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FOIA Number: 2006-0458-F
FOIA
MAR~~~R
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Communications
Series/Staff Member:
Don Baer
Subseries:
OA/ID Number:
10134
FolderiD:
Folder Title:
Medicaid
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Section:
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THE WHITE HOUSE
WASHINGTON
February 7, 1996
MEMORANDUM TO MARCIA HALE, DON BAER, AND GENE SPERLING
FROM:
MARILYN YAGER
CC:
ALEXIS HERMAN
RE:
GROUP REACTION TO GOVERNOR'S MEDICAID PROPOSAL
Thought it might be helpful for you see some examples
of the statements national organizations have released
during the past several days in response to the
Governor's Medicaid proposal.
These came in unsolicited, however, if there are
specific groups that you wish reaction from, please let
me know and we would be happy to place an inquiry.
These organizations and others are doing a press
conference on Monday at the National Press Club in
opposition to the Governor's proposal.
�REACTION TO GOVERNOR'S MEDICAID PROPOSAL
The attached includes statements from the following groups:
American Academy of Pediatrics
Children's Defense Fund
American Hospital Association
National Association of Children's Hospitals
Alzheimer's Association
National Association of Public Hospitals
National Association of People with AIDS
National Women's Law Center
Consortium for Citizens with Disabilities
Justice For All
Family Voices
Three statements were signed with the following organizations:
AIDS Action Council
AIDS Policy Center for Children, Youth, and Families
American Counseling Association
American Medical Student Association
American Network of Community Options and Resources
American Occupational Therapy Association
American Psychological Association
American Rehabilitation Association
The Association for Retarded Citizens
Brain Injury Association
Center on Disability and Health
Children's Defense Fund
Cities Advocating for Emergency AIDS Relief
Consortium for Citizens with Disabilities
Families USA
Gay Men's Health Crisis
Housing Works
Human Rights Campaign Fund
InterHealth
International Association of Jewsish Vocational Services
Justice For All
National Association of Child Advocates
National Association of People with AIDS
National Citizens Coalition for Nursing Homes Reform
National Community Mental Healthcare Council
National Health Care for the Homeless Council
National Mental Health Association
National Minority AIDS Council
National Organization for Rare Disorders
National Senior Citizens Law Center
National Women's Law Center
Project Reform
San Francisco AIDS Foundation
Service Employees International Union
Texas AIDS Network
Women's Legal Defense Fund
�r•·"--o- ··-
American
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Academy of ;
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n.--.... Sr.-. N.W. · . .·
Pediatrics
LIM .4tlft NMfh
Yllhinpl. DC 3000S
CONTACT:
News &elease
M~rie 1'blq)
JOlt KILLUI:
PcbaUII)' 7, 1996
Leigh Ana Bh1t*in
2021347-8600
1001336-,41S
GOVERNORS• MEDICAID PLAN BUAXI PROMISE TO CARE POR YOUNG
Gaaraat... eovtraae for teens eUmbaatecl aad treat11111t for otben dlnattued
WASHINOTON, D.C. -· Mcdlcakt" s PJUauisc to expand coveraa• by dul :year 2002 to all
low-iDCome cbildren and adolescen1S younger than
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aae 19 will be brukcn if the Natioul
Oovemon• Assuci1tlon (NOA) Medicaicl plan It apprnved b)' CoftlfOIS and lipcd illto law
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by the president.
"We bave entered the Twllitcht Zo.oc of bcaJth care pollc)'," AAP President Maurice E.
Keenan, M.D•• aaicl.
•we ccrtaiDly commend the aovenKmJ for tboir bipartillll don.
bowt:v•, 1be)' bavc manapd to propose a plan that disproportionately impacts upon tbe bald1
care situation for children of low·t.Dcome IUd workq t'amilila."
Tbc AmeriRD Academy of Pediatrics lakes iaut. witb many of tbe Medicaid proviSions
includina:
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Failiua to auanmtee caveraae for adolescents. aps 13 aDd older;
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Potem1ally denyhlj acmcca thAt cbildreo currently receive
tbroup tbc tarly and Periodic Sct·ecoiDg. Diaposis ad Trntm~mt
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(BPSDT) prQiriDl;
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LOAvioa it to ~tate~ to define disabilities. which c;ould result in different lc\cls
or QlrC for ~bildrcn with special hwth r.are Deeds dependina on where they
liw;
�- 1'202 N1
til~"{
OOVERNORS' MEDICAID PLAN
2·2·2
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RlversiDs eurrem law aDd stllte rolieies in reaards co
priuriLizloa ~D'a Deeds. Today'• cyltem plat.~!t! children's
needs ll lhe bel4 of the liue. Tbe NGA ploD push~~ them
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tbebltk.
ChUdrln mU:c up wcU over half of all Medicaid rec.ipimt• and las than a quarter of the cost.
With more and more children of workina famllics l01iq private h.:aJth iuunnce throuah a
decline in employer de~ndent caveraQe. the services Medicaid provjdes are essential.
"Why abould teeDs be dunned to yean Witbout seein& a pcdlllri~iuT' Dr. K0C1181l aid .
..Why would we deay them tbe oppor1Uaity tn talk to a medical professional about all tbe
cbaJleJliCS they wU1 face •• dcalillg with pn:sswc to expcriment with drup, alcohol and
10xul activity, achievina an adequate level of nutrition md coplna with a ~hule new ranac of
ernoliorw?
"'To the preoideatind mem~:s nf C.nnarcss. pediatricians implore you not to accept this
proposal bliDcSJy.
Medl~~ is not just
about fed«al a
11ate
budaet •viftas. It's al10 about
ttfferina adequate health care for those vulnerable popuJatica wbo otberwiac would have
DO
ud• place to 10 for help. All children and adolescents deserve a fair chance to be bcalmy
aDd free from diseases."
The .4metlc;Qt1 Acatt.my of Pt~dlt~lrics 11 tm organiz«iDII of 50.000 Pft'lUitrlclanl dediCDted to
1111 healrlt, lafety o1UI Wllll·brlng of llf{tmu, t:hildi-M. atlol•R~tllt.c tmd )IOUrtf adult!.
�Feb-06-96 06:21P CDF
CONTACf:
Deaalt Smitla
704-339-6266
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Stateaaeat by Mariaa Wrialat Edellllu, presicleat ~ 1M ClaDdrea's Delease Fad
tile Natioaal Govenon' Assodatioa Welfare ud Medicaid Proposals
I am deeply saddened by and oppose saronaly the proposals by the nation'aaovemon to
dismande and slash crucial federal health, nutrition, and income safety nets that protect millions of
children: Their health and welfare plans would leave many more children poorer. hunpier. sicker.
and at pear.er risk of abuse and nealect. CDF uraes the Conareas and the President to ~ject these
flawed and-child proposals. No proposal that leaves children worse rather than better oft should
become tbe law of the land.
February 6. 1996
.!S £ Slfft'l. NW
WoiSIII"I(tnn. Dr .ltiOOI
ll•lc.oph!Jnf> .!II.! lo.!K 11·11·
�February 7, 1988
TBE NATIONAL GOVERNORS' ASSOCL\'DON PLAN ON
MEDICAID: WilY IT'S BAD fOR CBILDUN
• ll woalcl eUJialaate
,..._teed coverqelor poor cb.Ddra 13 dlro... 11
)'tall otaae wlda
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covcrasc would bo pba$ed in, Uftdao oarnnt Jaw. by October 2002. But cluriaa tht "Wlve mont1tt ~i
the NGA proposal would "d panmteed Medicaid coverase for 400,000 dtildlen in wodcing poor talliUes
1). In the year lOOl, dle: proposal would dmy swmuaLcw WYCI... to 3 anJfticD poor children . . . tl
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• It ,.·ould eUmlaate carnat law paraatcea daat cblldrea wiD receive ~venae or all medlcaJly I
can. Even the chil<lleft :whO would receive covcn&e mder the NGA proposal would not be ~t
~fib.
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The proposal woUld ~· EPSDT's (Early and Periodic Screen in& Diaposis, ind Traam~) 1
that children mwl ~ivc Ill mcdic.ally ~ tcf\·iccs. States oould :flatly day ;oov
prescription dna.-, fot example. even if a cbUd's doctor says 1here hi no otber way to tnat! an i
· stop severe pain. :States cauJd likew1sc deny coveraae tar dental care. bearing alds. eyesl~ses. ysiAJ
· therapy for childicn With :disabilities, or other serYices that are crucial to children~s dev~lopm · and
teamina.
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States also would: be siva unlimited fieedom to detennine the ~mount, duration, IDd scoj,e of n:ices
with in cuvcnxl W.tmb ·eemsorios. r or cxarnplo, .states cC~Uid limit childl'lft to a certain nwnllltr of ' lpitAI
days per year~en ~usly ill children wbose doctors say more eire is needed to avoid ....ve ~·
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• 1c would eliaainatc 1uaruCeed ~aida covenp for chUdna who an diaa\led ucontbaa to fedi.ra1
Instead. :.tatcs could limit. u: they • fit. the number of children with disa~ilitics wbo receive
j~"lp:ardize hHkh r.nverage f'or mo~ than: two million children with disabilit1" w1lo nqw rec=eive N ·
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deflaldoas.
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Wonl paraatell of cov•raa• for elaiW,.. ucl ,.r;aa
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NOA •;o wei fare propoul• s~es woa&ld have DO lepl responsibility to aive AFOC tb poor fern Dies;
~1c:di\:atd :.Ions \\ith AFQC. Medicaid co\lenae would au luns• IN Jwa&81l~ tor us millloa ohi14rcn
Ari>C: :and 3rc over age '12. four million pamltS now receiving AFDC. 88 ~of whom ue wc:jmm, uld abo ioSt
¥Uill'~nt.:c:d ~overage. These 'are some Of America'S poorest funiUes, COmmonly Witli income belpw :; ~perceDt' Of the
• I& "uulcl eliminate
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• ·ac ~·ould den)' .~.... to t~enl ~·111 ~ overtan ~091 ,,..,.. dala~ ~ CO\'erlp. Even tjle
that exist on paper coule: prove meanmsless m practice. af states know they ws11 aot be enforced. i
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• It \\'oald allow states'to coatilb1te mach laa to Medicaid, fordua ftu1ber c•tbackl. States like New York tha·
cum:ntly must match t~eraf spending dollar for dollar could instead put up only 67 cents for
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1 dollar the-receive. To meet even dlcse: reduced matcbiD& obliptions.. swes could use! provider ~oftllions aDd tax 1·that the Busi
Ad•ninistratior. and Con8ress:outlawed ia tbe early 1990s. Ac:ording to the Consressional Budget .
1bese practi:e
were used to c:irr.umvent ~tatfi matchin1 requirements in the past. States could withdraw; billions of cbllars they now spen·
on Medicaid. dramaticall)' cutting COVel'llle for families.
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• It would let sU1tes use redenl Medicaid 4ollan to pay for curnat
respoutbiUtles. Medicai
used. for example, to pun:haiic ila>"UiliDW rua ~ wodcers a&ld retirees with; isomos ~· 275% 'of Dtlloll~, or tO pl
the cost!i of operatins State PsYchiatric hospitaJs. State funds fieecl in tiM process thin could ~ u to flmd 10
ccnstruction or other projects. essentially divertina Me41ca1cl ftmds &om tbelr Intended purpose ofprov lng health
for low-income
famili~
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For mo,. lnf,... . on .welfare luu111, please con• Deborah Weklttafn (112-UII) • D ·
(812-3518) In CQF's fllfilr lilcoma Division; on Medicaid 1111-. p.._ contact Qragg!H
314t) or s•n Oftrn (U241H) In CD"• Hulth Division. On ~ 1asuea at Olft.,.llr tm
....,.., pl.... CIOn• an... ~wee..., (812-381) In CDF'a Oflk:tl of Gowmment AtraU..
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February 7, 1898
TBE NATIONAL GOVONORS' ASSOCIAnON PLAN ON
Wi:l.ll.UZ: WHY
rr-5 BAD FOR CJIILDRIN
The National Go~emors Auoclllion unanimously adopted 1 welfare ~fonD resolution oo ;
february 6. Closely foll~wlqdle appmaA:b ut lbc wolftrc bW. paMCd by C'Oftll"GGI ~ vetotd ~ tbe
aovemors agroec1 to aban4on the Waal paraatee for cash auistaDce, to be replaced V(atb block 1'1\BDl'
ruponcl when recessions. ¢ause increased ilecd. Under the pemoa• plan, states could also dtoo5o
bxf sbmi'Ao aool mealS p1'01nn11.1Dd ·for f'osrer ~ and adoptioa assislaace for ~and nest
Here's why the aovcmors' plan would hurt d1ildreo:
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would DOt
IJ'IDIS tbr
,childreD.
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, Needy dandrea aacl ,.mmes woal4 •• loqer be able to coallt oa b-* taco• ~apport. Uke
welfari bills vetoed by tl» President, &he auvauoaa• plan cnda the p~r~~~too that llOHy famiU.S ~·
minimal assistance, and ~ifes SlaleS to impose a lifetime limit of flve yais or leas. whether jobs are ailable or
aot. While the plan woufd aHow 20 pemeDt of lhe caseload to be exempt ftOm 1lle tbie llmk. m~
.llu&L (27
percent) would be unlike~y to wort because tbe parent either bas or is wing for someoae wilb 1 dlsibil ~. Families
in areas of bip unemployment would also have to compete for the scarce excmptio~ as would famil' where
parentS work oontinuou•ar· but ll veiY low ~-
• WlaeD uuemplv) uacui au• p0l'ei1J rlM. fecleral ftaacls woald aot ~~~~ eaoagb to meet ~. • for b..X
taeoiD' support. 1be block •snm for cash aid and work remains Oat-ftmcW for 7 years. Tbe sov
' plan does
inelu~ a S2 bB1ion con....eacy. fimd tbl& ~ could tap wben unemplo)'IDIIH or: ~ sump UK. riaQ, buL it illl uot
aear1y eaough to meet ~:need dlrilaa riassioo. Carina the downtum;oftiJe ~1990's, fictaoal AFDC
&mcfiDI arew almost S6 ~11io"' three times the amount iD the continaiiiC) ftlnd.
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The ao~·
. resolution
up ~ 2$ pcrooat of1Uir ~ina without losina Ill)' Weral &md, !U ~Ami! ,. in
by the President. In addition, staleS could shift up U» 30 percent of funds ~ income ~pport ad ~
prvsaams.
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• federal staadarda fo~ cJlJid eare quality wouN be eUmlaated. While illc pemon' ~ talc Cbc positive
st•.P nf 11Ming S4 billion; over seven years fDr child care, this plan, like the 1till vmed b)· tho Pnadeat, would gut
federal heal\h and safcty;rtquiremeti1S for child care. and cut funds to impmve ud expand the supply o dlUd care.
