
rep~aled.
medical records, and recommending corrective
In the absence of
, actions. States must also' survey nursing homes
this protection.' providers may charge
beneficiaries .thediffE~rence between what
,
to investigate complaints by residents, family
'
'
members. and otners. Last year, these state
Medicaid pays and what the provider normally
. 's~rveys
charges.
Studies show that low-income persons . ,
'.
in more
"
than 600 nursing homes: Inspectors found
delay or avoid getting the medical care they
need because of cost-sharing requirements.
~ncovered s~rious probl~ms
deaths due to misuse of phYSical restraints. drug
2
overdoses, and other problems. These
This results in the subsequent need for more
inspections will no longer b~ requiredurider the
costly care and drives up costs in the long run.
Governors: plan.
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Cost-sharing pro.t~ctions a.nd prohibitions against
balance billing are essential elemenis,of any
.
.
, package which seeks to guarantee health
Histo'r'y shows that, without 'federal'
'.
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" ..oversighi, state enforcement of nursing home
~
,
coverage for low-income populations.
,:slandards is episodic and' ·inconsistent.
the 1987 nursing home
reforr~
In fact,
law was enacted
after congressional hearings exposed
.
Section IV
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.QUALITY AND AVAILABILITY OF
CARE JEOPARDIZED
"
.
widespread problems due to inadequate state
enforcement.
States do not 'have laws in 'Place that
'
adequately protect nursing home residents,
, Current law includes provisions to protect
. Medicaid b~nefii:::iaries agains,t poor quality
. through nursing home surveys 'and enforcement.
The National Citizens' Coalition for Nursing
health care. The Governors' propos~1 c;ontains a
Home Reform recently examined ten states'
number of features that threaten the quality of ,
nursing home laws. Nine of those states did not
health and long-term care.,
' meet minimum federal standards for nursing
home surveys. Enforcement provisions in slale
Murelng Home Quality Standard.: While the
laws vary dramatically. and states often do not
nursing ,home qualitystan~ards that were
aCI when they find seriousciuaiity~relaled '
passed in 1987 appear to remain intact, fede.ral
violations.3
enforcement ofthese standards is repealed.
Under current law, stales enforce these
Managed Care Protectlone:, Under current
standards under the guidance and oversight of
laws. states must seek waivers from the federal
the federal goyernment. The Gpvernors'
government before requiring Medicaid
'proposal gives the states the authority to
b"eneficiaries to enroll in managed .care. The
determine '~II enforcement strategies.
Govern?rs' proposatrepeals this waiver process
Famlll•• USA
1334
Q
St,e.t, NVI
W••hlnflton, DC 20005
12021 8284030
�GOVERN
and, apparently, all managed care consumer
compromised by the loss of this funding.
protections concerning access to Quality care.
Beneficiaries wllo depend on these hospitals
Without such protections, there. will be no
may have to suffer from inferior treatment or the
standards
reg~arding
Qualifications of doctors or
loss of the facility from their community.
other health providers, no standards to ensure
that beneficiaries-especially those in rural
areas-have adequate access to providers, and
no limits on the number of beneficiaries one
S.c,I... V
ENFORCEMENT MECHANISMS
"
COMPROMISED
~
managed care plan could serve.,
, The Governors' proposal' establishes new
As states move growing numbers of
.
Medicaid benefici~aries into managed care plans,
enforcement procedures for beneficiaries who
particularly vulnerable disabled and elderly
are inappropriately denied care. The proposal
populations, strong consumer protections are
prevents individuals from bringing an action in
vital. Without these protections, a stat!'! could
federal court on any dispute over eligibility or
turn over most of its Medicaid funding to one
benefits. Instead. a person whose federal or
private managed care plan. The plan could hire
. other rights have been violated will first have to
a small number of doctors to serve a large
exhaust siste administrative a,?peals procedures.
number of patients. Even if the plan provided
then go to state court, and, finally, petition the
inade,Quate care to beneficiaries, it could pocket
U.S. Supreme Court.
enormous profits. Audits have documented many
.
abuses in Medicaid managed care plans in the
for the individual who is derlied coverage or
past, including: contractors that received large
services. First, it requires an individual to go
payments but provided little service to enrollees;
through the entire state hearing appeals process
fraudulent or deceptive marketing practices; and
before bringing his or her complaint to ,state
failure to provide required services, such as
court. Many states have very slow and
childhood immunizations.
cumbersome processes which could cause
a
This process presents numerous obstacles.
serious delays. Second. federal courts are the
, Safety Net Provider. Tbreatened: The
.
usual and best arbiters of disputes over federal
Governors' proposal eliminates all health plan
law. and the slate court system is often ill-
and provider reimbursement protections. Some
equipped to deal with rights ariSing under
of these changes could compromise
federal law. last. given the crowded docket of
beneficiaries' access to Quality care. For
the Supreme Court. it is unlikely that the
example, the proposal eliminates the provisions
Supreme Courl will grant many petitions for
of current law that assure extra funds for
review. 'As a result. there will be little or no
hospitals serving a disproportionate number of
federal judicial oversight of violations of federal
low-income people (the Disproportionate Share
law.
Hospital, or DSH. program). Safety net hospitals
The Governors' proposal also gives new.
in communities where many Medicaid ~
authority to the Department of Health and
beneficiaries live could be severely
Human Services to bring an action in federal
. Famlll.. USA
1334 0 5t,eet, NW
WashIngton, DC .a0005
e
,aoa, 828-3030 .
�umbrella furid 'covers guaranteed populations '
court on behalf of an individual. However",' :"
'"I
because this is a new function for the
andopiional elderly and disabled benefiCiaries.
department, a new enforcement division will
The funds are available to cover boih . ,
. have tO,be est~bljshed. It is ~nlikelyttlat the
guaranteed 'and optional seJ'Vicesfor these
department could devote sufficient resources to
beneficiaries. Optionally 'covered children 'or
this effort at a time when its funding and staffing
families with incomes above the guaranteed
are being reduced.
eligibility income levels would not qualify for
. umbrella payments. Excluding children and
The individual's righf to bring a lawsuit in
,
•
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, . families above guaranteed eligibility levels is
federal court.is a cruc.ial, feature of the Medicaid
program's guarantees.
A right without a
troubling when states have experienced much of
meaningful remedy is a hollow right. A
their enrollment growth in this category in recent
meaningful guarantee to coverage must
years.
therefore include a iederai private right of action.
Many Questions remain about the
. umbrella funds: '
S.ctlo. VI·
HOW DEEP WILL FEDERAL AND
that experience unanticipated growth in inflation
STATE FUNDING CUTS'
or an unanticipated use of more costly services?
• Will
B.'
umbrell~ money
be.available for states
If not. the pressure on states 'to reduce services
Uncertalntt:Ovar Fadaral Funda: The'
wilt increase:
Governors' proposal sets up four different pools
of federal money states can draw from. The .first
two comprise a state's finite dollar allotment.
• Will
umbrella funds be available if the state
covers more high cost seniors, for example, but
fewer than anticipated 10wer-cost people, such
Each state will receive a base amount
n~t,
determined by how;'much it spent in. its cho~en
as children? If
formula for determining these amounts is yet to,'
provide coverage to new o,Ptional elderly and
me pressure on states to '
.. ,eliminate eligibility for higher-cost benefic'iaries
base year, plus a second amount that allows t h e '
,,'
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will increase.
state to cover projected increases in enrollment'
.• Will money be available if the state wants to
'growth, case mix, and inllation. The exact
disabled coverage groups that it previously did
.,.