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• Tile plaD would p11t mon cblldna at riak abue ud aeaJed. The Jtroposal ~•ou!d undtrmioe
of foster care and adoption lb:5b&~~l\1C Cur ~ and neal~ 'hildn:a. lc \vould aiw stcto~ cho optio
fUnds ·ror foster care, adOptiQC\ ud iodepeodeat livins sen-ices, in excll.._ fer 1he tlfmbility to ase
pataftteed doJiars for -& of a rap or child protection activities. lr iS Ukcly 1hll e~ble dllldNa iD
would no longer be gunnteed foster care ~md adoption assistance when tbey cannot tpve safely at hom
state did not opt for a ~. most otbcr federal child protection proaruns. including th~ aimeclat.cbild
PftV~rio"' •ntt f•mil>· ~~I'J10i't. wauld be repealed and replaced with a child protection block 81"1ftt
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n~ plaa wouW taJidCmalae tlao aatritloaal 1afety aet for claJiclna. Sw.s would b. allowed to
gu~tee of food stamp~ an~ convert the piOiflm to a block grant. The governors' pla.'l also acceptS
food smmp
cuts over seYen:1~
ndur..iq lUuc1 ~iUII~WC co 14 wiWou ehilclrcr.:.
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;o,...,.. Info·~ Oft_.,.,. ~au-. please contaGt DeboraJl Welnslaln (ea~ •
(882-3511) In CQF'a:Famlr 1ncoml DMIIon; on lltdlcald ............. ~ OJ811ift1
3141) or Stu Djorn '(112-381) In CDF'a tt..ntl CMalan. OD GMM ....._ ar
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laue~, pit... contact a.. IWiena, (1824111) In COP's Ollla ot Gove...... A.....
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�FAX UPDATE
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Contact:
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t/No£o '"
Wednesday. February 7, 1996
Kelly Fisher (202) 626-4629
TALKING POINTS ON NGA PLAN- The NatioMl Governors Associtltlon .,
Medlcoid proposGl is a maid bag. Tlul NG.A. acknowlMlga In pt1rt 1M ctmcem.r
ofmmry, including AHA, on COWTtllfl and btlMjfu, tlllll 1M proposall.r 1111
Improvement over 1M rt~conciUation conference agreetMnt. But It falls shorr of
current law, the White House proposal, the conservmlve Democrat "Blu Dog •
approach, and our principle of guaranteed coverage for vldnei'Gble populations.
With too littk detail and no legislative language lt'l imposslbt. to lssu a .
Uftnltlve statem~nt -- but Mre II a SW'111111D'Y of tM NGA pllm:
Coverage - Mandated coverage for those cum:ntly eligible under Medicaid,
such as the elderly, pregnant women, and children up to 12, is a step in the rlaht
direction. These are populations in desperate need of paranteed coverap.
However, several other groups bave not been provided a guarantee, pll1icularly
the disabled, who will be deftned by individual states, and children ages 13 to 17
who, while not curremly covered~ are scheduled to be phased in u a result of
OBRA '90. There needs to be further parantees for these populations.
Benefits - The plan mandates coverage for physician, inpatient hospital aud
outpatient hospital benefits, another improvement over the conference asreement.
But, states· are free to alter the amount, scope, or duration of these and other
services, which could weaken the coverage mandate.
Boren Amendment - Not ouly does the NGA repeal the Boren Amendment, but
it gives states the authority to set all health plan 8Dd provider reimbursement rates
without interference from the federal government or threat of legal action by the
provider or plan. This could have a devutating impact on providers who deliver
care to the vulnerable populations covered under the program. threatenin& their
financial stability and, as a result, beneficiaries' access to care.
Provider taxes - The plan repeals current-law protections against increased
reliance on provider taxes. This allows states to shift their fiduciary
responsibility to providers -- taXes that could also be levied inequitably &mODI
providers.
State match - The NGA plan lowers the floor on the amount states must
conmD\lte in order to get federal matchin& funds. This could cut additional
billions of state dollan from Medicaid, hannin& Medicaid's financial integrity
onA itC!
~hn;tv
tn mPPf' thP
cnt::a~~nti!",.O
m!:IA•
tl"\ t),• .... ~1a u.~,..
•eh• ...... :.
�National Association of
Ch1ldren's Hospitals
N•.A•C•H••••••••••••••••••••••••••••••
StatcmCAt
LawTmce A. McAo.dn:wl
PrellcleDt aad CEO
Nationll Assodat1oo of ChJldren's Hospitals
GOVERNO.S' MEDICAID PROPOSAL:
DET'I'ER TitAN CONGRESS' MBDIGIW'"T PROPOSAL
BUT snu SHORT Of CHILDB&~S NEEDS
While better than Congress' MecUGrant leplationt which "-'Ould replace Medicaid
me NAtiOnal GoYemon AleociatiOft't (NOA)
Medicaid compromise still &Jis thoR of children's neccl for national minimum
standards for medlcally necessary care and access to pediatric speCialty pro-.tden,
leavtn& chlldren with speda1 health care needs espedally vulnerable.
with a la.qJely Wlfenered block pane,
Nor does the sovemon' proposalcaraet fedurally IDAftdated Medicaid payment
adjustments co hospitals devoted to
a disproportionate share of low income
patients. bulaul, the NGA proposal eUmtnues the federal requirement for sucb
acljusunenta as well as federal requiremente b adequate payment to aU hospitals.
Disproportionate s~ payment adlustmenw are crtdcal to the ability of children's
hospitals to serve children in thr.lt' colllft\unides, reprdt... of economic n.eecl.
semna
A suons<:r propoul for sua.ranteeilal ~uverage for vulnerable populations has been
advocated by consenative Democratic and moderate Republican balanced budget
advocates. They would control spending with a cap on federal funds pu eligible
lndlvtduaL while maintainifta national ~t::and:ards lor dUlt.lnn's eJ.iaibility, medically
necessary~ access 'o spedallscs, and ta.rge'ed disproportionate share paym.ena.
NGA proposes to modify Conaress' block annt to rep1ar... Medicaid. ~ most
tmportanc modUlation Cor chJldten is the NGA remmmendatlon that C\'CIY state must
cover, at a minimum, call presnmt women and cblldtcn under age ~bL wtch &mi1y
incomes below 133" of the federal poverty standard, and all cbildren between age 6
and 12 wtdllncomes below lOU~ o.t poverty, as required under curtenclaw.
Congress' MediGrant oa1y requires states 10 cover cb11dren under 13 with family
· in<:omea below 100" of poverty. NGA also would require every swe to c:over the
dtsabled, leavtna the deftl\ldoo of the dJsabled to eadl scacc, subject tO fcdcnl cCYicw.
,._.rion fll
'en ~rluo Srm. Alcxaftdria VA 1211-4
ha Alit... ., chc S.ioall
(70)) 684-1355 Fa (703) 684·1589
OiJcln:ni HOtpiu ac ~ 1utmu1011
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While asreeifts to a minimum set of bene8a allstate& must cowr, NGA would
allow any state to impose limitS on the amount, duration, and scope of such
benefits cowred indMduals may receive. Until Consrcsa establlshed a national
slaftdud for medically neccasaty care for chJldrcn ift 1989, many srata limited
the amount, duration, and scope ofbeoe8ts resarclless of a patient's condition.
for eDmple, before ~~~ many scates Umited inpatient hospital care to a fix!d
number of dzys. reprdleee of bow sick or iftjutecla cbJld wae. Conpess'
MediGtant also eliminates tbe federal requirement of ~rage for medlcally
oeceewy cue for chdclreo.
In addition, NGA's proposal does not include eandardt to ensure chu chJldten
have appropriate access to pediatric specialists expeft in the health care needs
of dlildren. Congress' MediGnnt also eliminates the current law's
.reqWrementl to pro&eet children '• aeceu tO pediAtric pto9'iden.
The proposal problbtcs providers from pursums eD!on:ement of tbe law
through the courts and makes tbe fedetal couns available to lndlvtduals, only
after they have exhausted state administrative and Judldal review.
Chlldrm wltb SIJ'fiel Nccdl
Cblldren with special health care needs, such as chlldren with cbtoftic
conditions, disproportiooately rely on MecllcaJd. 1bey are especially
vulnerable under NC"tA'I pmpnql for one or mo~ of the loUOwlfts teUODS:
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State~
would have the abWry lO limiL ibc n~r uf disabled chl1dren
who quaUfy Cor ellpbility.
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It is precisely chUdren with spedal need~ whn aM thtl! most vuln~le
to atbittary limitS on CO\-etase. Even limits that may be appropriate for
chiklreo 0\"etall can Impede lhe abWty of dlllcltcn wilh lpC\:tu b~Lb
cue needs to have ICCe$$ to the medically necessary care they require.
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Children with special needs often haw: the patest suswned need for
accesa not jUSt to an individual pediatric spec:ialjst but to a team of auc:b
speciaUJta who CAft meet their complex ncecb. Wlthouc protections for
children's access tO pediatric spedallsu, they are especially vu~erable.
The need for protections for chlldren with special needs was underscored last
week by the National Committee for Quality Assurance, the maoased care
industry's a«redi~uon body. It nleuecl a new toOl to ~uacc Medicaid
managed care. But lt explained that the tool contains few performance
tneasura Ullg\:U:d exdustvely to the special needs of children witb rare
conditions, because they have not been de:veloped. The absence of such
eftluation measures makrs it the more Important tO June standards for
medlc:ally necet.'ary t'.2M •nd accen to pedbtrk providut for c:hddtca.
an
TOT~
P.04
�QVEmONS ABOUT THI NGA PROPOSAL ON MEDICAID
1.
Will It J"cally •auuaotee" <:uvcr11¥t: fur vublerabl~ poplllatloast
It's not clear. NGA emphasizeS that its proposal will guarantee coverage.
because funds wt11 not be limited to an arhhnry h1ndc pnt r2('. A ~tP. c-.san
seek supplemental funds illca eUgtble population JfOWS more than ~ctecl.
HowctCI', It Is unclcu whether the Npplemenw lunda will be un11aulted, and
lt II unclear whether the state sdD. will be oblipted to cover vulnerable
poputaUons If they run out of block pant and supplemental funds.
z.
Do the eH.albWry standards c:mer aU ddldrca aow rec:d~a MedlcalcU
No. NGA keeps most of curtent lederallaw's eli&ibillty requlrem.encs for
children, with two exceptions. First, it drops Cederallaw's commitment to
phase In eljglbWty for poor teenagers over the next six years. Second, lt allcnr.'S
states to establish their own deftnltion of disabled chddren wbo qualify. subjeCt
to Wenlapprowl, inst.e4cl of nqui.tkls all •tatcs to mcc:t a minimum federal
de8nldoo. 11 now is the law.
~.
Does the propo~al require every state to pnmde mecllcally necessary
cue for chlldftDP
No. Undu the T pl'OYislons of •EPSDT," aurent federal law requira a swe
to ccm:r aU beneJlu. - wanc.latory and opaollll - chat a child may require tor
medically necessary carc~ The NGA proposal_, It will •limit" the T potUon
of EPSDT. It also says mat states should ~ •complete flexibility tn deftnms
amount, dul"'.tinn, and fW"O~ of se~." Conpesa amended the "T" portion
of EPSDT In 1989 precisely to prevent states &om limiting amount, duration,
and scope of benefits hl way~ lhat deny medtcaUy necessary care to dUJ<Iren.
4.
Docs the proposal ~tee cblldreo.'s access to pecllatric specialists?
No. It pves states total flexibility in dcflnins provider access and
reimbwaement stanclarclt. lc spcc:Ulcally aa)'t, "Stille~ musc ...be unburdened
from any federal mlnimwn quali&catfon studatds such as tbose currently set
tor obstetrtdanS and pedlatriclaos."
5.
Does It taqet disproportionate share payments to high DSH hospltal81
No. lbe proposal eliminates aU payment protections for providers, includin&
disproportionate share (USK) ancl Boren. It folds each state's cumnt feclenl
fundll\J for OSH into tu block grant. The propo&al only would n!CJUire sratH
to use sucb OSH funds for "health care lor low Income people. • ID addition,
the Pfnl'OSAl speci.6e2Uy prohibits ptOYiden !rom having any lcpl cipca to
challeop a state's Medlc:ald propam In either state or f'edetal couna.
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AJ,ZM.:IMEirs.'
~SOCIAliON
.som.on.., SfMid lw ltlu
STATEMENT ON GOVER...~ORS' AGREEMENT ON MmiCAID
February 6, 1996
Today the nation's 1overnon agreed on a proposal to restructure Medit'.aid. 11 ia wriuen
leaves many questions WWlSWered. However, it raise.• many oftbe same
critical issues that caused the Alzheimer's A~socia1ioa10 "pposc the Mcdka&id proposal the
President vetoed. Conar:ss most resolve these issues in a way that parmr.ees persons with
Alzheimf!r's disease ud othw"TT who dep:nd upon Medicaid me basic health and loq term caze
in gcmQal tcnu) a
coverage they need.
•
Adequate funding to !NNantee CQ"""Ue The aovernocs• proposal purports to guarautee
coverase for certain groups of beneficiaries and to allow states to maintain coverqe for
all optioDal poups in 1hc cumm Me:!icaid program. That ..guaramee.. \\iU have liUle
meanina. however, unless tbe fuDds states need to prnvide that COYW&I• arc .JJo
suaranteecL The govemors' proposal does not appear 10 live states that gumDtee.
First. it provides for aD agrepte. cap on federal fUnds accordiDa to a formula nnt yet
dctiaocl. (The tcmnula In tile vetoed bill waa not adequate to guaramee coverqe.) ODce
~ ·aaarcsate cap is reac~ there is DO reqniremeut that a state maiataia ~-.e for
pencms in 1be propm. AA '"insuriDce umbrella• W01IId be available iD certain
UftMitidpated c:iroumstecca. Whether ur DOt lbal"'tambld.la" wouL! auazantee coverap
depeDda upon tbe amount ot moDe)' available IDd the circumstances under which a ~tate
wulcl draw from it '!be per capita cap proposed by naoderates in the House aDd Seaate
and endorHd by tbc President i!C ._ mueh more oert:Wl ADd straishtf'urwud way m
guaraauee coverage while rcstraiDins spending.
SecoDd, scates would have to put up less money or their own tn dm~ do"-n ted8ral tunas.
rn some ot'tbc lariest states, the match would be an by as much as 20%. Further, the
governors would elimit1Rte proviaioas in eurrcnt law tbat prubiblt staW fi'om usiq
provider taxes to get around the matching requirement. Ancl1hey appear to drop current
rules that PJCCludc »l.altCS from using other federal fuDdJ as their matcb.