. ,
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be detided. A third pool 01 money 'Will go to
'
, not?
states that have high illegal alien and Native ....
American populations.
• Will money be available to cover extra people
The fourth pool of money is a' new so
who qualify because they are under a new
called uinsurance umbreila.- This represents the
optional category of people whose incomes are
heart of.the compromise r~achedby the
.below 275 percent of poverty?
Governors, and-pOSSibly due to the tentative
nature of the compromise-is the least clear.
'. Will states figure out ways to
I~
is
~ga·nie· 'the
system so that filore money flows to them
supposed to provide states with extra funqs.
without the guarantee that beneficiaries will
when there is unanticipated. growth .in. certai~
g!!lt more or better services?'
populatic)Os qualifying for c!,~erage. The
FCimill•• USA
f 334 G St,a.t, NW
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.The Governors' proposal statesth~t:
Washington, DC 20008
1202J 828-3030.
�GOVERN
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"Appropriate provisions will be e~tablished to
matching dollars. Current, restrictions on prOVide.
ensure that states do not have access to the
donations and taxes will be repealed. Congress
umbrella funds unless there is a demonstrable
enacted these restrictions after some states
need." Until this language is clarified and the
cegan to "Qame" the system to minimize their
unanswered questions are addressed, it is
own contributions. In the late 1980s, several
impossible to determine how much and under
states asked Medicaid providers to make
what circumstances states can tap into federal
"voluntary" contributions to the state; some
umbrella funds.
states imposed
There is no way to determine how much
~pecial
taxes on providers.
, Counting this revenue towards their share of
federal savings the Governors' proposal will
Medicaid payments, states drew greater federal
produce. Dramatically different results are
matching payments. They then repaid the taxes
possible depending on how the details of the
or donations to Medicaid providers in the form of
funding mechanism are decided. A central
higher reimbursements. States thus increa'sed
question is when and how can states claim
their federal Medicaid matching lunds without
federal contributions? Jhe plan could become a
spending any real state-generated revenues.
,
,
block grant with a small rainy day
conti~gency
fund designed to be used only in unusual
This practice is now limited under federal law.
The flexibility to determine what counts as
circumstances. Alternatively, it could result in a
their match will also allow states to use other
flow of money to the states that enables states
federal funds they receive as their match. This
to cover significant increases in' enrollment.
will mean
t~at
states may spend littfe of their
own, funding, but divert federal dollars
~eceived
State Share I. Reduced: The Governors'
through other programs from their intended
proposal would lower the current ceiling of 50
purpose.
percent for a state's matching percentage to 40
Finally, states ,could require local
,
percent. Today, states contribute between 22
governments to contribute some or all of the
percent and 50 percent of Medicaid funding to
required match. Several state government
draw down th'eir federal share. This change,
officials have already proposed "block granting"
would allow 25 states, including such large
their Medicaid and/or welfare programs to local
states as New York and California, to reduce
counties. A Medicaid program run on acounty
their state funding by as much as 20 percent.
by-county basis creates an even greaier
Preliminary estimates indicate that, if a target of
likelihood of a "race to the bottom" among
$85 billion in federal savings is reached, the
counties fearful of attracting persons in the
state match change could
resu/~
in states
guaranteed categories who need costlier care.
withdrawing as much as $214 billion in state
Medicaid funding over a
seven~year
period. 4
State. Determine What Count. A. Match:
States will also have unlimited freedom under
this proposal to determine what counts as their
CONCLUSION
The National Governors' Association
proposal to restructure Medicaid leaves many
, unanswered questions. Because the proposal
e
only an outline of broad areas of agreement, it is
Famlll•• USA
f 334 G
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Washlng'on, DC 20001J
(202} 828-3030
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, ,open to vastly different interpretations.
I,n~eed,
A real guarantee
it
01 coverage must include
three important elements:
has been characterized by some in Congress as
very similar to the MediGrant block grant they
• The benefits package is meaningful and
passed. Until there are more details, it will be
responsive to medical needs;
impossible to make a complete assessment of
• Benefits are available all year long, and
the potential impact.
beneficiaries can afford them; and
Nevertheless; ~ number of important
B~neficiaries are able ~o enforce their
conclusions can be drawn. Some people who
•
are now assured coverage will Io'se'that
rights in federal court if a state illegally
guarantee. Vital federal consumer protections
denies\them care.
related to Medicaid managed care and federal
The Governors' proposal does not meet',
J
enforcement of nursing home standards 'would
this test. The plan does not guarantee
be lost under the Governors' proposal. And while
meaningful health coverage to anybody; instead,
proponents claim that the proposal contains a
real guarantee of coverage to defined serVices
, it provides assurances to Gpvernors that they'
will be able to cut their states' budgets,
for specific groups, the reality falls short.
"
famili•• USA
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ENDNOTES
1. Children's Defense Fund estimate, February 1996.
2. An excellent summary of research findings can be 'found in "Cost Sharing in Health Insurance-A Reexamination," by M.
Edith Rasell, New England Journal of Medicine 1995:332;1164-1168.
3. Jae Hee Kim, ·State Laws are InadeQuate to Protect Residents,· in Congress BrinQs Back the Horrors: BudQet Bill Rolls
Back NursinQ Home Standards. The nine states not meeting federal standards were: California, Colorado, Florida, Iowa,
Kansas, New York, Oklahoma, Rhode Island. and Texas. (Consumers Union: 1995.)
4. Center on Budget and Policy Priorities, "Reduced State Medicaid Matching ReQUirements Under the Governors' Pro
posal.· draft. February 8, 1995.
Famln•• USA
1334 G Sfr••f, NW
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(flO.2) 8.8-3030
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NATIONAL GOVERNORS'" ASSOCIATION MEDICAID RESOLUTION
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,:The Administration full~ supports the significant victory, achieved by the De~ocratic
Governors in' reaching agreement with the Republicans on a financing mechanism that ensures
that "dollars foHow people." However, we have concernsabou.t each of the ,four elements '
that make up the Medicaid guarantee--' financing, eligibility, benefits and enforcement. '
MAINTAINING THE GUARANTEE. '
(1)
Financing. We support the concept behind the umbrella in the NGA resolution
because it, allows financing to increase as enrollment grows. However: (1) states get
guaranteed. allotments even if they reduce' coverage, contrary to the current system
where federai, fiI).ancing rises or fall with changes in ~o\'enige; (2) states can reduce
their match from 50% to 40%, meaning that either federal spending will rise, or if
federal spending is capped,overallcuts ,in Medicaid will increase by an additio'nal
$140 billion; and (3)st~tescould;substitute state dollars with'provider taxes ahd'
donations, effectively reducing states' real Medic~id spend,ing.
.
Our Position: Clarify that we have sorile
that CBO may have «ot:lcerns as welL,/
(2)
.
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conc~rns
about these provisions, indicating
"
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Eligibility: NGA repeals the phase-in of coverage. for ,1.5 million children aged 13 to
18 and ,allows statesto define disability,' "
Our Position: Retain kids phase-in and, as in welfare'reform; let states limit,
disability definition for alcoholics and other substance abusers and t~ghten defini!ion
for' children under SSI.