•
l,.gng term care gpyerap. The aovemon' proposal "~s" lona term care coverqe
for elderly po.rsons·only if they meet the inco.u1c IIDd resource standards for SSI. This
does not include most of the people who now receive Medicaid lana term care. Th"Y fall
iniiD tbc Oi~Llunal categories - ettber their income falls within a cap set by the stale or they
are "medically needy" (i.t. they do not have ennnib moaey to pay dl.c total c;ost oC their
loq =m care), While tbe govemol'S would allow states to serve these optional groups, if
states are nnt JUIU'IDteed tha moDe)' to pay for Lbue services, they will have to cut tbem
out oftbc program.
AlZHEiMllt'S DISfAS£ AND IWATFn
WubJnacon Ollct 141~ F ~'.
r'\t~Q ASSOCIATION,
""c.
n. sute -,o • WIFI\tfii!OO. DC ~DIICM • ""'"'' ,m;, )9:1·~~~ • Fu
(liiJt
'951109
�FEl -06' 96(TUEI 19:27
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P.003
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Covenae oip:.rsou wilh cllsabWties iS even more problematic. Current law scu unifoDD
definitions of disability. Tbe governors would let state• dew cliaability how•ver they
want No one with a disability would any lonaer have IDY t"edall\lll'lll* of coverqe.
•
Enfqrccmcnt of &R"""""I· Owuantces are meaniDgtW only if they are emlorctablt. The
sovemon' would Umit individuals' access to federal COllftl to eaforce their ripu UDd•
federal law.
•
Spau•al impoyariahmcm. The 1uvemors' make no provision for the spouse of a DUrSiDa
home resideat. Spousal impoverishment protections of current law, which protDct a
mildmum amouDt ot'lncome and resources for the community spouse wt allow states to
provide additional protectinn, must be retaiDecl.
•
Homo ond oomqumio· bMw ean;, lbo aovemon indieate they "'Oulci "liBDificamly
broadal" lema tmm C8le opticms. lf1heir propout elinriaatea ham. . ill GU~r~Dt la&w m
expaDJicm ofboma IDd coiiUDUDity based caze, this is a poshive developmat IDd cme1be
Associatioa wrmld eDthua.tically S\lpPOit. Huwevcr, this CIDIIOt be used to daly
ll\II'SiJII home bcufi11 to persou who need 1bat level otcare IDd for 11.11nm then . . ao
occc:ptable updoos mtbe commliDity.
•
NJili!JI hgma quali\y. The aovemon indicate that "states will abide by tbe OBRA'I7
standards few ll1ll'liD8 hoiDCI". IC they llrO reten1q to 1be wataecl-ctowD -.ion of thole
staDdalds in tbe vetoed bill, that is not acc:eptable. C\mQt federal nuniug home
staalcbads muse be m•tnurined, as must tbe standards for iDsti1udoas for J*'!ODI wi1h
mc:mal retazdation and d.evelo~mP.Utal clilabiJitiq, The Asaochl&iunls aJao COJlCel'md
about the govemon' statemcDt tbat woulcl give stata "tlexibility tD determiu
e-.aforecmem SlnltOiica" for oUDiq home staDd.alds. This c:aamat be interp&eted to
eliminate tederal respcmsibility for ensuriq enforcement.
•
HJniU Home PiSGrimjnatiaa.
•
Kl&Jes Reprdina Famib' Assets. Current law sets reasonable limits en traDSfer of assets
and rules ahnut J.ieDI Oil property ofM~d bcneftdaries, amllt makes clear that states
may DOt bold adult children respouible for their pareats' lona tam care hi11e. n.
aovcmora' JBVPOsal does not address these issues. Provisions of current law sboulcl be
The sovcmors' p!vpulllls lilal about provisions of
cuzrent law that protr:ct Medicaid bc:Deficiaries !om discrimbultioa in admiainn to,
11'1111Sfc:r aad discl•qe 1tom nuning bames. Those protections must be retaiDecL
retained
�.'\
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•
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· I'
II
. .I
!dEMORA~DUM
TO:
lntaated 1'artica
FROM:
Larry
s. oaao
Prcaidcnt. National As&ociatiOI of Publlc Botpicals
DA'm:
february 7, 1M
Preliminary A.Ueument of Nllri,.,id Oovernars'
Assoeiauon Medicaid ketona
I
Propoa1
The Natiuual Oovr.mnn' Auociation 'NGA} )'ISWday approved a proposal ro reform
dle Medlclfd propazn. Tu lheir woida, rbo proposal represents a compromlle d\at "t:iendt
die ben upeas ut the current procram wi&h ooncreuioaaliDd admiftis&radoa altematl\res
IOWIId aclrlr.Ytn~ • Slleamlincd ud stacG-tlcxible t.llh can l)'l&tm dw JlllliiiWD lallb
·caw 1.u CMU most needy citia:u.' ne Nalional AaOclallon ot PubUc Hospi11b (NAfR) is
derply mncet&Md about cbo impact tbc propOIGl would bave on Medkald ndpi&:nts and ~
low lncnme populatiOftS. 8Dd on the ability of safety ne1 pmidm to a.nt ror their padcDts
~~~--.
.
Ou.r initial miew of the available su:DJIIIria iodica&es that the Oovemon' pzOposa1
appcara to be desiiD'd primarily to redact are sper~cJin~ nn mediAl assistaftge, not ID
~aibly IOlorm tM Medicaid propam to balc:a C&l-e for the ftltioa's V111ncnblo !
populations. AJ toclay'a ticw Xortc nmes• l'dhuri.itl aa:watdy summed \:IJ, the Go-iemon·
reforms ue •harsher toward d'.e poor 1D b) n:~pects than anythinc Coqms hat pwed or
tbac the Republicana pnvarely MJOdared ,.,ilh Pn:sideatt Cli:aton. •
1b1l Memorandum wiil surttmariu: some of our priDcipa.llnitial COftCII'Ils wltb
Gowmon' Medicaid propusal.
J.
uw
..,., from tlu c..mlll ,,.,., Bltlllkltll,
The Oovcmon' proposal would guarantee some U•yec uadeftned level of benefits to
some (but DOC all) currently eli&ible populatiO!\ JfOIIPit bul would repeal L'lc cumnt;
individual entitlement to a defined lMl Of beneftts (lnclualin& all CUI'RIIt f~cralrcct~ts
u to &he amount. duration, and scope ot benel\ts). Tbi~ n::Lteat frnm the cum:nt lc-101 of
covuaac for low income pop~lations come& ar a ti~ whtm nu:11l data from tbe Lttlploycc
• •A"''III.U. UllllftA. . . . . . I"UBB.&&i .......
Aiolllola.II'IZW'WUA~MWel\'ft'SD IWAIII.Ge~•(ftl:41~ 1/AJL•'IIII..aecla
i
�Bea-.erJ~~Rearcb
hlstitutc ~·cal lhal the number of unlDsund A.menuuas has inerea~ ID
:\9.7 millicm. Such a retreet willtucerbatt an already uemenduu• btmlen of un~
cart OD bo~Pitals and other prO\·iders Who 'Cr8ll qe Dllrnbal ut h income patients~
includinl the 64 NM'K member hosplWI which provitlftl uw:r S4 billloa ia bad debt lnd
charity Cll't in 1993. SUI"'\lnaq tbe individual ~cit1emcnt without ~ftC c:ov-. eo
popWatiaU for a dtftned amouat, K'ope, auxl dutalloo of bcaefisl wW daqcrously ~
1ft already ft1aUe belldl em .Cety net
~.
. , . , "Pro-Mif Pu,••, StcJtulmrls
The Govemon" pnJpota1 wnuid repeal the BoreD Amendment and otber I1I&U&+rJ
provllloU IOVemin& at~r. nd~ at which providers arc rcimb\lned and WOuld liVt ltllll
co~ cli-.:relion ., ~ provide~ p&)'mcl\t rates at aay level tUy cboOie. NAPH ""ieva
that lhe llrOVWODS in tut'l'eftt law JO\emi~ providlr paymem m'lliC be rwdned. Wi~
llaese prolectiOM, there is no assurance dlaC safety nee provJdets wlll be adeqwttcly
reimbuned lor tbe care they provide tO vulnerable populationl.
In adctitioe. tbc Oovemors·· proposal would elimilwt the federal private riP& 1of
acdoa ia C\ll1Cftt law for bodl beneliclarles and provldrn. Rmeliciaria would have a
limited ability to xck to enforce dle Medicaid Ja.ws ia lllde court, but prDYfden would ha\'1
no ptiYIIC riJbt of actiOn an state coun or federal caun. NAPH believes thalllffl i
comprombo Medicaid ltGisladon m~~~t rmin a pri~are c:~u.: of Kdon for boda bcnetiOiariel
and prvviderl. 'lbil imporwn enf'oreemenr ms:hi<ism allows iDdivld'llal bcftcf1ciariH lftd
tbe piO\'i4en wll1ch care tor u-tn lU c:nCorc:e the Medi:aid laws ud hu been 11 tffective
way ror llfe&y nee ptovlden ro liChic:vc: state a~tabilhy on bcbalf of tbe padlftts ibey
sene.
~aJ pmvi~ions in tbc OoYcmon' proposal would work lD tudem to pemtitx
daDJUOUs era...U'·" of states' responsibi!itlea to finaDce car. for lbelt most vulnenWlc,
populat1oos . .\1\he New York TimcJ swes. tbeso fea&Wa ohbe Oovemon· prup~1 are
deqned 1n &ive the aovcmon "ptcaey of room to reduce su Medicaid fwxlL • NAPR
canJI)' uqca the Coapess to ret'ocua the deball oa ftndinJ J!IDie ~ciau ways co deliver
bealtb care to wlncrablc popuiAti<ms, a"' oa limply reducinJ»~ spend;nc.
Far ~Umple, the Govttllors' proposAl wuuld set the minimum federal matctuaa
perceaiiAt for all stares u 60,.. Many s&xt=. wollld lhc.rcfclce lla¥C tbcit state matc1ia&
percenrqes reduced, wi&t1 thto l'QUll tbat the 'tate would have to tpeQCI fewer stale dOLlars on
medJcal ulfslance co dr.aw d~, its r.-ral allocatioa tban it the cuneat federal ma. .
percen~qe amalaed in ~t!TC"Ct. For an ~talcl, once a nate 1w drawn down its entiN federal
�-
P.4/S
Mmo trum NAPH to lnteratc.d l'Utiea
Pe=bruary '7, 1996
'•"'
I
aUooatioa, lhlrl would be DO tn,:auive for 1 awo 10 c.:xpcnd addilional~U~te dollara OJ\
cntdlcal auiatuce bec:1u~ tht.~ wt~\lld bo DO a.ddidODal tnatdlina fecSenl1\&ldiftt. Tbe
litely effect will be a diAIIlWC red~tion ill ltaiC lllCdiaal UISla=ct fund1na Ill lddi\b110,
lad 11 dw 111118 time A\, the anticipated loduccioa 1D fldenl Mtdkald ~· The ta
Yptk D• eslima&es that , . , would save ov• $200 bUllOD undlr dUa prvpusal
the
nm smn ~over IWiu tbo Ill~ fldlnl avlap.
at"'
4.
lf•,.Z o/ l'rrlriMr atll.Mtll Gwii'IIIIM ProlttfiD••
The Govemon' proposal would abo ftpeal ttte pruwidet~ tu and
intcraoWIINDCftlll tmnsfer (IGT) mmcdonl in (..'U&tent law. 1\ae would tberefcne ~
nothinc prohibiting states trom lhifdns thrir mllleh requirements on co 1\ca.lCb care prOV'iderl
or localJOYiftUillllt&-Or from ~ provider tax and IGT PfOI1'GIIIS to finance 111t1r
entire MtdDid proaram. NAPH Suppurlll relalnina tbctc protections in currenc Jaw.,
I.
It,_, f/
1111 .Widlttri4 Dl.YpmpotfiDIUIII SluJn Ho,., Pro,..
Wblle \be OovemCJI"S' l,a"'ppOII wollld include tile fwMiiAI "IOdlltd whb cum:tJl
~ sb.te ho.pilal (DSII) apcndinJ illiiCJl IWI'I ftdtnl aDocadan, It ~nuld
repeal 1117 'fiiWremtnt that u.y ot all of IMM fullds be plld co lboae huspilals lhat ~ a
diip~Up0ftiouu: nwntx:r of low mcomt pratieftll. While the propc!111 wnuld appear ' ~
lhat dlfliS funds be speat on c. for low incocu pop\lladona, ~ is ao ~
ll"eC:lfted by which this would be ~liiMcl-a piO\'llioD that i• basically mcanift&tcu i.a
lhal it is DO differeat tblft tbe purpose of dlt OYIII1I piUinAl. MOftliMI', wi\Cil COUi)led wilb ·
the IWCPO!Id repeal of tbe C\IZ!Iftt provider u and lOT pn1~ias, this ~
simply opcu tbc door to tbe so.me awe lbusa of che DSH prouam that the ~ uax Ud
TnT pmvisions were ~ted to curb, while loc:klnJ ia lhe cw·rent lCYCl of t'edenlSP,Cilding
INII ill till IMIU wlticA ~GN dull4 IA1 DSH ltulffllll- These well-pubJiciiDCl ab-1 stand
u & 1ooc1 example of what ~~ ,,..beD Slate) ~tre &lven ttcmendoua flexibility to ·.&It
fedclll t\mds but art prO\'ldld wid\ Walequale nvn&)\t on bow chcy spend UloSI f .Jnds.
IWber du wrldnl 11w.
state1 A
h1ank cll«k, NAPH 14es till Coaanu lnateld to
a moze ftsc:ally ~\'Pl'"'ih1e DSH propoal t1w Wleb DSH fwM1& 4lreclly <Ri
hoaptaala ..W. tM. hi&he.~ prcportion of low iDcome and Ullialuftd padellu. OS~ (undine
BUppott
il eaendalto d•Me utban public hospimlsiDCl heAlth sys=ma that pnMde 1 sub,lll\tiat
vv!W1"z ot uncom~wed services ro tbe poor. Theil am the bolptta1s fo: wtridl DSH f'unds
were primaril1lntcaded wbeD Conama.- dw p:ocram. 1hb plUIJUII1 recnsnizes that
to1ne avinp cauld be acncrated from ncluced DSH spelldiag, bluu.w not all DSP.. fuads
11-e 'uamtly used by states for their illa.aded purpose. As in propos~~l• currently uGdcr
cnn~deraticn, mch savinas should be Pued 1D over dme (e.J .• n~M fundin& shO\Ikt be
reduced only aftu the flrst two yean of lhe leVen·yea.r cyc:le p:uposed for the hudpa
�rEB 07 '96
ee: eGPM
202 624 1222
.....