'
'"
(3)
Benefits
\
"
,:'
. " Adequacy,j Requirements. NGA. eliminates the' "adequacy" requirement so
states can determine 'the amount;' duration and scope of services without
limitation.
:
....
Our Position: ' Retai~ adequacy requirement.
•
Statewideness and Co~parability:' N9A repeals statewideness and
comparability for optional' benefits and may repeal these requirements for'
mandatory benefits.
'
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"
�Our Position: Retain the comparability and·statewideness requirements for
mandatory benefits; Until now, we 'have also, maintained statewideness and'
comparability for C?ptional benefits. We could go farther by giving states '
flexibility on optional benefits, but the President believes that we need more
information about the NGA position and would need to discuss how these
distinctions would be' applied in order to protect again~t discrimination. For
example, we might be open to offering different benefits to broad categories of
beneficiaries (e.g., dIsabled v. children) but not to dividing berieficiaries into
very speciDc groups (e.g., AIDS pat.ients v. stroke patients).
,
.
,
EPSDT (Early and Periodic Screening, DiagnOSIs and Treatment):. NGA
rede,fines' EPSDT so states need. not cover all optional 'services 'for children.
Our Position: We have cl~ified tJ:!a(states are not required to provide the
benefits they give to children under the "treatment" portion of EPSDT to other
populations. In going farther, the President shareS Governors' concerns about
abuses in the EPSDT program'but feels strongly that we need to address them'
carefully. ", '
(4) ,
Enforcem~nt. "NGA elimipates
providers and, h~alth plans. ,
!h~; federal 'private
right of a~tion' for 'beneficiaries,
:,
" Our Position: Repeal Boren 'Amendment and make clear that providers can't' sue over
payment, rates. Reiterate the President's .strong support for a federal c~llse of action i,n
eligibility claims.
'
"
We agreed that, if really pushed, we could go farther. We could eliminate any private
right of action under the statute for providers (e.g., over q!lalifications). We could
also require that all individuals exhaust administrative remedies and that, while all
eligibility claims would be heard in federal court, most, benefits disputes (factual
disputes not claiming .violation of law) would be heard in state courts.
OTHER ISSUES
, We also have concerns about the repeal of Title, XIX and believe that, instead, changes
should be made to the existing Medicaid statute .. There are also second tier but critical issues
apart from the guarantee that we did not discuss (e.g., nursing hom~ standard enforcement,
financial protections for families, the Vaccines for Children program) that we need further
clarification on from NGA., ,
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Tt-iE
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SEC~ETAAY Of ,~EALTH ANp I~UMAN SERVICES
WA$WI,.OTON.O.C, 20201
'.'
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,r,
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'e
',:
of
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U.S. SecietafY,of Health ;md frunuin S~t\'lCes"
..
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at
,Committee ,onFiD~nce
(
",
, Unfte~ States':Senate
,
F®rua.ry ZSt 1996
, ~,
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�¥r. Chairman., Senator Moynih(Jll' and ,members ofthe Committee: I ~anr to thank you
tit,
for giving me
th~ 0pPoftunity to testify [oda~:at>out the NarionalGovernors'
Association (NGA)
resolutions on Medicaid and welfare and the. 'President'S visibn fo~ reform in these areas.
"
of bipartisan leadership
Throughout the. years, lhis commluee' ttas built a great tradition
on these issue.s. We look forward.to working closely with you
.
reach bipartisan consensus o~
,
to
. Medicaid and. welfare refonn legislation.
This hearing, com~s at a critical juncture in our nation's history.
Right now. from kitchen tables t9the halls of Congress, we are engaged ina historic
. debate about the sizc",scOpe, and role of the federal govemment.
This debate is about much
more than deficits and devolution.
At its heart, it's about who
we are as Americans ~- and what kind' of legacy w~ 'want to Jeave' for our children.
The Clinton Administration believes tha{ We must balance the budget in seven years and
,
.
" shiff more responsibility to thc.. states andiocal~ommunities~ ,Bm, we
<
•
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must do
,
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it in a way that·
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is consistent with our values.
As the President has said· time and time again:: We" can balance
.
the ,bUdget
and find
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'
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common ground --wilhout turrung c>ur ba.cks on our values, o.ur families.
.'
1
and our future.
�"
We believe we cangive' the state's the flexibility they 'need -- while stili' maintaining a
•
"
fede~al-state
strong
,
"
partnership built on a foundation of shared resources, accountability to the
.'
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"
taxpaye'rs, ~nd ,national protections for the most vulnerable Amencans.
"
"
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ThaCs why'the 'President bas
propos~
a coinmon sense plan that balanCes' the budget,
gives new flexibility ~o the states. and reforms welfare and Medicaid. without breaking our
. .
.
promises to ourcitizens -- from the seniors)iving in nursing h~mes to the families struggling
,
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to break 'free from, the chains
,!
.t . .
, : .
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of poverty.
That is {he c~allenge we mus( meet
as we work to reform Medicaid and wdfare; ,That
is the standard by which we must judge any refonn. including the resolutions'recently adopted
by the National Governors' Association..
We greatly' appreciate the effonsof the NGA in faspioning a bipartisan consensus. on
'the foundations of a"plan and ilieir ongoing work to add tunher detail t6 t~eir ,resolutions.
.
,
believe. that
-,
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ihey have made a positive contribution to the debate and 'have increased
We
the
likelihood that Republicans and Democrats will produce bipartisan ~olutions to,ref<;>rming our.
"
welfare
~
Medicaid
:
program~. While we applaud their tenaci{y and their contributions.
do have serious questions about some
of the proposaJsthey have put forward:
questions about
ma~ntaining n.ation~l objecrives and the federai.:.state partnership necessary to achieve them.
•
2·
we
�It is DOW Up ,to this Administration and this Congress robuild on' the spirit of the
•
Go\'e~norS' ,efforts."
It i$'time for all of us t6work':
tog~ther
to reach our mutulil goals:
flexibiiity for the states: incemive$ for AFDC recipie~ to move from welfare to work; the
preservation of health insurance coverage for those who need it most; , and protections for ou~
T,'
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most preCious resou~~ 'our' children. '
MEDICAID
Let me rum fust to the Medicaid program. Medicaid provides vitally important
health and long-term ~ coverage foi' 36 million Amcric.ans, and their families. including the·
, followif\&:
care for 18 million low-income children;
o
It provides primary andprevcntiye
.
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I('covers 6 million individuals with disabilities •• providing the health,
rehabilitation, and long.term care services that would other~ise be
unaffordabJe fOT these'individuals and their families;
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It covers 4 million senior citizens •• including long-'term care benefits that
provide financial protection for beneficiaries, spouses, and the adul(children .
of lhose· requiring ~ursing borne care.
'Finally. it pays the Medicare premium and cost sharing for low incoine
seniors: which is the only way to inaketheusc 0) Medicare beoefiL~ affordable
fo~ these iridlvicSu~s. . .
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As part of his balal~d bud8~t' plan, the President has proposed a carefully
desig~ed"and ba~anced approach 10 Medicaid refonn.
His plan
pr~setves Medicaid (ti~e XIX
of the Social Security Act) but makes important changes th8t will gi"'"e statesunpr~edenred
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flexibility ro.-enhance the program's abilityt? meet the
~eeds of the people it serves. The
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President's plan: ; .