Memo {101ft ~A.PH 10 Interested Partia
February 7, 19M
qncrDCDt). witb tN: remaininc DSll fund' blreeted on those buspiwb ~er~lna a hlp voluma
of low iAcomc ud uninsured patients. This is the appcoacll or ll~e wnMWtive House
Democnaio •Coalition• proposal, and one beina aiven bipaniMn Seaare co&llidmliUD !u
welL 1'bcy would zcducc tederal DSH speftdin1 but maintain a rede111l DIM runctiq pool
tblt would be p!OPO!tionally allta&cd amonc hospitals wilh a 1nw income utiWallun l'llt Ill
llll*dlll251.
• • • • •
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NAPB &baras tbe GoYetftOtS' loal of «ua.ru*ina bcaltb care to our nati01•a
wlnerabJe populations. But uw aumntee must be a meaaialful ODO. a rodcnl a~t.oc
en1urina dill low lDcome lftd unlns\ired pallenu receive all*ified Javel of benefits. .It must
be supported by adtquare State and fecleral f\Danclal reaourcea for 1bt safety net provi~
which care tor the~~! pupulatiuns. and by an effective enforcement mtObanism for ACh:;MIIg
Mate aewuntlbility. Anythlnalfts wtU damaae "'le safely nM health system in many !Uba.a
and mettopolltao areas. md will dwuy ~,;1111 ro "'Ire lor uuly needy oldzlns.
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�f£1 OS 'N 15 48
TD-~66~18
NATIONAL \VO~IEN'S LAW CENTER
eoa....aooaUy.. Approvtcl Meclkalcl TnDSI'OI'IIIIltlon Ad
.llarmflll to Womea llld Cblldrea
The Medicaid TnmsformadOil Aca- the ConpcasionaJly -approved t'lan to conven
Medicaid from u entitloment proaram into a block pc, and simultafteoualy to slash its
budaec by 5163 billion aver the nat stVen yean -will be panlcUlarly barmfu1 to wome~ and
lbeir familia. women compriae ov• 69" of Medicaid beneliciariel betWeen \Jae aaea of 18
aad 64 wich at least ci&ht pezgenc o£ women overallllld 11 ti of women in tbe 11-24 1110
rlftP dependina 01 Medicaid as their only source ot bealtb insurance. DlsmandlDa tho
proaram ancl aunWsl it over to the states With very tcw federal ataAdanla or l'roteclionS coukl
Jcavc nearly~ anillioft people, includinc6.3 milliOG low-income womca and obWirea, without
acceP to critical ballch la'rices. Pused by both the Houle and Scnara, die Act wu vetoed
h)' President Clinton wbcn he volaecl the Budaet ~ Act.
Poor Wom• and Children WID LAJSe Vl&al Hwl&la luura~W~ Covtnae
• wt&hout a JUUIDtle that all who are eligible can Ob111n necessary meclical services.
many poor women wm slmplJforao ....wa1 health treacmenUJ or shoW up in cmcqacy
CUP. utdaas - at area& cost bodl1D &heir 'hcalch and to a health care delivery system uy~n1 eo
outb COlli.
• 'l1lc ~Dladvely hiah rife of woma ·1396 vs. 1,. ot Dlllft· who receive Medicaid bas
been an imponanL factor in women's lower rates of uniosuranc:e diiD mon'a: 13.11 of
women. as oppoaed 10 17.8 "of men, are uDiasuTed. Without MedicaJd, ~ unillsUIInCI
mte for \\'OI1Ia1 wiU rite.
• The only provisiaft that would afforct e\'en minimal procec:tion to individuals now
eatided to Mt»ald is a RC!~t that stater provide coveracc wfamilies with illco:1t~ up
to 100• of poveny and tha1 inolude a child nndet 13 or a prtpll\t woman. Bow~er. ~tares
would bavc such wide discredon in dcaminiaa what benefits to offer that ~or beallh
ftiiCII of ~t WOIMD aDd kids could be ipored.
e The Mcd1calcS Transfarmation Act coatains set as1da Cor ccrcain aroup~: low·
income familia, :WW·incomc elderly, and tnw-inc:ome disabled. However, the nqutrement
that scates spend~'" ot what they speat iD pteYiol" yan C1992·94) on these croups comes
with condhions that are likely to result in atatc expenditures of anly about 44 ~ of wbal SUl&c.s
have spent iD recent Jeal'l Oft these key posM~ladolll. Under this formula, hundreds of
tbuusands of poor women and dlildrcft oould lote coverap.
• Tbe clbablod arc further harmed by a p:vvislon tbat permitS the aaaa to define
•dlsabJal•, witb few prcMc:tions to cnaure that whole groups of disabled people arc not
dmpped fmm che roUs. 1be only Rquircmcnt ia tbat diubled fndlvlduals who qualify for
S\&pplcmeotal Security Income (SSI) would automadcaUy qualify tor benefits. However, u a
ICIUlt ot lbc stata' authorky to define lhe disabled 8DCI SSt wu of S20 bi11ion Ill h Welfare
Blfonn BtU, bup mambcn of dillbled people would ftnd cbclnaelves OUL off from SSI- and
thus widl no
ot banetita•
auaran•
........
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rce os ·as 1s 4& T0·4SS621a
~
Act seta Che income leve1 !or elipbility at 3001 of the poYaty liae.
However, this merely means Chat people below this income level D14 receive benefits.
1bere is no auarantee lbU lhcy will actually receive coveraae. or tiW crucial types of
•
..mces will be covered.
Moreover, lhere is tbe posalbillty of tremendous variadol wilhlll
anes between atata, resultin1 in a system or potendally arbitral)', inequitable, and lnadequace
health caro eav....,e. In tact. the Act specifically exemptS saara from ux feCluil'ementl to
piOVide Uftifonn stat.ewide coveraae (mcludina acrosa polldad subciivisiona), or tn paranree
equitable eowtt~~e &o aimDarly li&UUed individuals.
• In addidOD, abe Aet expUclLly denies applicants, befteficiaria, and ochers tbe riaht
to sue to enforce eliaibility determirWions and other provisicfts ·a d&bt they have under
current Jaw. In essence, tbis means that people wiU be deprived of an important mechanism
for wurtn1 tbat CVCD the minimum •tanduds conllined in lbe Act are actually enforc:ed, at
the same time that states are arantccllicense to treat low-income ildMduals in very disparate
ways.
Crltkal Jlealtb Sen1ces Caa le Delllecl
t 1be Act e1imiDates almost all cuaent auaranu:a of coveraao, aivina the states
near-~ clilcretlon Ill dcdcliq which booefita to provide. The
paranteed services
would be child immunizatioas and (~~ate-specified) family p1aMinl
1bia Jeav. dlc
maJx
.mea.
provision of esseatial medical semccs subject t.o ihe whims of cub-ttnpped state leadetl.
WOIIICR'a haalth MrYicel that would be jcopantized include:
QIDtsalii&IRDdxt eeoi• mQ U PaD IIJ\CUI. m&mQlQilllDI·
IDd AMJinl far
¥1V'11YtmnsmJgcd dian.
·
Medicaid covenp of theSe die scMccs ia especially \rital, because low-income
wo.-. ~ 1P.U likely to have cancer detected at Ill early staae and heace more likely
to suft'er seva consequences than women from htpca ~ bnakett. 'nMxt!te the
r.:t IIW ead7 dcteotioA and h'eatment saves raxpayers the expense of later, more
costly tnatmeot, these preventive seMce5 are at arave risk in sucn an undcl"fwtdecl
pqram.
pnmalll. matcmiU ;uc. pd 'ClYkes to JOUDI chiJdo;n.
l'lalalll ud mu.nicy care are vital ro the bealth of women and infants, reducing the
inddence of life and balch • tDdan&erina prepaacy c:ompltcadons, 1Dw btnb weipr
babies and infant monalily. s-. would be required to cover children under 13 and
preanant women, but there is no Rlquirement that cenain benefits be offered.
Moreover, with prenatal and infant care scrvlua compedna with nther health services
for a limited amO\Jllt of money, vital benefits (such as prenatal care) that are required
under curl'ellt law could be elimiDated. Stare bud&cts as wellu women. and children
will be advenel)' atr.-1, u ~ery dollar spent oa ~ care saves $3.38 in tbe
coat of ClriDa for low birth wdaht infants.
HA110NAL WOMIN'S UW CFNI'II, WASHINGTON, D.C., JANUARY, 19M
2
�rce os ·se 1s 47 T0-45&6218
T·880 P. O.Ci05 HQ - - ---
61Mlion Smiw
In CDntrast to all other aspects o1 the proposal which would l!'lft& wide latitude to che
atues in decidlna how to spend federal dollan, the abortion provision would prohibit
the states from usin& federal funds for abortlca except. 10 ave &he Ute of the woman
or whcft the prepanoy ruults from rape or ineest. This provision cuts the Hyde
amcftdment into permanent Jaw, denyinJ poor women a critical health service and
precludina the possibility that tbis restriction be addressed annually throuah the
appropriations p~ u k hu bee in che pau two decades.
• Even If a patdoular avice is offered. tho Medicaid Transformation Act would
allow stateS to impoae deducdbles. premiums, eo-payments, llllCI ocher types of eost·lbarina
for the provision of services. There are no limits on theae coa-lharin& requirantDta. except
that for familia wlcb prcpaat women or children under 13 Uviaa below 1001 of poverty
the costs should be •nominal•. AU types of cost·sharing are a bUl'dln on low·tncomo ·
families, and praont a cliSiftoendve to sa:1: medical oare, no matter bow
or painful a
eonditioa may he. Underfunded Slate procrams will have a 6Jianciallnterest In deferrlnc
people from using services, and lhere are few limits on bow much stateS can charp.
senous
A Few Spedflc Provlslo111 Could Help Womea ObtaiD Esseatlal Beuefltl
• £aali1J PJannfna sprypa
:w.ctlcai4 it 1M liDaJe laraest source of public funding for eontracepdve savices.
The Act ~ecaw the curreat ud important requirement that au aar.ea COYa' fami17 p1unias
services. However1 dJc cWn1natioft 0l th• oo• federal malcb. aDd the fact tbat . .
leMccs will be competiDa with other health services. meaDS that family plannma seMCel
could be reduced *siderably. While Cbls may eul eost1 in the short-tenn, putdna IIIDU1'CIS
luau fAMily piAMiDa HVM maney clowft the road: each dollar spent on family plaanina saves
an averaae of $4.40 in health aad welfare costs.
• Mental
Hra1Jb
AnoCber important issue for women's health is coverage of mental health setYices. A
combilwim of physiological, IOdal, environmaual, and cultural factors contributes to bleher
ra1es ot some I'DCidll DlHsael, pat1ieularly ~. amona women. Tbe Medicaid
Traa.sfarmadon Act prohibits tbe JmposUion of treatmettt limits or financial JequlremcDiS on
mental il1nesl semcea that are not Impaled on olber smvicet. This will allow IDw·income
women &be lretdom to leek help, without discriminatory R\!SU'icdons on mental health
services.
• PtHxisdna ConditiQDs EJciYiAO
The Act abo provides protection for women with pro-existin& conditiou. It probibUs
stares from deayina or excludina coveraae for c:aWn services on the bull or-a procxbtica
NA'I10NAL WOMEN'S LAW CEN'I'II, WASIIINGTON, D.C.,JANtJAIY, t•
3
�rca OS
'9G 15
48 T0·4SGu18
r-eeo ;,GS,os r-ses
eonditioll. 'Tbis is very impolWlt for low-income families, which disproportionately COnsiSt
of women and childreft. Oae family member with an unin»ur&blc chronic or pre.abdne
condldon could banknapt • low-income family overnight.
FJderlt W0111111 Wm Je Bani OJ&
• Federal nursina home lllftdards would be wealucd because current quaiUy
UIW'IIICIC ltlftdatda tor llunina facilities would be eliminated, threateniJia 1.3 million nunina
home residenca. 751 of wbom are women (65 and older). lftltlad, SDta would have ct.
optiDn to eltlbBsh and self"CClforoe all standards fnr safeay, adequacy of care. and tra~ment
of residents. federal enforcement would only be allowed In die Ga~C of a Slate' a tmlure .,
conect csetldencica- a jucf&ment baled upon rcpcxts ICftcra&ed by the stare itself. Prior to
the ODACtmeDt of federal standanll in 1987, c:onditlans in numy nunlns homes raopd from
inadequate to deplorable, and enforcemcot was both weak and inc:uullstcftt. With i&a
wcebDed enforcement and romedy requirements, the Act would do tittle to prevent
conditions from deterioratina apin.
• Mile a nunina facility may have every intefttion of pRJVidiq the bigbelt quallty
of care, the Medicaid Truaformadon Act would make lc very dif&u1t to do 10. Tbe
propo.S fundina cuta would fon:e homes to cut staff and reduce saW:es. The Act appears
to anddpate this, u it redUC* minimum ltaffin& reqllirememts aad trainlDc tor nunC.• aidca,
ad estabUJbeS wcuu proreotlvna aplut WlWGilted traAsfM and dischara•.
• Another cost-cutdaa option 1M Act prvvidca tur nuniaa home& is limply to refuse
would no lonpr be required to accept Medicaid patimts,
muy will aot. because Medicaid pays less tban other payen. 111e ACt apaaa the c1aor tor
cliaclimination aplnB Mcdlc:aicS bene6claries in the admiss\ons ptOCeU, aDd will leave many
bendidatlcs with no altemadve for lona·term care.
Medicaid paillltl. Because homes
• Nuy famrua of WOillell in nursina homes would also be harmed by the Act.
While it retains current protections qainst spousal impoverisllmellt. me Act unduly b\\rdeu
middl.class l&llllt ch1Jdrcn ol n~ borne resiclents. because it permits nunina homes to
require adult ehildrea to pay tor their parents' care. Only adult cbildren livin& below the
saate's median income are exempt from 1hb reiquitcii\CftL Howewr, the mediaD household
IMamo ia America Ia 132.264. and the average cost of nunina home cue is $36,000. Even
a middle-class family would be placed under extreme finanetal~&~a~, oaec lis aviea• were
deplefcd. if forcCid ID pay tor this espensiw care.