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preserves the federal guarantee of '~ongresslonaUy«t'ined benefit package ,',
for Medicaid beneficiaries';, " , ' , ,'",,'
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preserves MediC8id pretectien for all currently eligible groups;
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maintains our shared ftnancial partnership with the states as they provide
health coverage to' needy jndividuals;
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, prevides
unprecedentcdncw flexibility so that states cau better manage their
pregrams and pay pr~vjder5 otcare arid operate man,aged care and' other
arrangements, witheut unnecessaty federal requirements. while main~ining
programmatic and fiscal accountability; and
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centributes federal savings to the balanced budget phm through the use of a per
capita caP en federal matching that adjusts automatically to' changes in Slate
Medicaid enrollment.. changes the economy and reductions in
disprop()rtienate share ,hospital payments.'
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you know , the, President stroni1yopposed -- and ultimately vetoed -~ ~e
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Congressienal approach to Medicaid refonn because it did not meet th,es~ standards. The
Congress voted torepeallhe Medicaid pregram and replace it with a new "Medigranr"
program that did not include meaningful gu~rantees of eligibility or benefits. The Congress
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, alsoprop6seda"'block-gram" funding meChanism thai breached the 30 year tederal
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partnership with the, states to shar:e in changes in state Medicaid spendi~g.
As I "mentioned earlier;, NGA recently approv~ the outlines (.)f its own Medicaid
refonn plan. which has bee~ helpful to' {he·dcba{~. Inpanicular, we have been pleas~d that
the Governors, appear to agree with one of the key elements of our plan ~- namely tha.t
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federal fina~~ing must ~e responsivetOaclual,andofr.en unantic'ipated, changes in Medicaid
,enrol1ment in the states and' changes in the economy. '
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�Howe,ver. while the details of the NGA plan are still not completely fleshed out, we
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are co~emed that the clemerits of the NGAresoluti'ondo pot reflecnhe, p~iori~~es set OUt in ,
'me President's Medicaid ptan in
cenaln, areas. ' These are: (1) the need for ,a real,
enforceable federal guarant~ of coverage to, a congressionally-~efil1ed benefit package; (2)
appropriate feder,land, state finanCing; B,nd (3) gualiry standards, beneficiary prot;:ctiom ..ADd.
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accountability!
, , , The federal euarantee of cOverye and benefits'
The federal ~guarantee" of cov~rage and benefi(s is at the core of the federal
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Medicaid program. ' Unfortunately, the terrn"guar3.I'!tee" has been assi,sned very different
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'meanings in me context of the curremMedicaid debate. , When we use the
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term guarantee in
the context of 8 federal statute like Medicaid, we mean a real guarantee t composed of three
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interrelated components:' definitions of 1>, eligibility; 2) benefits, and 3) enforcement.·
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let'S beginwith eligibility. The NOA plan sets out a number of current law groups
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that states must Cover in their plan. However, problems' rem.ain in the· NGA definition.
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First', it repeals (he current lawphase-in of Medicaid coverage for: children ages 13-] 8 in
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families with income below the federal poverty level -- a bipartisan coverage expansion
signcdinto law;by President Bush.
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In addition,th~'N·OA.n:&'olution repeals the federal standard for defining dis&,bilily and,
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. replaces it with 50 separate: state defllutions. 'Jl1ishas the effect of timing Medicaid
coverage and benefits for those ,,-'ilh disabilities uncertain and variable around the nation.
For example. it would be possible for states to USe restricted definitions of disability resulting
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in very"limited coverage for populations whose service needs are pronounced and among the
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most costly . 111 such situations. we are concerned that llarrow state definitions of disability
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could preclude indjvldua Is with HI~, certain physical' disabilities, ()r mental illness. from
rece.iving critically needed services under Medicaid.
We should not turn back the clock on
'those with disabilities by permitting 50 different ?tate detioitiQi)s for purposes of Me.dicaid
coverage .
. ' 'It appears that the Govem~rs' have retained the' linkagebetweeneash assistance and
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eligibility for Medicaid. However, there are still some outstanding questions that require'
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clarification, including h.ow currently co\'ered~p~lati6ns. like the welfare-'to-work eJigibles,
will be covered afrer the cnact:rn.ent of welfare .reform.
Benefits
Eligibilily is only one ~omponent of the guarantee •• because the question is eligibility
for .what •• bringing us to bt~fits.
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as "guaranteed for the
The NGA resolution lisu benefits that are ch.aracleri~d
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~uaranreed
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benefits defined as optional
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the.curren£ program would remain optional,and that there
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.:, would', qe. an additional set of jong-tenn'7~r~optioJ'ls.
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populations op.ly. "The resolution also says that all other
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�This new framework raises several unresolved questions. Tlle first relates to thl:
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adequacy of the' benefits, Current Medicaid laW and regulations already give states'
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substantial. flexibility in defining , : .durarion"and scope of benefits, and states have,
tht amount,
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used thiS flexibility to re~ndto [heir unjqu~ circumstances. This latitude is tempered by a
very reasonable constraint -- benefits must be "sufficient to reasonably achieve theil'
purpose". We have concerns that by l'pedtYing "completc"flexibHity on amount, du'ralion"
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and scope. the NGA propoSal provides no &randard against which to a~sess the
reasonableness
of a state's benefit plan.
Without a standard, any federal "2uarante.e,"is
illuliory. We believe:,the 'Gov.ernorsunderstood. this as they acknowledged
,'rt their testimony
last week that the provision in their resolution on this issue has shoncomings that need to be
addressed.
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'{he NGA, resolution also is silent on the current ,law standards
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ot. comparability and
"statewideness", of ~ervice.s -"-among and within eligible groups -- for mandatory as well as
optional services.' In the absence of fu~er information ab9ut such provisions, there is no
standard against which the "guaranteed!> benefits and potential discrimination againsf. cenain
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groups or diseases can be assessed; and therefore weare concerned ahout the potential for'
discrimination against certain groups or diseases.
The NOA proposal al~o would limit the treaunent p(ml~n of the Early and'Periodic,
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ScreeniIlg, O'iagnosis. and Treaunent (EP~DT}'program" so'mat states need not cover all
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Medicaid optional services for·children" "The NGA does not yet specify
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~xactlY how this
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would be done,. sq it is difficult [0 assess the impact of the provisi~n -- other than the ""
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, ceruinty that som~ children would nOl receive treatments'despite
me clinical
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EP$~T screening and diagnosis'process~
recommendations' for, those servicesarisi'ng from the
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Enforcement
The thirdessential component of the federal guarantee is enforcemerJ. Implicit in' the
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be~efits' is the nOtion of a meaningful enforCement
concept of definedpopuJations, and defined
mechanism. A federal cause of ae-tion for beneficiaries assures
that those seeking a remedy
for the deprivation of medical care receive the ,same due process, rights eveO'wbere in the
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The NOA resolution requir~s states to provide a'state right of action, but
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eliminates any federal right of action for individuals an:~ providers. who. assert that a state is
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'VIolating federal Medicaid laws.
the opportunity to petition rhe
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The onlyacces~to federal
u.s. Supreme
COUrt
cc>un:for si\ch claims would be'
for review oia decision of a Slate's
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highest court. '
TheNGA. provlslon~ pose a number of serious questions and concerns.. Under th~
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proposal, we believe Medicaiq \\.·ould be the sole federal statute conferring benefits on
individuals with QO possibility of tederal enforcement by its intended beneficiaries.