,... Nlllaall w...·• a.., c.... • • ..,...ec Cllpllialioa .._ . . . . . wadi~~..._ am .. ....,... 11111 .....- .,....•• ~ep~
....... 'n.t C.. IleuM . . . poiiiJ.,.... ., ........ ID MIMe ... llleir a.dlila ..... olai1d ...Oft, lllfiD)D
...llllloa,IIPftlllu01iw rfll* ......... ~ ldll llfull .,.. . . _,., P'!IIJic .,.....,lA
ud IDCIII _..,. wW. .,..W
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4
�E XE C UT I VE
0 F F I C E
0 F
T HE
06-Feb-1996 07:14pm
TO:
justice
FROM:
owner-justice
SUBJECT:
NGA agrees on Medicaid
Justice For All
beckyo@names.org
NGA Medicaid Plan
JFA has obtained a copy of the National
Governors' Association plan to restructure
Medicaid. The following is the text
of what was disseminated at their sealannual meeting in Washington, D.C.(For
staplification the only portions that
appear below will be what pertains to
people with disabilities. For the full
summary, please call BeckyO.
THE NEW PROGRAM
Within the balanced budget debate, a
number of alternatives to the existing
Medicaid program have been proposed. The
following outlines the nation's Governors
proposal that blends the best aspects of
the current program with congressional
and administration alternatives toward
achieving a streamlined and state-flexible
health care system that guarantees health
care to our most needy citizens.
PROGRAM GOALS: The program is guided by four
primary goals.
1. The basic health care needs of the most
vulnerable populations must ~e guaranteed.
2. The growth in health care expenditures must
be brought under control.
3. States must have maximum flexibility in the
design and implementation of cost-effective
systems of care.
4. States must be protected from unanticipated
program costs resulting from economic fluctuations
in the business cycle, changing demoqraphhics, and
natural disasters.
P R E S I DE NT
�BLIGIBILITY:Coverage remains guaranteed for:
*Preqnant wome.n to 133 percent of poverty;
*Children to age 6 to 133 percent of poverty;
*Children age 6 through 12 to 100percent of poverty;
*The elderly who meet SSI income and resource
standards;
*Persona with disabilities as defined by the
state in their state plan. States will have
a funds set-aside requirement equal to 90
percent of the percentage of total medical
assistance funds paid in FY 1995 for persons
with disabilities.
*Medicare coat sharing for Qualified Medicare
Beneficiaries.
*Either:
-Individuals or families who meet current AFDC
income and resource standards (states with income
standards higher than the national average may
lower those standards to the national average);or
-states can run a single eligibility system for
a new welfare program as defined by the state.
consistent with the statute, adequacy of the state
plan will be determined by the Secretary of HHS.
The secretary should have a time certain to act.
coverage remains optional for:
*All other groups in the current Medicaid program.
*Other individuals or families as defined by the
state but below 275 percent of poverty.
Benefits:
*The following benefits remain guaranteed for the
guaranteed populations only ••••
-Inpatient and outpatient hospital services, physician
services, prenatal care, nursing facility services,
home health care, family planning services and
supplies, laboratory and x-ray services, pediatric
and family nurse practitioner services, nurse midwife
services and Early and Periodic Screening, Diagnosis
and Treatment Services. (The "T" in EPSDT is redefined
so that a state need not cover all Medicaid optional
services for children.)
*At a minimum, all other benefits defined as optional
under the current Medicaid program would remain optional
and long term care options significantly broadened.
•states have complete flexibility in defining amount,
duration and scope of services.
PRIVATE RIGHT OF ACTION:
•The following are the only rights of action for
individuals or classes for eligibility.
-Before taking action in the state courts, the
individual must follow a state administrative
appeals process.
-states must offer individuals or classes a private
right of· action in the state courts as a condition
of participation in the progru.
-Following action in .the state courts, an individual
or class could appeal d'irectly to the u.s. Supreme
court.
�-Independent of any state judicial remedy, the Secretary
of HHS could bring action in the federal courts on
behalf of individuals or classes but not for providers
or health plans.
•There should be no private right of action for providers
or health plans.
SERVICE DELIVERY
•states must be able to use·all available health care
delivery systems for these populations without any
special permission from the federal government.
•states must not have federally imposed limits on the
number of beneficiaries who may be enrolled in any
·network.
PROVIDER STANDARDS AND REIMBURSEMENTS
•states must have complete authority to set all
health plan and provider reimbursement rates without
interference from the federal government or threat
of legal action of the provider or plan.
*The Boren amendment and other Boren-like statutory
provisions must be repealed.
••one hundred percent reasonable cost reimbursement"
must be phased out over a two year period for federally
qualified health centers and rural health clinics.
•states must be able to set their own health plan and
provider qualifications standards and be unburdened
from any federal minimum qualification standards
such as those currently set for obstetricians and
pediatricians.
*Por the purpose of the Qualified Medicare Beneficiaries
program, the states may pay the Medicaid rate in lieu of
the Medicare rate.
NURSING HOME REFORS
•states will abide by the OBRA '87 standards for nursing
homes.
•states will have the flexibility to determine enforcement
strategies for nursing home standards and will include
them in their state plan.
PLAN ADMINISTRATION:
•states must be unburdened from the heavy hand of oversight
by the Health Care Financing Administratio.
*The plan and plan amendment process must be streamlined to
remove HCFA micromanagement of state prqgrams.
•oversight of state activities by the Secretary must be
streamlined to assure that federal intervention occurs
only when a state fails to comply substantially with
federal statutes or its own plan.
*HCFA can only impose disallowances that are commensurate
with the size of the violation.
*This program should be written under a new title of the
Social Security Act.
FINANCING:
Bach state will have a maximum federal allocation that
provides the state with the financial capacity to cover
Medicaid enrolles. The allocation is available only if
the state puts up a matching percentage (methodology to
�the sum of four factors:
base allocation, growth, special grants (special grants
have no state matching requirement) and an insurance
umbrella, described as follows:
l.Base.In determining base expenditures, a state may
choose from the following-1993 expenditures, 1994
expenditures. Some states may require special provisions
to correct for anomalies in their base year expenditures.
2.Growth.This is a formula that accounts for estimated
changes in the state's caseload (both overall growth
and case mix) and an inflation factor. The details of this
formula are to be determined. This formula is calculated
each year for the following year based on the best
available data.
3.Special Grants. Special grant funds will be made available
for certain states to cover illegal aliens and for
certain states to assist Indian Health service and related
facilities in the provision of health care to Native
Americans. States will have no matching requirements to
gain access to these federal funds.
4. The Insurance Umbrella. This insurance umbrella is designed
to ensure that states will get access to additional funds
for certain populations if, because if unanticipated
population. FUnds are guaranteed on a per-beneficiary basis
for those described below who were not included in the
estimates of the base and the growth. These funds are an
entitlement to states and not subject to annual appropriations.
be defined). The allocation is
POPULATIONS AND BENEFITS. Access to the insurance umbrella to
cover the cost of care for both guaranteed and optional benefits.
Tbe umbrella covers ALL guaranteed populations and the optional
portion of two groups-persons with disabilities and the
elderly.
ACCESS TO THE INSURANCE UMBRELLA. The insurance umbrella is
available to a state only after the following conditions
are met:
1. States must have used up other available base and .
growth funds ~hat had not been used because the estimated
population in the growth and base was greater than
the actual population served.
2. Appropriate provisions will be established to ensure
that states do not have access to the umbrella funds unless
there is a demonstrable need.
s.MATCHING PERCENTAGE. With the exception of the special
grants, states must share in the cost of the program. A
states's matching contribution in the ·program will not
exceed 40 percent.
6.Disproportionate Share Hospital Program. current
disproportionate share hospital spending will be included
in the base. DSH funds must be spent on health care for
low income people. A state will not receive growth on DSH
if these funds constitute more than 12 percent of total
program expenditures.
So, the above in a nut-shell is a broad SWDDlary of the
text that was banded out at the closed door press conf.
at the NGA meeting.
>From first read of their framework and without seeing
�detailed legislative language it is difficult to know
where to begin to respond. Allowing states the right
to define disability, to decide scope, duration and
benefits and taking away the private right of action
pretty much spells TROUBLE FOR PEOPLE WITH DISABILITIES.
The action should be simple: Call President Clinton
and thank him for hanging in there for a federal
definition for people with disabilities and encourage
him to stand firm.
Call Congress and object to the Governors' proposal
Call the media and explain to them why the Governors'
proposal spells trouble for people with disabilties.
JUSTICE FOR ALL111
Becky Ogle
E-mail: beckyo@names.org
Voice: 703-836-6263
�E XE C UT I VE
0 F F I CE
0 F
T HE
P R E S I DE NT
07-Feb-1996 11:34pa
TO:
justice
FROM:
owner-justice
SUBJECT:
Defending Definition of Disability
Justice For All
beckyo@names.org
Defending the Federal Definition of Disability
There are multiple aspects of the NGA'a proposal
to Restructure Medicaid that are worrisome for
the disability community, and it is our hope that
each and everyone is activating their networks
to speak out against the NGA attempt to·rob
people with disabilities of their right to Medicaid •••
When defending our stance on why Medicaid Must Retain
A Standard Definition of Disability, the following arguments
or talking points should come in handy.
-"Flexibility" to define "disability" for Medicaid is
just "flexibility" to eliminate the MEDICAID SAFETY NET
FOR PEOPLE WITH DISABILITIES who are currently eligible.
There is absolutely no other logical or rational reason
for such flexibility.
-Under current law, in order to qualify for Medicaid a
person with a disability must meet TWO CRITERIA:
The person must be poor, and
The person must meet the SSDI/SSI definition of
total disability.
-The $SDI/SSI standard is basically an inability to work
(i.e., a person is unable to maintain substantial gainful
activity), but it has developed significan precedents and
refinements.
-The SSI standard has been developed and FINE-TUNED
through regulation and precedent over the years to
address complex disability cases, such as:
.
•conditions that are sometimes disabling and
sometimes not(so-called "intermittent disabilities")
that may make a person unemployable, but not
�necessarily permanently disabled(e.g., multiple
sclerosis, epilepsy, asthma);
*diseases that are progressive(e.g.,Parkinson's
HIV/AIDS)
*disorders with non-apparent symptoms or effects
(e.g., severe fatigue associated with lupus or
with lyme disease);
•illnesses without standard medical profiles or
which do not show up on lab tests
(e.g.,high functioning developmental
disabilities or other mental and emotional
disabilities);or
·
*diseases that have different manifestations in
different groups(e.g.,cervical cancer in women
with immune deficiencies).
-Without such a well-defined and uniform Federal standard,
people with disabilities will be CUT OUT FROM THE MEDICAID
PROGRAM AND, IN MOST CASES, FROM HEALTH CARE ALTOGETHER.
\
-operating under an overall funding cap and without clear
disability eligibility guarantees, States will have incentives
to limit or eliminate coverage for those people with disabilities
who may require more complex medical care.
-People with intermittent, progressive, or other complex
disabilities. will have no reliable precedent on which to
rely and will be forced to re-define and re-ligigate their
disability for Medicaid.
-States will seek inexpensive healthy people to count
toward their funding formulae and neglect to find those
with chronic and complex needs.
-Without uniform standards, PEOPLE WITH DISABILITIES WILL
BE FORCED TO MOVE TO FIND STATE MEDICAID PROGRAMS THAT
MEET THEIR NEEDS.
*If some states provide eligibility and benefits and
neighboring states do not, people will have to move
to get necessary health care and services.
(For example, in the early days of the AIDS epidemic,
many people moved to California to get access to the
health care and services denied them elsewhere.)
-This, in turn, will create a "RACE TO THE BOTTOM" in
which no State will want to provide benefits that might
attract more poor, disabled people to their program.
-This competition to provide the least will ULTIMATELY
LIMIT BENEFITS TO PEOPLE WITH DISABILITIES NATIOHWIDI.
-without uniform standards, people with disabilities in
States providing care will experieQce "Medicaid-lock,•
similar to the job lock of employed people with insurance.
�*If a
care
it a
fear
person with a disability is eligible tor health
in one state and not in another, this parson and
child their family will not be able to move tor
of ineligibility in another state.
-Without uniform standards, people with disabilities and
their families will be caught in CONFUSING'AND TOTALLY
UNNECESSARY BUREAUCRATIC DELAYS.
*The social Security Act will continue to have a functioning
definition of disability for purposes of its SSDI/SSI programs.
*In addition, each State will have a different definition of
disability for purposes of Medicaid.
*People with disabilities and their families will be forced to
undergo tireless, duplicative State and Federal testa,
processes, and paperwork-often at a time when health care is
needed immediately. The cost of this duplicative process should
be factored into the equation as well.
-Without coverage under Medicaid, low-income people with disabilities
will be shut out of the health care system altogether.
•since Medicaid is currently, by defintion, limited to people
who are poor and who cannot work, if a State finds a person
to be inelible for the new program, that person will have
no employment-related insurance and no personal income or
other assets to use for health care.
THESE ARE THE PEOPLE WITH NO PLACE TO GO.
THE ELIMINATION OF A FEDERAL DEFINITION OF "DISABILITY"
ELIMINATES THE FEDERAL GOVERNMENTS COMMITMENT TO GUARANTEE
HEALTH CARE TO LOW-INCOME PERSONS WITH DISABILITIES AND
MUST BE REJECTED.
(The above talking pts. or arCJWDents were developed in
concert with Georgetown Federal legislation clinic. Many
thanks.)
Justice For All will continue to place other talking
points on~line for everyone's use. Please use them
often and widely, because we all have a lot to lose
if this proposal were to make it into law.
JUSTICE FOR ALL111111111
Becky Ogle
E-mail: beckyo@names.org
Voice: 703-836-6263
�FAMIL~OICES
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Polly AliDa
About
MediOnmt
Date:
February 3, 1996
~ledlGnat 01
an
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'na with Co-.emoa
Ill Japli•tlou for CIIOdna wttll Special Beata• N-a.
1am rcspoadiDa to tbe newest infonDI!ion on McdiOruu as the parent or an ldolesceat
Wl1b multiple disabilities and u oae of the co-fouaden and ibe clhector of family Voices.
My focus is on children v.ith special health rare aeedl (disabilities lllcllorchrooie
conditioDS). ID the deliberations •ound MediGraats, please remember that wbile moat
children who arc Med&\:u~ m:ipii."Dbl are poor, 1bcn UIIRIDY Mccllcaid reciplads from
middle-class families who have becD fiDaadally devl818ted tiy the health ud otlla' costs
associated with their child's condition. I have attachccl tbe family Voices oa.paacr 1blt
describe• tbe importuce of a •troll& Mecllcaicl propam for our chil=n. u wdlu another
description of the combined imptrt of 1hc maay cblnpa tlkiDa place in the programs that
t!Mhlr. '"
Cld-
MoaWII
To:
From:
tn rli~ Our C'~ll witb cpecial blllth GIN neeclc at home. 1111 all OhiJUca
should be•
t. Covenp:
covaed,
• Wbll will happeD to Ycnmastal with special Jallh Clre Deeds now
Medic:aid wbo happen to be bctweeD 12 and 11 )CID of aac? If tbeir timilies CIIUIGt
·pay far their healtll CAlC, who will? Ia maay wa,s. lldolcaccnts are ~;hall,' ia acal
· ofhealth care becau.se of the eDviroamcats hl wlich they Hvc ad so to scbooL
• V.'hat wiU happen to diildnD with speciaUaldl caJe Deeds in states wbae Medicaid
eJipbility is above tbe poverty ntca lislod tor cbildna ill Medianm D? Pw example,
New Medea'• Medicaid pnenm just waat 1D 1"" ofpovwty. lfNI'W Maico
retaiDS its commitmCDt to pay for heal1h care for~ as• 6-12 ..WO a
lduw liS%. bul above tooele, lade dollarl,llOI maiCh will be used. Do dJt
IOvmlOJI Wlll1 tbit?
• Who will pay for me health Clle of those childreD • do DOt fit witbiJl tbe poverty
&uidelinea? Do tbe gG\'CI"DDO'S undentand 1bal1bae children willllill get sick. break
hnnM. have ar.cideD11? \\'Ilea it eomes to cbildnA with special health eare Delds.
wbo will pay for their caze, much of it quite GJ*IIiw? Total sta1e dollars? County
fullds? Hospilals, duoup Ell v\slts? WW ftntllcs bave 10 institutimaJiR 111*
cbildren witb disabilities (at much greater ex)JCIIC for all coaccme4) so thai their
children receive dle health care 1hcy neecl ill order to survive?
• Allowin& each state to define ..disabled" invites chaos: people with disabilities will
move to ttltel with broader dofi.Diticms; ADA v.iJJ be iDvokod; t"amilioa wi1ll children
with disabilities, cspeciaJly those who are poor or wbo bave become poor, will be
forced to relocate to a sta&e with a more favorable Medicaid propam.
�--~
~r
-,...,., •
• The eliaibility related to "SSJ staDdards" abo varia from state to stall - ud ill
molt stata is quite low. AaaiD. u wi1h powrty pideliDCI for childra. tbae wl11 be
11\aftY iDclividuals witb disabilities who haw beoo oovtnd by Mecliclicl wbo c1o aot
meet the SSl eli&ibility th!abold, but who will still need beal1h em. ud will ooly
be able to receive it u· state dolJan ~ used. or if they eater an mstituliOD.
• Thousands of children 11rith special health care Deeds wbose &milia could DOt t1Dd
them adequate bealth care coverqe (because ofpre-existina conditiou. Medicaid
income pidelines, inadequate beDefits pecbaa. etc.) bave bcCI1 able to live • home
t111nueh tbr. Klltic Acdrctt Waiw:~ and nchcr hmnc end c.nmmunitJ·ha.a wahcr
prosrams. Vt'bat will be the status of such waiver pt'OII'ImS? WiJl the federal
leaislation at least not prohibit states from eontinuins or ena.ctins DeW waivers?
2. Benefits:
• How specifically defined are the benefits listed? For example, docs outpatieat
bospical services include therapie1? For rebabilitatioa or habilitatioG?
•
Tbe benefits listed are deftnitely l•ss adequate thaa EPSDT. Who will pa)' for those
necessary and c:ost-cff'cctivc acniccs oace iDdudecl iD EPSDT ancl not listed in
MediCirlm U - equlpmem (wheelcbaln), OUipldCIII dleraplet, many early
iDteneadOD.scrviccs. etc.?
• Most lona-tam care dollars • eatm up by llllniDa bomes Wdtutioas.IDil
ICFMRs. Dara show tbat home-care aad the use of penollllaasistants areiiiUCb
mare colt c1fectM; far tbc cldc.rlr. people witb cliabiJltlcs, llld chilclrcD willa tpcoill
health an nceds.ID Older 1D save mcne health care clollan, will MecliOnmt U shift
1he bias ud die formulas 1D home care?
3. F~ifta Set·Asides
•
savma
If1hcrc is true interest in
Medicaid dollan, there should be IOIIlC iDvestiptiOil
iDto the set-uide fanau1u. apecia.Uy those daat favor institutionAl Nne ('nmrifle
bomes, state instituticms, ICFMRJ, etc.) over care ia tbe commuaity.
4. Overall Impact
• 011 Vulnerable popwations. Refaring to children wi1h special htalth care needs
alone, tbe imJ*t of 1111hc beakb cue cllaDps belna discussed and taJdD& p1aco
could be disastrous. We are fast ~achina a zevolutioa iA bow bealth cue is
financed and delivered 1hrouah a mass of state. federal, and admiDistradw chanses.
with very little ia.farmo1ion Dbovt iu ~mbinecl impacL Has ayoae calculated the
lWil iw.-.l uu uuc M.UIIll \.JaitJ wlag •WaJd ax.c.d Medicaid lor pR~nti''6• 66Uk lad
habilitative- ct~~e'/ 'lhe title of MediClraut U SI)'S ""Special Ptptecttop Pmvlslca...
Would h be possible to at least continue to pmtcct 1bose d1izenl a1rady emolled ia
Medlell4 bY JDIIIlWJUDI11\CJr Ohllbl<Y. OVIDII1DIY CIO DOC meet IDc<lmo &tnd Olber '
requirvm811117
2
�• On the Health ~- Most health care providers, wbe1ber ph)'ticians.
hospitals, or clinics, depend on a combinatioe of aowmmem ad private iDsurance
nimbwtementa. When on~ piece of tJw equatioa it outlchaased clraatically lad
swiftly, what iJ the impact 011 the health care Wrutructu~e iD the states?
• On State Budaeu. What projections have been made on tile impact OD stale budgets
as tbe down-s•zana of Medicaid takes place? Projectioas shoulcl factor ill not just tbe
loss of federal dollars. but the populatious UDCO~ the effect on hospitals. dinica.
and od1er providers.
•
Eft'ects of Cuts Beyond Medicaid 011 Vulnerable Oillclrell. Proposed federal budaet
ems In cdueation. (lDEA lllld Put H). \lcvclupu.alla&J di:AWWU~ AFDC, aud SSI
will have devutatillg efl'ccts on children with disabilities. We receive calls cwryday
&om state leaders about even Featcr cutback• iD state budgets for programs that
Npport and assist our children. The ovenll impaet offecleralmd state Nncfina
rcduc:tions on our most wlnc:rablc child.rm should be pD't of Medicaid discussiou.
3
�-·
···-~ ·····---·--~-----
-
~ICES
JWy/A\AAUit.l995
Flll\ily Voices: A tlarional JIISSrGnll nttWOrt or &mililllnd (riena ..,ak;nt"" tealt of chaldren •·ith 1ptCaa1 h•ttta cu. ftC\.~
When the Bough Breaks: It's the Combination of Untested
Congressional Cuts That Will Hurt Our Children
fo~milies who
h•ve (hildren with lpeci&l hellth neecb hlvt
learned to combia\•lti1'Yicw from the foUowins prosr~ma:
L Medicaid - ffderal iunds marched by Stites pay for htaltJ\
,.;~,. frw childl'lt'l" wh~ .,. poor or dilablecl
2. Public Hullh Serrice • Mlttmal Child h~aldt CMOO block
,..ant lundA atat• ("hild"" wtrh $pedal Heald\ Care Nttda
<CSHCN /Titlt V) chileS htalth prop-am; Indian Hea!th Ser·
vice CIJiS) funds health .Wa nn and nff rPIIII'Mitlonl
3. OU4nn'• SS1 • Plowta cub benefits INS Med1caid for
poor children wlth SfVtft ciJIIbUitla
IDEA • l'aru 8 and H protect kids with special needs and
fund same edw:o~tion and relalld aerviees. , • ...,. Traininalr
Information Centen (P1'1s) IIIJst faJftilies with education HI'·
\lkel. Mafty PTls work with Family Voica
Cdllpts prt1pt1111 ,., tlrt11Jfl8dr ri/ lhttt ,,.,.,. EWII
RrtSSitnrtll ICtion wall fJ1«111urwlrrlb t,f ~. tfr.ltt14m~ r&Jitlr
4.
-Con·
,m.1 lwtlltla rrtta. If •II four,,.,.,., tlllmgr, llw mJJts tlnlfll
lwllsattDUS/tWtlwiOmillbrAmrrlaaltdril4mtmiM,.,#etluolrit
'-'tlr allftlilion.
brl,.,.,.,.
DAVID
Now. David is ababy of llxiiiGNhs who Uves In tbe nnlSouth.
'*Jhinllal INa dille pounds at btnh.bt lllcl cardtK and
odalr c:omplkaliaDIINI .., lirUftld 10 the Newboln lnlao
.aw Guv Unit (NJCU) ulalllp cl\llclftft"llapllll. ne cmts
for David's tw0-11\CW\d\ NICU . .y md canllK surprt.es
~-lib Wn&ly hnldllnlurallce 1Utame ap. HJt 11\GtMr
41'* htrjob 10 caN lor Dnld, 10 he Is now IDcamHII. .It far
Mldle·•kl All Auwrklllllndlln, David 11111o lllllblt ror a
MrViee5. Davlclll expected ID Uft I normal cN1dhaocllf hi
.:..a& r&-elv• w.kl)' d.-.plw anc.llnlam ldlmiiiiiOft. vllllc.
diK and neuroloSY pediatric tped•llstl repluly, and be Cldd
lor by hla peciJ.IUkiM. He lbouW . . , ...... deYelopmll\·
tal p~ INl recei~ special educadan saw. ttlrou&h
Ida ftnt ynn oleleawu&~'IIChooL
f•tuRl Medicaid cull wW limit c:Nidn!n't hclpitaJI in pn>
..utlfta the NJCt7 c.re that
Da11cr•11te ...a ......w hilt
Mildly futwe. Now that David II on Medicaid. he reUts on
Medicaid cnaMpcl care'- tpcdalty care, ped.i.lllk vlalll, •
clftelopment.al proarun. and therapies. But 10 far, INNpCI
cue wUJ Aot pay for either pecbatrlc •pedaliall gr llwr.p&a.
Ald\oup David couJcl ..-IKS health ~en-icw, DiS bqet reductiON fora!d cuts ift c:hiJcl hc<h care,; betilt-. hla Drs W'Ut
il lix houn away. Low reimbursement frolft Medicaid aNI
d)£A Put H lftaaA Davkl CAn l'ft'eive Only mil\ilftal.mctt ll
the local dewlopmental pretchool. David's falftily wiD need
care coord&naliOI\o poercouualift& aMIOIIIC iped•liaNI hcahh
seniees &om the ttatt'tlitle V /CSHCN prosram. Howlwr,
bciUMNII'Ue'DdeV ...... wullalhadwhcftDeYid'tltale
decfded tD 1111 htalth blcxk pll\11 funds for adults rllblr thaD
cNklre.tMtnlaecl~-p!OIIUNI~~
.Mhislutilylrl 10M- II 0.\'icl annot leceinr
Nun11oft MMC8 d\&dl\1
ol the INCilcll
IDvabMN JNCit Ill David wGI be lolL
•*
.._,._."",_...much
�FAMIL$ICES
SorHimportant Facts About Medicaid ud Childra wltla Special Healt• Cart Needs
-....
......
...
1. Mallc.W Pnvtd" Accus co Essential Healtb Care Servica for OUclna witla Special Rill*
CucNeedl
~
"
.u.~
,., tie.-'*
............
_..
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__,
c_..o.r..
.......
...............
,..,....
,....
Fewer ud fewer of America•s cbildt~ with special health ~re aeeds are ftOW ocr.wed UDdlr pm.
luunnGe. Ia &ct. '.be aumber ot children wbh tpeeial balm can a.ds whose puara ca bep Nil
iMurwf under 1M fmWy•l halth iatul'llftCI piAl\ dooliaca ~ l'K· M1ft7 Gila dUJd1\11 wlda 1CYC11
special hcal1b care~ IWID ~hen covued by privau bcahh imunnce, haw inadcqaa11 oovcnp tblt
olea clou DGt provick da11 ~ L)'PO or maem ~cue lha& Cbly mquue. Medicakl bu ~ cli&ible
daildteD widlspccial beahh care aeeds to receive imponant pmcnwive IDd ratcr'lliw lalda .mea
wbile beiDa nrtured at h01n1 by their families in their corrunun4ia. t.fedicaicl1bus awaiOCilty die
em~ atkecpq cbi1dren with d.isabililies iD institutions.
O..H41
,.,,_
a.a,__
,...
.......
,......
,...
,...
VIlli ........ MD
..
.,.,,, I
W.Lu*r
2. r.laRclnm widl Spedal Huhh Care Needs Qualify tor Me&aid ill Snea·ll WaJs...NoM of
Silllple
•
Cbildral under the aac of six whose famil)· income is ap to 133% af po\ICftY, aad du'ldrcD w11a were
bolD after September 30. I 913, whose faaftily inoome il•p tD 100% f1 pcMI1)' 11DW qu11i1y 8w
Medicaid iD every seat~. Some swn have ~paDded CO\'alll rn IMft more cJdldrea \Vheliw a.
famil• with a low ilame.
•
J.j of IIIIi, cbildnD who b~ qualiftcd for lhe Supp!cmeatal Security 1Dcaao (SSI) a.ilda'e
Pcusnw also ncdve Medicaid ID 31 statn. Cblldral wida diubililies IDDIIInt 111111t till pcMdt
~
......
...,.....
............
,_
pideliDCI. 1'biiD they must hr.e a dlsability tbat is oa 1111 SSIIICdic:llllslbc or dlllr clillbi1ilr
..... be 10 . . . . . it prohibits diem 6om ft&nctionia&. OCher chiJdreD. AbOid toO,oao
cbildnm a~~ in me SSI proaram. but not all afthfm Hw in 1111e1wt.ere they C1D ako I'IOii9t
Medicaid. 1\e CWRDt Perscoal Responsibility~ (PIA) pub Umb oaeliaibiJIIy lllll:.ldftta ill
die SSI a.lctr.'a Prop:a.
Nit~
.......
,.,
...........
M
•
n •
.....c..«
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a.e,Ao~Ua~
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Clllll . . . . .
:....,
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a.dllr . . . t.teCIIII
........ Iii
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Cblldn:D Ill mo10 1baa ;)0 states may qualify for Medicaid 1hraap specill lane and COIIUIIWiity•
based waivers aDd amcndmoa.. Children must meCl stall ddenninod dnhitionl of&hhi1'J, t..r
pUCilll' iDCCIIDI is noc ~ into account. 'These WIMn provide ciUldna wida critic:ll home care
services dial miahr nnt hr. l'O\tCM under 1heit private innt~DU plus. 1\e ~Wwn abo proWID
haldl OIMCIII to cbiJdrcn whose beal1h we expwes baw beea 10 arcat 1bat tky baw na
dlroup dar prhu; Maltb iuurll\t:e wmqa ll.!ld wnnM have to live ill aalnsUIUiiaD iD orc11r tD
qualify Car Medicaid.