Review by federal couns also promotes efficiency. As a practical matter, common
sense tells us that those aspects' of the Medicaid 'program that are conunon to
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all states should
�be subject to consistent interpretation and administration. 'When
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the same question arises
across multiple jurisdictions., docision·making in the,l'ederal court sys~em ~aximizes
efficiency and predictability.
This is panicular~y true, when Medlc~id in[er~ClS, a~ is often'
'the c:ase. with other federal starutes (such as Med~care, ,S~ial Security. SSI and AFDC),
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Federal courts are more ex~rienced in analyzing these federal programs and are better able
, 'to understand and decide cases involving
relation~hips among
rhem. When courts are be,iDg
~11 pan,tcipating jurisdictions~ we should '
asked to interpret statUtory provisions that apply to
not construct a system that will enc{\urage different outcomes in different states.
Suits against states filed hyprovide~s
over payment rates have caused the greatest
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, problem to the states. Uhder'1he Administration ~s plan, the Boren AmendIilem and related
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provider payment provisions would be repea1ed, thereby eliminininB' these causes of action by ,
providers. Thus ,~mder 'the Adm"inistration' s plan, state 'concerns aboul J!mi(ingih~ir
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exposure to suit in federal court would be resolved largely.. '
On balance, when we assess [he
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thre,e components required to
make any guarantee
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real -- the definitions of eligibility, benefits~ alld enforcemenr in me NGA resolutio~ -- w.e
continue to; have' concerns beca~
does not appear
the {eden.l guarantee of Medicaid coverage and benefits"
to be t~al and enforceable for rccipic:,nts.
E~ncin~
Theseco,nd key'
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issue is the fimloClI\i c'()ni~.ined' in the NGA resol~ti·on.' The NGA
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resolution would replace the ~urrcnt financmg,system' .a combination of a
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payment and a payment adjuStme~t for une~~'pected incre.ased enroilmenL ' The Go\'emor~·
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,financing mechanism has the poteritiallo be cread\'e
~ind'
a workable fonnula that constrains
growth withom providing incenfives Io drop coverage. Their funding approach. which
ensures Medicaid dollars increase with enrollnlent, re.prcsenls a c~nstructjve addition
debate.
the
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As the Governors have nored, however,' these provisions mustbe fleshed out in
much greater detail before anyone cim assess whether the financing actually flows based' on
changes in em-oUmem. and the economy.
The NGA proposal also includes(wo changes in the state share of financing
Medicaid. The'minimu~federal contribution to me.financing of Me~ic'aid woul~ inCrease ..,
from SO percen.t to 60 percent •. and stales" use of provider tax and'donation financing
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mechanisms would
" While
o~e again be unconstrained.
the~
proposals are appealing (0 many slates! they raise significant concerns.
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Depending on (he overall su'Uclure of the ' .
program and on stated~jsions:,aboU( program' .
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spending, raising the mininlum federal match. rate from SOpt:rcen[
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60 percent either could
Jesuit in significant increases in Jederal spending, or reductions in SLate . contributjons to
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Medicaid -- and in t~talMedicaid funding for, health care, For example. an analysis of this'
provision by the Center on .Buqget and Policy Priorities indicated that if the seven-year
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federalfur'!ding red\ictiqn':were $85 billion' state matChing requirements were fC'.duced in
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the same manner as .the congressional r~condliation bill, stares could reduce state Medicaid
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funding by as much as $182 bUUo'n'to $214 billion over'se~en,years:' Under'thi~ scenario.
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the total federal and state seven year cut could total from $241 billion to $299 billion, and
, ,the funding cutcould be between 19 percent and 26 percent in'2002. '
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Detining and revising ,the appropriate feder4l and
level$ will always be one of the tnost"difficult issues
to
sUteco'ntrib~tions
and Spending
settle in any Medicaid reform plan.
There is no 'question that these matters merit car~ful auenr.ion in . long-lerm. However,
[he '
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given the enormous fiscal implications. the., President's plan proposes
to gain advice from an
, intergovernmental advisory conunis~ion on the appropriate federal' and state funding,before"
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, the Congress procCe<is to change"the current distribution.
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The NGA ,plan would also pennJt uncopsTrained lise of provider ,tax and donation
financing approaches for tile ~~tate~ share of Medicaid. These are the exact mechanisms that'
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the Cqngress recently limited -- in
the case'of'taxes -- or outl~wed.completely
-- in the case
of donations. During the. late 1980s '~ndearly 1990s~many states look advantage of these·
funding approaches, costing the federal government billions of dollars and helping drive
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annual Medicaid spending grQwth rares
up
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~veU over 20,percent. Th,e :Congress wisely
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enacted, limits on lhese mechanisms IMt remain appropriate today.
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In :tddition,the NGA proposal treats Amerkan Indians and Alaska Natives (AI/ANs)
, in its category of "spedal grants" .that includes -grants to ceccain states
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cover illegal aliens
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and to assist Indian, Health 'Service and related,faciliti~ in the provision of health care to '
'e
Native. Americans", Native America:ns ,have a unique status in that they have a governmenr
to 'government relationship wirh the Uilited States that distinguishes them' from other special
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populations. Based 'uPon this legal status, 'they are entitled
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TO benefits
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promised under federal'
trea,ties and trust responsibi1iti~s ~nd to any benefits for whkhthey ~reotherwisc eligible ,as
U.S. citizens.. The NGA resolution regarding Indian Health services does not acknowledge
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[his legal rclali,onship. nor does it recogni~ 'the fact that American ~ndjans possess dual
citizenship, They are citizens, 'of both 'tile stittiand their tribe, The NGA, reSOlution does not,
reCognize 'the state: government' sresPo~ibilitiesto, Anle.rican Indian citizens: We are
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concerned by policies which make the federal government me sole provider,of healm carero
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American Indians
and Alaska
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Natives and abrogate the right
of the~e citiuns to participate in
stare funded services 'on lhe same basis as any other state citizen."
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Finally,' we aU have to examine the NGI\'.:proposaJ and finarici~g structure in the '
" context of the effon by the President and the Congress ro achieve a balanced budget in seven
,years. We do nOl yet know whether this plan 'Will achieve the scoreable savings that are
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required under the President's balanced 'budget plan -- or under the congressional proposals.
If" it does not" it would have to he modified to produce savings. 9therwis~, other portions of'
the budget' would <tlis.ve to be revised to bringtbe bud2et into balance.,
lX2t~~tl.ons
for benens:larles ami taxpayen
"The NGA resolUlion would repeal (i(l~ XIX and create a new titl~ for the Medicaid
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�program. This has the effect of seriously, compromising the framework for, quality standards,"
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beneficiary and family finaniial protections, and program accoUntability., '
The NGA resolution is silent innHmy ar~s. In other areas where [he resolmion is,
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specific. some long-standing pr(lt.cctioIlS would be reduced or eliminated.
For example. the
NGA resolution eliminates the federal role in monitoring nursing ,home quality assurance.