3. Medicaid Caarantees tlaat Eli&iblt Cbildrea wiD RrceiYI AD M~n, Nlftltar, llnhb Can
dltoup till EPSDT (Early Periodic Screenifta, Diaposil, ud Treatment) Pro&,..
Wbilc priYatc health iasurance plans miaht acx include all health care services requilcd by a child 'Widl
. , ... heDida ouo . . . ErSDT maDclata that UU)' hcal&h eM: sc:mce appiOWd by Medicaid wldcb il
coasidend medically DDCeSSI")' for a cbild must b4l pmvided. This pnwisiaa allows c:llildna wbo ar.
cliplo Ill' Medicaid to recctw appropriate comctavc ud pm'CDWi~ seMccs. suppU.. IDd
equipmer& (iadudina assistiw ccmmuniC4cioD devices. durablo Ddica1 Joodl. autritioaal auppiiiDIIIII.
pcnonal. usinmce, speech dlcrapy, physical ~. ud occupaliaaal1herlpy. IIIXIDI c6erl).
A lltiiiMIG,_OOII Nmrort qf,.,., atiiiWirt4J !pedflla M W ~c:r.rw.. _,_ ~ llftiiiiJ Cllt NMII
P.O. 1aa 7M. Aterw.tr-. ~- MmM &'7MI /'IM ~'~IIDJOS111'7.utr
~P.82
�-.
OZIOS/88
11:18
Febmuy
tt3CT ZC1T
---
---
GOV'T JtEUTIOMS-- ••• PlJILl( LIAISON -
liiiiOO IUU:i:-
s. 1996
Dear Govemom:
We ue wdtlDg to express our~~~~ c:oacrm ~Medicaid plOpOSils UDder discussiou at 1lds
week's meeriOS of tbe Nadcml Govcmoa' Associadoa. We u: exiRIDely tiOabJed by 111111Y poteDiia1
featwes of die pmposa1 we UDde+ Rand you am c:oDSideri.Jll. Of comse. M baw aaly limited
illfonDIIiOD about the deta.Ds oflbe proposal. However. if our UDdeastaDdiD& II COliC
•
Tbe plOpOAI snbmndally c:uu back cunaat JUU11D8S ofhealth covcrap tor saian. cbUdzaa.
people wldl. disabildes IJid wowea.
•
1he proposal UDder discussioa. ill fact. may DOt pnMde a uue paraarcc of health iasunDce
coveaae 10 IDJOae. Aftl:l a swe's reduced federaiiDCI SID aDotmeD~S haYe nm 011t, it is aot
•
•
•
elear wbeCber aay beoeficiary woalcl be~ health iDsuDDce c:ovcnp or wbether·a
state could mm away e\'eiJ stet. qualified applic:aDIIDd pat him or her oa a waidnsllst.
1be proposal pad)' reduces the beoefits ~to uyaae wbo docs wlDd up eJiaib)e.
wbdber a seaior. child. persoo with ~Dkfes or Olber ada1t. It cculd eUmiMre 111111)'
earegorles or J1W3IIII:Cd balefits as well as basic federal c:ow:rage m1es aequirina states to
fundsh medically DeC'e&SilJ cue.
The pmposa1 dramatic:aDy zaluces 1UDds stares must conldbate to Medicaid. Stares could
avoid $200 biDion Ill projecred Medicaid spendiq ovu 1be aext ~ yem. fordq eDOI!DOUS
curs Ill coveraae.
1be proposal makes 1t impossible for beueBdadcs and pmvide11 to bold Stall:& acxmnrabJe iD
tedera1 c:omt for breakiDJIDDI Jaw. Even the Dmitl:d fcde:nl safegawds tbat do exist Ill die
poposa1 coaJd prow meaningless ill pacdcc wldlout Ibis basic dgbL
1bese pJOposals woaJd cause tadble lwm to more lball3S mDBoD AmaiCIIIS whO c~e~»eDcl em
Mdeaid for esscntlal cownae otbeallh caze IDd loDi..fam ca&
SiDcelely.
· AIDS AcdOD OJaDdl
Amedcaa QMmsem"' Asmdarioa
AmerbD Medical Studeat Assoc:ialiOil
AmeDCIII Netwolk of Community OptiODS Uld Rcsomces
Amedcan Rebabilitadon .Associarfon
"Ibe.Aa:
Celder OD DJsabllit.J aDd Healrh
Qdldzea•s Defeme FUDd
Ccmscxdum for Cidzeas with DisabDides
Fmn1iesUSA
IDiaHaldl
Jinematioaal AssodadOil of Jewish VOCIIioual Services
JUStice for AD
Nadollll AssoriadOD ofCbild Adwcares
Naliollll Assoda1icm of People wi1h AIDS
Nllioaal Otizeas Coall1km for NIDSiD& Home Rcfoan
Nadonal CQIDDD1Dity Meatal BeaJdv:ate Comlci1
NadoDal Health Cam for die Homeless Councll
Na1ioaal MCIII:I1 Healrb AssociatioD
NalioDal OEpDizalioD. for Ram D1scxdels
Nati01181 Senior Qtlzeas Law CeDrer
NadoDal Womr:D•s Law Cearer
Sill fnoci!M AIDS FoaDdadaa
Stnlc& &DpJoyees IDtaDadoDa1 Ullioll
womea•s Lepl.I'Wense Faad
�01130118
14:08
ttzoz 111 co11
GOVT IEUTIOMS
December 18, 1995
Dear Mr. President
The undersigned organizations write to support the concept of a per capita cap
as a positive alternatiVe to current Congressional proposals to block grant the Medicaid
program. The Medicaid program provides basic health and long term-care services to
approximately 38 miiDon American men. women, and children. The block grant11g of
Medicaid would jeopardize coverage for fami&es - especially seniors, children and
·persons with disabilities - at a time when fewer Americans ara receiving employer-paid
health coverage and the number of uninsured persons continues to rise.
By linking federal funds to the number of people eligible for Medicaid services. a
per capita cap would allow states the flexibility to respond to changing economic and
demographic conditions. M~ _Importantly, a per capita cap - unlike a block grana creates a disincentive for states to remove people from their Medicaid program. We
appreciate your commitment to the per capita cap as 1111 Important safeguard for the.
health of America's most vulnerable population&.
Slncemti.
AIDS Acaon Council
AIZhellnel's Assoctaaon
American Academy of Pediatics
American Civil Liberties Union
BazeiOn center far Mental Health laW
cathoDe Charities USA
Catholic HeaJih AssoclaUon of the United
States
Center on ClsabDity and Health
Child Welfare League of America
Chl1dren'S Defense Fund
FamllesUSA
Famfty ServiCe America
Generations United
lntarHealthiProtestant Health Alliance
Legal ActiOn Center
March of Dimes
National Association of ChDd Advocates
NaUonal ASsOCiatiOn of ChJidren•s HospitalS
National Assoclallan of Counties
National Assocldon of People wllh AIDS
Na1fonal Associalloft of Public Hospitals
NatiOnal AsSociation of Social Wortan
National Assacladon of State Ombudsman
Programs
National Citizens• Coalition for Nursing
Home Reform
NatlonaJ COcnnlmlty Mental Healthcat8
Council
National Council of Senior Citizens
NatiOnal Mental Health Association
National Women's Law Cent•
Older Women.. League
San Francisco AIDS FoundatiOn
Serlice Employees International Union
TB AIDS CHizen Adlon Project
The Ate
women•s Legal Defense Fund
Worker Options Resource Center
�011~0111
1':01
ttJOJ Ill COli
GOVT IEUTIONS
IOOJ/OU
WHAT MAKES A GUARANTEE TO MEDICAID MEANINGFUL?
Overview: A guarantee to Medicaid coverage means three essential thlnp:
I) Eligible people can get care at any time during the year. not just while lha
money lasts;
·u) Thera is a federally defined set of beneflt8:
Ill) Individuals have an Individual right to federally enforce their guarantee.
1. Individuals who meet the eligibility criteria must get care at any time during the
year, not Just as long aa the money lasts.
One of the main issues under debate Is whether federal spending Is Umlted par
beneficiary or by Imposing an aggregate cap par state. For a guarantee of coverage to
be meaningful there must be an assurance that as &niTOIIment Increases, states will
continue to receive matching funds. Arri -gu&rantae• wilhln an aggregate cap Is not real
unless the states agree to cover all eligible people wlh 100% state money once the
federal cap Is reached.
Enrollment grows for many different reasons: recessions. demographic changes in a
state. changes in employment opportunities. Federal funds must be avaDable ford
new enrollees and not limited by an aggregate cap per state. Otherwise, states may be
unable to serve seniors or children who become sick late In the fiscal year, after their
tuncr~ng
has run out.
11. A benefit package must be federally defined.
Without a federally defined benefits package, benefiCiaries are not entitled to anything.
For example, as Sen. Chafae has said, a state could provide two aspirins a· year and
call this their benefits package. States could also decide, for example, that certain
benefits would be offered only In suburban communities. States could cover benefits by
county only if the county government contributed to paying the cost.
111. Individuals must be ablt to enforce the guarantee to coverage In federal court.
Federal enforcement of federal law Is necessary to ensure that billions of federal dollars
are spent as Congress intends that they be spenl Without federal enforcement. states
could override Congressional decisions. Without federal enforcement. states would
have the ultimate authority to decide how the funds are spent and where within the
states the money Is distributed.
�To a lla\1\¥ n:J Ql5 '96
11 : 34~ 11-£ Me
Consor.tlum for
-
Citizens with
Disabilities
~.
~~--
.
----- -·
-- -
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--
----
po~JuarY: 2, 1995
I
l
•
•
malll&aia dlllbdlvldual fedoral onllt1eaD& 10 Ncdlcaicl-4o DOL la:.pC nform ChiL ..... a
block IJUI& or •DI adllr agrqaro cepped pqllllllt to tbe ltllel.
matQttla die all'lal· fldenl cJcf'nltlnD ot clllablltlJ. ·
•
=
•
•
.•
mahtahl accell tD tbl Ml nDp otmlftdMo&71Dd apdoaal•vta.•
IIIIIQtaln die curnn1 prtVIII rJab1 of ~lollhlllftiUI'OI ~ ID ...-..
I
Jbe crldcll fedenl·roll ~.-u~r 111m1a Ud canaumer ~. a rolo dla\ Ia ·
r lmponaDliD . . . ono.a .-mlor'lloel.
n. ~ rogopl• tbat Gbllll" nut bo made 10 1hl Modlcakl PfOII'IIIIIO maU k maro efnc:leiL
~ we ~1 urp 1uu co locu on nd'orma W\ lmpm~·dlo proaram tor Meclkald
beDiftc1arloa.lid proccc~ conNm~r~. • slmpl)' that urtvo 10 acc:omnd1t0 dlo 1t111:1' desire ror reww
flderall'lll\1~·
luod an a lon1 and often 11111 Jalllor)' of troaUDOnL otpeopll wlm dilabWdot Ia dlt period pdGr 10
federal ftlad'DJ aDd ovenlaJI, pcoplo wtdl dtllbtltd• llrODilJ auppan a oanUftutd lldenl I'OIIID
manitotlaa aad onf'orComeftl or &a. w.Jicald PlOP•· lndlld. IL wu widuprNd mllb'allmlllllld
&buR orboaddar,. t111t bu lod to Jncrcued rocSmiiDvol'llllllll and cwomam 1brouaJa 1111
Modk:alcl propaaa. Tbo pu& ~ ~ ptop!D wltb dlllbWlJea tonlhlcJowlgroa& d..., for
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CCD Hftlih TaiiC Foroe
FROM:
Jeff Crowley
D1te:
FebNary 2.1881
Re:
Medicaid Letlllra .
I am enClosing a copy of a tetter that the oo-ohllrl of the hMith 1nd long
term HI'VtQea talk forcea hiYieent ta: Gingrtoh. Dole, A.rf'rwl, DeLay,
Gephardt. Stenholm. ChlfM. Breaux. Ouchle, Kaaeeblum and Jetrorda.
••••
........
......
....
• p JL)Pl •
' We encouraoelndlvll@lill or;anlutlona to use thlllettar u • ·temptate and
Hnd your own lettera.
---
1am allo enctoeing an outline of the lateat •oomproml•• propoul from
the governor~. 1atrongly encourage paopb 10 make oalll to
e.
• 'Niahlngton offlcel of govemcn regllfMinO your conoem with the ·
propoul. I haYI only given a O~riOfY glanoe at the Oullne, but It lookl
lllct 1 modlftld bloclc grant. It allo allawlotatel ta clatlne dlllblllty.
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Finally, I allo auggllt that people piBI odl to the 'Malta HOUH tD
uplaln why thll propoul wauld be unaooeptab'e and harmfUl to people
with dlubDWII.
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·
PI••• caD me If you,:V..V. any que1tionl.
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TO:
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TO:
• The Honorable Leon Panette
The Honorable Donna Shllala
The Honorable Allee RMin
The Honorable Harold lckea
The Honorable Carol Raaco
· The Honorable ChriS Jenning~
The Honorable Marlyn Yager
Me. Patay Fleming
Mr. Jack Ebtler
Ms. Nancy-Ann Min
·1
FROM:
Jetfnly S. Crowley, M.P.H. S I·
Astociate ExecutiVe DlrlciDr
U111l ...... IIW
IPr "-DC
DATE:
January 30, 1888
.. (Ill) . . . .
Re:
AIDS Coalltton Letter to the Preeldent on Medicaid
....
...........
--.,.
Via Facaimile
Attached, please find another AIDS coalition letter regarding possible changes to the
Medicaid program. We appreciate the President's continued leadership In ftgl'tlng to
protect Medicaid, and would like to reWorce the Importance we place on four criUcal
188U88 that we have learned are vulnarable to being c:ttangecl:
•
Protect the current federal definition of dlablllty
The cunent SSA definition for determining dl~ must be maintained for eligibility
determinalona for Medcaid. People who tutr. train alcoholiem and/or drug addiction
mutt not be excluded from eligibility for Mad1cllcl.
ProtKt an lndlvlclual'a ace•• to federal courta to enforct provision• of
the Medicaid atatute
The experience of people with AIDS ln fighting for Medicaid eligibility end to accesa
aervlces hat demonetrated that individual& need acceae to the feeleral couna to
ensure that they receive the health coverage for which they qualify.
•
•
Protect conaumtr choice of managed care plene
Choice among provider plana Ia nteelllrY In order tD create market pressurea tor
provldn to locate In ..,derlerved areae and to ClUte Incentives for plane tc add1'881
systemic problems such as insufficient capitation rates. poor oversight and poor
monitoring.
..