Yet without fC4eral monitoriniand enforcement of state and facility compliance, the
bipartiSan uniform quality standards established by the Omnibus Budget Reconciliation Act of ,
, 1987 could be undennineti sigQiftcamly. _.
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The NGA resolution makes no mention of quality assurance requirements or '
monitoring re&-pOnsibilitiesfor Medicaid managed care., This is a ,particularly important area
since Medicaid managed ca'Ii enrollment is increasing so dramatically": about one-third of',
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beneficiaries are now in managed care, a 140 percent increase in enrollment over the pasl
three years. The President's ,plan'recognip:s' the'need for updati'ng managed care 'quality
standards. It repeab; s~me outdated approaches and require~states
improveme?t
progra~
lO
establish
aquality
that must include developi!lg appropriate standards for Medicaid
'contrac'ting health plans' and using dita analysist,o (tack utilizatjo~ and managed care
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,outcomes.
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Finally, the NGA resolution does 'not clearly address beneficiary and family fina~cial
protections such as spousal i~po~'erishment and family respon~ibility protections that have
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�been central (0 (he Medicaid program forsorile time... The NOA resolution also doe~ not
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address (he imposition of t:o-payments and other cost sharing for Medicaid beneficiaries .
.Further ciarific::ation in an of these 3.reas:is needed, because ~ese are central elements 'of the
financi~l securitytha( Medicaid provides .rQd.ay f('lr benetlciaries and their families .
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U;t me conclude by' focusing on one. fundamental strUctural' issue -- whether we
approach the task .of Medicaid reform by making changes in the current title. XIX ofthe .
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anew titlc. : We
Social Security Ac{,~r by repealing ilia!. program and replacing il' wjth
support reform~ not repeal. of Title XIX. The potential unintended consequences of
. repealing and repla~ing this program are staggering -.:: for states, be~ficia·ries.providers.and
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we federal g()verrunem, especially when you consider that it would reppen thirty years of
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settled litigation: The Congress' can address many of the most pressing ,concerns abou[ any
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Medicaid .reform plan by' amending the current law.
From the begiruliqg of the ~\lrrent:Medicaid debate. the Ptcsident has maintained that
Medicaid must be financ.ed through a fe~eral-state partnership that ensures federal funding .
and provides ,a real, enforceab.le guarantee of c-Overage f('lia defined package of health and
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long~(erm Cart benefits. 'ine President's ,pla~ propOSes unprece~entect new flexibiliry for "the·
stares in how to operate their programs, pay providers, and use managed care and other
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'delivery arrangements .. while re(ainjnga~ revising key standards related
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to
quality and
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beneficiary financial prorectiolts.The Presiden.t's p~opllsa) would achieve those objectives ill
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�. a way that would also help contribute
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a balanCed budge.t by 2002. We believe ·thal the
NGA resolution has made a siiTIificaor contribution to our mutua} efforrs to refonn the
Medicaid program. We lool: forward to working with the Governors. Members of Congress,
consumer groups; health c:.are
pro~'iders",andother inte~estedpartlesin the near f~rure
on this
important issue ..
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WELFARE REFORM
Now I would like to tum to welfare refomi. Let me start by reiterating some POinlS
the President made in his State of the Union addre~s" Welfare caseloads have declined by
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1.4 million. since March
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of 1994~- a dedine of 10 percent. ,A larger Percent~ge of. those still
on {h~rolls are' engaged
in work and relaicd activities.'Fewer children livetn poverty.
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Food'stamp rolls have gone down. Teen pregnancy rates have gone down. '
At lhe same
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time. . child ~upportcollections have goncup. ·as the Administration has improved Slate
collection efforts, the IRS'sseizure of income ta~, r~funds~ and
me ability of the federal,
,government to make f~eral employees aCGOulltable for the suppon they owe lheir children,
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Over the la.n three years. wt have ,':Vorked \i/ith govemor~ and dcctcd officials'to give
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37 states the flexibility{~ design ~elfarereform stra~sies thal meet {heir specific needs.
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This Administration has encouraged states to' find innovative ways to .ffiove people from
welfare to work and to promote parental responsibility. and these effons ~In:ady are making
a' difference fOrll'\O~e th~n 10 'milli9n' recipients'throughoul the country~ ',States. led by
Governors of. both parties; now are demanding work; time·linliting assi~tance; requiringt,eens
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in. school and live, -at h9me;'and &trenglhellingc.hild suppo~ enforcement.
stay
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.Presid~nt <;linto~ also
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has worked wilh'rhe C.ongress:to expand dratn~tically
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Income. 'tax Cred.it to·.il1$~ work ba;~overwelfare; . ThIs 'progra~: which Presid'en£
Earned
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R~~gansaid was the,·tBpsfpro:familY: pro-wprk iJ;ritiiuive undertaken by the. UniredStlltes 'In
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paid 'about '$1.300, less in inCOIrlC 'tax wn they
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would have if:' the laws hadn~t been changed
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. 'Yet, a5the .~~ident· saiq inJanua;,we,sbpuldtkke
adv~ntage of bip~rtisari
consen~us: on time limits,wo~k req~irementS,~d child su~port'''enforcement t~ enact national '; .
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, welfare rcfonnlegislation. The President has consistently c,alloo forbipanisan w.~l.fare
,refonn and the 'Administratioll
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to put
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applau~sth~ w~Y'Re~ublicans,arld Pe~o:cratsca~e together
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fonh theNGA~~mme~dations:.AS, you may. recall, '- thePresident.stanecl us down
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this road wM'n he bt"ught t<;>gether.~ bipaqisan itouP of congressionallead¢rs', ,Governors..
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.. "a~d fede~l and local '~fficials to di6C~SS welfare reform
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We,all
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at the, Blair:,House last year;
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~'ant welfarer,eforyn !.hat prof!l~tes '\vork,
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requires. respOnsibility. and' protects
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children~ Real welfa~e'reforIl'!,is first and foremost about work: I'C'.qUiring re~ipi~Jus' to '.
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. ' make the 'transition into the)w,ork force 'as" qui~kly as possible an~gl,\'tng, them, ~he tooIS d~ey
: ,need to entc;r and succeed ,in 'tht: labOr market: 'Thr~'Witl'require
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achange in'lhe culrure:of
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offic~;; so' tha(e~ery 4'alori provide's"s~pport aJ~ encouragem~n~ for thC'tr~nSition' to
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�,'The President. as part of his balanced budget plan. has propose<!" balanced approach
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welfare refonn that ,achieves these goals. It replaces welfare with a new. rime-limited,
conditional entitlement
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in return for work and giv~s slates ne'w flexibility to design their own
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. approaches to ~elfare refonn. Witlli~ two years, parents must go. to work'.or.lose, their '
, benefits, alid afte~ five years., benefitS end. ·The plan provides vouchers' for children whose
reach
parents
the time limit, and protects states in t.he event of economic' downturns or
population growth';, It also ha!\. rough child suppon enforcement measures and preserves the
'na,tional commiunentto nutrition assistance, foster care, and adoption assistance, preserving
states' ability to respond to growing cas~loads ..
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ThCAdministration will continue to 'judge legislation 'adopted by the Congress on the
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basis of whether it promotes work, responsibility. and family. and protects
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child~en.
And,'
following the example of the NGA and the. Senate last fall. we strongly. hope for legislation .
that will be endorsed by
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majority of Democrats and Republicans in both chambers of
Congress.
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. The NGA proposal makes numerous mOdifications to the conference welfare bill,-., .
many of which, if adopted by., the Congress. would be improvements. Some of NGA's
recommendations fall shan and should be improved.
On the positive' side, the NGAproposal reflects an understanding of the child care
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resources sfat~s will ne~d in implt~men{ing welf~lf'C reforln. f?Y adding $4 billion ·for;.c~ild
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�care above
the Jevei i~the conference·repon.fOf, H.R. 4', the NGA proposal acknowledges
that single parents can only find and Kt'..(IP jobs if their cqlldrcn ate cared for !lafely., The
additional inv~~tment ,is essential to ensure that child care
resources are available. for [hose
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re~uired to move from welfare
to work and
~. equally ~mportant •• to ensllrc (hat,childcare is
available Jor 10"": income, working, families at-risk of welfare dependency. W~. are troubled,
however, that the NGA proposal ,fails to illclude Senate, provisions for ensuring safe ~md
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healthy child care,' and ',that {he incre,ased ff.deral'spendirig does pot requ~re a state match.
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By addingSl billion to the H.R: 4 contin$ency fund and allowing Slates
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to draw
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funds if poverty rises, [he NGA proposal properly recognizes, that stales may experience, ,
unexpected changes in, population or downturnS in their e¢onomy. ' In. the event of a national
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econoinic downturn. however, even a $2 billion contingency fund
,rapidly. During the'la,sl recession. for
.might be exha~stCd q~ite
example, total AFDC benefit payments rose from '
$17.2 billion in 1989 to $21.9 'billion in 1992, a $4.7 billion incrcase.over r.ht base year in
one year alone. A provision should be
matching dollars
has
bee~
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add~
to the bill allowing s'tatesto draw down
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during a national recession" eVen if the $2 billion in ,the conlillie~cy fund
expended., We also tx:lieve the trigger mechanism should be improved to ensure
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greater responsiven~ss to the states' need for add itional"resou rces. '
The NGA proposal also would eliminate the requirement in the Sena[e bill thal states'·
'meet theirfuH 1994ievel of effon in order to be eligible for tlle 'continge,ncy fund. The
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removal of this rellulremenr would allow a ~[ate to draw down additional federal dOllan;
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�while actually· reducing its own COIltributioil to' the family ~ssist3nC'.c prog~am. It 1s difficult
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undersland why a SUl.tl! in need of contingency fund dollars to meet the demand for
assjstan~' would
simu1taneouslybe al10wed
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cut its o~n spending on poor families below:
the 1994 level. We support restoring the'contingency fund
rnainte~nce of effort provision
contained in H.R.4.
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The NGA proposai also prope~lY recognizes the jmponanceof child' ·s~ppon ..
enforcement
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welfare refonn. Last year" the President insisted that welfare refoml include
the {O~gheSt child S\lpportenforcem~nt reforms in thiSCOWltr)·:S history. Since then•.
Republicans and Democrats have worked togethe~ in a bipartisan spirit and includedal! oithe
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major proposals for' child support enforcement rcfonn .thal the Pre~ident requested:
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. streamlined paternity establishment,
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inters[ate child support
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laws. computeri~ed statewide collections, and drivers lirense revocation. We appla~d the
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efforts of the NGA and tbe members of this' Commiuee for their hard wock on the' child
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support enforcement provisions. It
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~s ~n bipart~&anship
at its best. .
On Food Sramps. the NOA proPosall!l1lkes two importantirnprovemems
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me H.R.
4 conference bill. First, it does nOI impose a funding cap on the Food Stamp program as £he
. conference bill did.
A cap on Food' Starnpspending w~uid jeopardize th~ ability of the' Food
Stamp program to get food
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peoplt: who need it. Second, the NGA proposal protects.
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families with relatively high shciter c~sts
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mos~yfamilies with children --
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by adopting the
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to, the, prograin'S deductions from
Senate's approach
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income,
The NGA:prop<,s'al ~isotna~s subsmntialitnprOvem~!,u,~o ~performanCe bonus
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provisions. in (he ~onference"a~e~ment 'by establishiIlga separate. funding. stream
to,
pay' for
It makes
bonuses -- rathel' than allowing states to reduce their maintenance of effon.
modifications to the work requirements to malet. them more .feasi~le and less costly. for states
to meet. In particular. the Administration is very' supportive of provisions that allow part
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time work for mothers with 'pre-school agc:cbildren and mat reduce the maximum number of
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'. pririlary work incentive for low-income parents. Along with child care end health coverage, '
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{he EITe is vital to helping pc::ople move from welfare to work:
Finally, the Administration is sUPlxmive of se.verat provisions that the NOA' adopted
from the SelUlte-:passed bill -- a 20 percent caseload exemption' from th¢ lime limil for
bauert.d women~ women with disabilities and others who may
need a hardship exemption;
a
state option to implement a family cap; and requirements that reen mothers live at home and
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stay in
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The Fede~al-State Partnership
Whileth~ NGA proposal itnprov7s o'n'the conference bill
in ,a number of ways, the
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Administrati.on has serious concerns about several provisions, While it is critical that states
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have, the flexibtiitylO design programs'to meet th~irspecific. n~eds, IHs equally e~sential that
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the federal govemmen[ ensure accountability, in the use 6flax dollars and maJce certain the
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safety net, for poor children is maintained. The
fed~ral-state
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match system under current Ja\IJ
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always 'has bee~ the "glue;' that holds this p~lrtnersh~p together and.. was pan of lhe welfare
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reform plan,the Administration proposed as part of its balanced ,budget 'plan.
A serious concernaboul theNGA propOs~1 J~eneral1y
partnership
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is tha~ the federal~s~te
I,havealready~entio'ned.' the Admini~rra(ion prefe~ ~
weakened.' As
rhe provision in the Senate bill that requires 80 percent maintenanCe. of effort of the 1994
level,. and a req,,!irement for a 100, percent 'maintenance of effon for: .1lccess'.to the '
conringency fund. We also oppose the NGA provision alJowing
suue to tranifer up to 30
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percent of its cash assistance block ~o other programs such as Title XX. (he Social Services
Block Orant.
Sin~lpnost stales'spend
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transfer efkclive1y permits substitution of fedc;ral dollars (or state dollars. "
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The problem is exacerbated in the Governo~' proposal by, the fact thIit tIle additional
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$4 billion in child care fund.s requires neither a state macch nor even maintenance ,of the FY
1.994 level of state·effort on child care,
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:, In total, these p~ovisions imply that sta~s COUld., by law ,reduce their spending "
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substantially 'under the MOE and tran~fer provisiqns while federal spendiflS on AFDCand
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, 'child care' pro8rams woul(continue. One,analysis preseritedbefore~e House Ways and'
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: , Means,Cornmit~ec by the C~n~erqn Budiet ahdPolicy Priorities last ~eek ~rgued that
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could :hypothetically tl?du(;e, 'spending'by' rnore'~'that $50
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':block grant funds t~', other activities: ,: Mos~ states would 'not' rCduc,esp:en.ding this·
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"they reduced spending to 75' percent ,of their current: effort and transferred '30 percent
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bimo~ove~ ,~e next se\'en year& if
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of ',cash,
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'd~~~tically ,but 'there;'isriorea~on;why
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3Jl~wed: ~ requr.e $~ndirig while
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',' Finally, the,J'fGA proposal, rieed~' to provid~, greater, ac~ountability for uXpayer dolla~s:" ,
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and strongerp:rotecti6ns against ,worker djspJa~ent. ' '.(>rovisioIfS shouid be ad4.ed that
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provide for
aci::q\lnt~bility in state', p,lan, i.plplemen~ati6nand ,'re,qu~r~ apr9gr~ specific audit'
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fe4eral'guid~lin~s.
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:Protections fQr Children
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poor childreJ,l. . Federal and sta[~child .pro'tectiO{\' progr~s provide a'n~s~ntjal safety net for':
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, p~otection system:f9r these, e):.aemei y vulnerable ,children. , Unlike the Seoate's bipartisan'
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approach to childproLtction, the NGA pro~sal jeopardizes this 'essential s~fety ,net by,· ,"
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a~lowing
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blo~.k gran(scurr(mtentitl~ments
s:ca,tes to replace with
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for
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Joster'care, ",
ind~pende~ Jiving and' ,~amilY' pr~~ervation. ,Withdi'sruroingly un~ven state p~ri~nn~~c~ i~'; .
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tto4.b~ing:[hat
<,this'area. it also is
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theNG,Ns pi<?posed:redesign o,f'the ~na~ion'schi14
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protection, system fa.ils to in4hlde "amcch3ni~m (0 enforceproiections vital for the lives and','
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wen-being of abused .~nd neplecred childre~: The, NGA proposal. ,also would block' granr
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. jmporran·[.p~ograms
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focuf,edionp~c\'ention of ~h'il? ab1.l,S~ ~ndhegie~f:.
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in~ludes
If the system
no targeted pl'e~enti~n ·fundj'ng. cris·is.dri~eQ d~Cision-making ~ay deplete resources for
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preveruion:
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:rQQ~d Child' Nuiruion.·: On be~lf of' the. Se.cretary ,of Agricul~r~.· I'd .like ,to,'
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issUes relating. to :the nutrition: ,programs. '. Wh.i1e the..'NGA. 'agreement does
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include
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som~', improvementsii~ tlit ccinfe~rict repOrt;s' pr6~isionson F9od"Sta~ps,
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the NGA
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proposal did ;n,O£ go.ast'ar.aSii shQuld,. aqd. serious ,concerns rernai tl .. ' ~'.
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. The' NGA' propo~l 6oiltin~~.s [0 provide astatc optioqfor, a'Food Stamp bl~};.g~ant .
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; be jeopardized if m~ny
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. . simpU,fication and i~creas.ec:t flexibility in the Foexi, Stamp progntm, we are srronily ..
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opposed'tJ a
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','states . ' ad"anrage('lf th~soption.as tbey. might , under the
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Food' St~rnp;b lock grant:
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'In addition, the NolA ~proposa.lconlinu~~s·tor.
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p'fopos~d Simptified:Program' to
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�households which rc:~ive both Food Stamps and AFDC. While the Administration
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supports a Simplified' Program and has developed its own proposal: the NGA proposal
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undermines natio~l ~lahdardS'1.h.a{ work
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and creates 8. hidden cost for states.
The, NGA propo~al s~\'erely time limits ~ood Stamp receipt for many unemployed
adulJs.AnYQnew~o; is not ~illing to work should be removec1 t'ro~ the program.
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But, 'ihosewbo, I ,
are willing:\O work should have the opportunity ,and the5uppon
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nece~~ary to put the4 to work. Many who are willing to work cOlild .lose their Food
Stamps because, Slates are ,unwilling or uIJable to provide stlfficiem wOrk and {raining .',' '
opport~nities.Without resources to provid~ 'work oppominities.
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states could face the
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burden of caring, for. thousands of people who, have Jost nutrition assistance.
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The NOAproposal ~etains the conference bill's,. provision for scnool nutrition block
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grant demonsu·ations. The block grant demonslr'd.tions would 'unc1e.T.TIline the
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. " proiram's ability totespo~ automaricallY to C(;ono~ic chang~s .and to mainta:irl'
national nutrition standards.
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Guarantees of fa;r and
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treatment. The NGA proposal does contain a requirement
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that states scr forth and commit themselves to o~jective crireria for the delivery of benefits
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and fair and equitable treatment. This is an improvement over the conferenCe bill. which
contairied no guarantees t~l Slates would commit to objective c.~1igibiliIY and other critt:ria
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and p.r:omptly and' equitablyiserve chose '7'ho, ~etthem. To ensure that applicants and
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recipients are not
~ubject
to arbitrary t~earment -- for example. being placed on waiting lists - .
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ana bind
commitments. Among those .commitroenrs should be applications,.
tb~ states to their
el~gibi1ity
and sanctions
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criteria, (lnd procedures and lime frames fOT.decisions .. Moreover, statewideness and equiry
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acrossfa~lilies in each state ~~st ,be the goal. . Applicants and 'beneficiaries should be tOld
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the reasons for decisions on tPcir r~~. Mistakes in the administration of the program
qnce' these 'objectives are mer. applic&Jlts, recipients and other
should be corr.~rable.
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taxpayers in each state will u:nderstand the benefits'and concomitant responsibilities under
their state plans.
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Restrictions On Benefits To' Immigrants
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The recent NGA proposal does not address' the immigrant provisions included in the
H.R. 4 welfare reform confereneebill. That bill woul~ have banned mos( legal immi.grants,
including the disablc:d . .the elderly, and chUdren, from receiving 'means-tested benefits.)£ .
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~urden and' ultimat~ly denying benefits to millions. of eligible
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children. This ~rovision alone would re~uire all 45 million srudents enrolled
~hools to document their ci~izenship
in participating
to participate. In the federally-supported school lunch
program. placing an enorn:-ol.1$ adrninist~tive. burden on local~chooi ·systems.
The Adminis~Iation 9Pposesdeep i\I~9 unfair cuts in ~ene.fits to l~gal' immigrants.
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responsibility for jmmisrants:; ',by extending d~ming provisions, until ci~izei1ship. Itis
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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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Carol Rasco - Meetings, Trips, and Events Series
Creator
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Domestic Policy Council
Carol Rasco
Meetings, Trips, and Events Series
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1996
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="http://clinton.presidentiallibraries.us/items/show/48176" target="_blank">Collection Finding Aid for boxes 37-59</a>
<a href="http://clinton.presidentiallibraries.us/items/show/36306" target="_blank">Collection Finding Aid for boxes 60-121</a>
<a href="https://catalog.archives.gov/id/647140" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
Carol Rasco's Meetings, Trips, and Events Series highlights the topics of discussion for scheduled meetings and events, the persons involved, and information on travel required to attend the meetings or events. Topics include health care reform, disability, employment, education, children and families, and communities. The records include memos, letters, reports, schedules, itineraries, meeting notes, flyers and pamphlets. Folders are arranged chronologically from January 1993 through 1996.
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
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1388 folders in 121 boxes
Text
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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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Families USA Medicaid Coalition Meeting March 5, 1996
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Carol Rasco
Meetings, Trips, Events Series
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 91
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/Systematic/2010-0198-S-meetings.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/647140" 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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10/12/2011
Source
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2010-0198-Sa-families-usa-medicaid-coalition-meeting-march-5-1996
647140