Protect current comparability and atatawldenets provlelone
Comparability of benefite among el f)enefieleriH and the same tevel Of aervtces
throughout a state are fundamental prln~as of fairness that should not be altered.
�February 7, 1998
The Pretldent
The VVhite Houee
Washington, DC 20500
Dear Mr. Prealdent:
We are writing to expree1 our extreme concern regarding the National Oovemol'l
Association (NGA) Medicaid reform propoaal. We are appalled at the Implication from your
recent comments that you may eupport this plan.
over the past few months, we have written to you on numeroua occasions regarding the
need for a strong federal commitment to protecting the guaranteft to high quality health
care for low-Income Medicaid beneficiaries-and we have frequently recognized your etrong
leadership In advocating for thit program. The NGA plan would be dovaetetlng to people
with AIDS and other Medicaid beneftciartea. The governors' plan repeals Title XIX-the
backbone of a meaningful guarantee to health coverage for etglbte beneficiartes-and It
does not meet any of the criteria you have established for acceptable Medicaid reform.
The NGA proposal IS nothing more than a block grant. which you have opposed, dreaaed
up in language meant to provtde assurances and guaranteeA that are, In fad, m•anlngleaa.
If you were to support thla plan, it would betray the cammitments you have made to people
with AIDS at your December summit and on eeveral other occaaione. ·
·
We beDeve that there are threo altical queatlona you must ask yourself In assessing any
reform plan:
\Nbo Ia QQ\IIrad?
The governors' plan taRa the beneficiary beCause it would allow states to define
disability for purpoMt of Medicaid eligibility. The NGA plan containa aeauranon that the
disabled would receive coverage. By removing the existing federal dlsabilty definition.
however, current disabled beneftclar1ea are vulnerable to becoming ineligible. Indeed,
before we had the current federal diaabmty definition there were great inequities In acceae
to MeolcaiCI among the disabled. It Ia easy to imagine that aome states would aeek to
define disability in a way that intentionally e~edudea some or all pP.Ople with HIV/AIDS.
\Nhat MNicea are covered?
The govemorw' plan falle the beneficiary because it would repeal current law provisions
related to atatewldeneee. comparability and amount, duraUon and scope. It 18 not enough
simply to state that a specific benefit wiD be provided. Benefits and services must be
provided equally In an parts of a state. benefits must be provided equally to all categories
of benetlciartea, and they must be provided in amounta determined by a health care
provider to be effective and medically necessary. State& ahould not be free to arbitrarily
limit 8CC881 ta MNices.
·
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�How •ro jnd!vjdyala onoyw gf reco!ylng the coverage fqr wblcb tney qualM
The govemore' plan falla the beneficiary because it takes away an Individual's private
rtght of actiOn. Tnla provision of the law Is abaokltely necessary to enaure that individuals
have recourse If a state does not provide them with a service for which they qualify. A
guarantee to coverage or beneftta it relatively meanlngleae unless there Ia a means to
enforce lt. People wilt, AIDS have uted a private right of action to fight dlecrlmlnatlon and
to gain the same access to prescription druga and other servicea aa other Medicaid
beneficiaries within their etatea. If these provisions are lost, people wltn AIDS could find
that, on paper, they are guaranteed access to a medication or a service, but In reality it II
denied to tnem.
It is essential that any reform plan be able to provide satisfactory anewe,. to all of theee
questions. Falling even one, than the proposal should be rejeotecl. Medicaid peymente
represent the federal governmenra largest form of financial support to the states, totaling
neorty $100 billion per year. we believe that you and the Congress owe It to tne AmeriCan
people to Insist that states are held accountable for the federal money they receive.
We urge you to stand ftrm, as you have done to date, in oppnalng the currant NGA
Medicaid proposal and any other plan that could threaten health care for mllllona of
vulnerable low...incoma American•.
Slnceroly,
AIDS Action counctl
AIDS Polley Center for Children, Youth and Families
Citlea Advocating for Emergency AIDS Relief
Gay Men's Health Criala
Housing Worka
Human
Rlgh~
Campaign
National Aaaociation of People INith AIDS
N~:~tlonal
Minority AIDS council
Project Inform
San Francisco AIDS Foundation
Texas AIDS Network
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January 30, 1QM
The Preaident
The White House
waanlngton, DC 20000
Dear Mr. President:
to protect the Integrity of the
Medicaid program and we would like to urge you to remain I'8IOiute in opposing deltructtve
ohangea to the program, including proposals for which varioul aovemora have been
ad'locating. Although we have already written to you on numerous occaslona, we would Uke
to share with you the pcrapeotlve of people wtth AIDS • you consider an ever changing set
of reform optlona. VVhle we support efforts to lmprow the Medicaid program. we urge you to
continue to:
We are writing regarding your strong leaderehlp In fighting
prqtact the cyrrent fedal'll dtflniUgn of dlaabllll¥
Over the past few months, various proposals have circulated to permit states to define far
themselves what Is meant by a disabftlty for purpoaes of eligibility tor MecUcald. FaDing that,
others have advocated for modlt/lng the federal definition of diaabllty In a way that would
exclude persona whose alcoholem or drug addiction II 11 matertll factor In a disability
detenninatlon. We atrongly oppo11 any changes to the currant federal definition of dlaablllty
for eligibility for Medicaid from the definition of the Social Security Administration (SSA) for the
social 11ecur1ty dlaabllty lnGOme (8801) and aupplemental HCUrlty Income (SSI) pragrama.
Furthermore, any federal defnltlon of dlaabUity must be expllcllly deelgnated as aloor. Statee
should retain the nexlblllty to use a broader dlubUity definition, ad their dlecretlon.
We eupport the SSA definition of disability not because It 18 a perfect ctaflnltlon, DUt becauae
It Is a practical compromlae that haa worked for the p•t thirty yean. It Ia broad enough to
cover persona Whose disability makes health care absolutely necessary, but It alao IUfftclently
na"ow to •xclude persona whO would not otherwise Qualify for Medicaid beneftta. In many
regards, this definition actually does not sem people with H!V disease well. Thla 18 becauee
the majority of peoplo with HIV disease are l~llglbkt for Med'IC8id benefits until they ara In the
. advanced atages of their Illness (genera~ requiring an AIDS dlagnosi8). In effect, people wHh
HIV diaease who are aaymptomatlc and who could moat benoit frorn .relatively low-coat
prophylactic treatment8 are denied coverage, and they only become eligible once they are
symptomatic and tnen require more expensiVe medlc:allnterventiuna.
Nonetheless, the current SSA dlaabftlty deflnllon has been tested over many years, and It
satisfactorily defines persona with various types of disabilities ranging from people with AIDS
who express a wide variety of symptoms to persons who are physlcaOy disabled and
functionally impaired, •• welt as persons who have mental Impairments. The SSA definition
is the best definition that is viable In the current political context end It ehould be uaed as a
minimum floor for disability determinations.
we oppose chan~es to the Medicaid atatute that would give atatee claoretlon to deflno dlsabUity
because this could only translate Into a loA of co\lerage for diaablec:llndlvlduals. Relative to
other categorieS Of benehelartea, the disabled are often the most vukler1:1ble to loas of coverage
and are frequently the least organized to counter efforts to deny them coverage. We also
..........________________________
)_
�nppose chanoea to the Medicaid atatute that would deny coverage to persona whole
alcoholism or drug addiction Is material to their dlaablllty Dtcause thla would alao ex\iiYde
coverage to people In dire need of health care. Thla particular policy proponl really amounts
to a moral teat of our society'& commitment to Ita moat vulnerable citizens. Pe,.ona whO autrer
from alcoholism or drug addiction Include many people living with HIV disease. Thle category
of beneficiary tends to be the poorest among the poor, and the lo8a of Medicaid eligibility would
place these Individual• at r1ak of being oomplotely neglecttd by society. While we will only
support changes to Medicaid that protect eligibility ford persons who are currently er,lble,
persons who 8Lifter frOm alcohonam and drug addiction are eapeolally In need of federal
protection.
Recently. In debating welfare refonn, a considerable amount of time was spent on a national
dlscunlon of whether or not It i8 appropriate to give cash benettt8 to persona Who are
alooholicl or are addicted to druga. The thinking on the part of aome II that cash beneflta eerve
as an Incentive to purchase mora illicit aubstances··With the federal government, In effect,
aupportlng an individual'• addiction. Leaving the merits of thlalne of reasoning aside, thla
88 me argument clearty cannot be made concerning accees to health care benefits. It would
require perverse logic to think that people would make themaelv88 alck juat to qualify fer health
benefits. Medicaid eligibility ahould be a route for overcoming one's addiction, but it In no way
does acceM to health care fOster further drug dependencoe. We urge you not to aupport any
changes to the Medicaid program that would deny elgblllty to any category of currently eligible
beneficiaries.
... .
prottct en lndlyldyal'a ace•• ta fldaral courtl to anfarct prqylalooa Qf tba Medicaid
~~.~
People with AIDS, unfortunately, have faced a long history of dl8crlmlnation. Various provisions
In the Medicaid statute and varlou. other fed•rallawl, not the leaal of which Ia the Americana
with Dlsablitiaa Act, have been Instrumental In fighting and winning ICC88I to Medicaid beneflla
and access to vnal aervlcea, including prescription drug coverage. It would be axaaaalvtly
harmful to beneftcfartes if the Medicaid statute were reformed In any way that linita ICC188 to
federal courts. An indiVIdual's private rtgnt of action Is an absolutely es51H1lial enforcement
mechanlam that holds states and providers accountable for delvering the care that they must
provide.
.
prqtact conaumer chalet of managtd care plana
We are aleo concerned that your Admlnlstra~tion may eliminate from your Medicaid proposal the
requirement for choice among provider plans. lneutncient capitation rate&, poor oversight and
monilo• ing, and poor plan administration are ayetomlc problems that would be laolatad from any
malbt presaure to improve If there Ia only one managed care plan within a state. In order to
create a MediCaid system that 18 efficient and lhat provldn high quality cere to ita beneficiaries,
Individual consumers must be able to choose among managed care plana and they muat have
a choice of providera within a plan.
Many of the problems that will arise regarding inappropriate health care or substandard care
are not caused exduslvely by individual health care provider&. Additionally. our current health
care system is problematic In that there are great dlsparltlel In provider acceaa tom one
community to anothor. One part of a city may have an ext.nslve choice of provktara, whereas
another part of the same city may have no providers. Thla problem II even greater when
conalderlng diaparltlea between urban •nd rural areaa and among historically und•rwrvecl
populations, such aa people of color. In addition to a ct.olce among managed care plana,
�IO:
information Ia necessary to make Informed choices among plana. This Information muet be
both culturally aensitlve and appropriate for the diverse audience of benetlclarle8. Informed
conaumore ohooatng among various plans are needed to make provider plana responal~e to
their beneflclar1ee and to exert pressure on plane to locate provldera In underaeNed areas.
Given the enormous ahare of foderaf ,.aourcet that support the Medicaid program, the federal
government must ensure a greater level of accountability by lnolstlng on choice among provider
plana.
prptact current compal'lbllltV and atatewldena• prarl•lo•
Ttle prlnclplea of comparability and atatewldeness are fundamental notior" of fairness ttlat
should not be altered. It 18 particularly dleconcerting that governors who profeA a deaittt to
improve their Medicaid pmgrams have advocated for the freedom to provide a aervice or
benefit In one place that they would not provide in another. Altemately, they seek flexibility to
provide a particular bonefit or aervtce to one category of beneficiary that theY would not provide
to another. Thia Is a nonsensical policy position that does not merit your support.
Throughout these paat months, many of our nation's governors have asserted that they could
do a better job of administering their 1tate Medicaid programa if they are given greater ftexlblllty
by the federal government. However, greater flexibility In admlnletratlon Is far different from
repeaUng the tiaalc protections that go to the hean Of tne Medicaid p•·ogram: guaranteed
aUglbi&ty to a guaranteed package of health benefits, and the means to enforce the law.
Thank you, once again, for your strong leadership on behalf of people with AIDS and other
Medicaid beneficiaries.
Sincerely,
AIDS Polley Center for Children, Youth and Famlllea
Cities Advocating for Emergency AIDS Relief
Gay Man's Health Crlala
Housing Worka
Human Righta Campaign
Nattonal Association of People with AIDS
National Minority AIDS Council
Project lnfonn
San Francisco AIDS Foundation
Texas AIDS Networic
Worker Optlona Resource Center
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White House
Medicaid Briefing
·
Document
September, 1. 995 ..
Revised 9/7/95 -- 12:15 p.m.
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White House
Medicaid Briefing Document
Outline
Page
I.
II.
Ill.
IV.
V. ·
VI.
VII.
VIII.
IX.
X.
Overview
State and Federal Partnership
Health Care for Children
Health Care for People With Dis~bilities
Long-Term Care and "Medigap" for the Elderly
Medicaid Coverage and Spending
What Medicaid Covers
Medicaid Spending Growth
The Republican Budget Resolution
The President's Plan
2
3
4
7
8
10
13
17
20
32
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Overview
• Medicaid covers over 36 million Americans.
• Medicaid provides three types of critical health
protection:
·
.
.
~
Health insurance for low-income families and people
· with disabilities.
·
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Long-term care for older Americans and people with . ·
disabilities .
. ..- Medigap coverage that helps low-income elderly fill in
the gaps of the limited Medicare qenefit.
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State and Federal
Partnership
• ln-1995, Medicaid will spend $15.6 billion: states
will pay an estimated $67 billion and the federal
government will pay $89 billion.
.
• States administer Medicaid under broad federal
guidelines, and rec~ive federal matching
.payments related to each state's per capita
.
1ncome.
3.
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Hea·lth Care for Children
• Medicaid currently covers over 18 million children: one out of
every five.children in the nation.
• About 1/3 of all babies born in the United-States are covered
by Medicaid.
• Over 90 percent of children with AIDS are covered by
Medicaid.
• It is important to note than an August, 1995 study has found
that the U.S. leads the advanced world in the percentage of
children in poverty. It also points out that poor children in
America are poorer than poor children in almost all other
industrialized nations [note chart on next page].
4
�Child Poverty Rates in 18 Countries
Finland
Sweden
Denmark
Switzerland
Belgium
Luxembourg
Norway
Austria
Netherlands
France
Germany (West)
Italy
Umted Kingdom
Israel
Ireland
Canada
Australia
United States
0
5
10
I
15
20
25
Percent of Children in Poverty
--
Source: Center for the Study of Population, Poverty, and Public Policy, August 1995. Poverty is defined as percent of children living in families with
adjusted disposable incomes less than 50 percent of adjusted median income for all persons. Income includes all transfers and tax benefits. Year
_fn.r: ..c..:a"'h.Adirru:atA j~ ffiOSfrecentdata available. .
5
�Health Care for Children
• Children can be eligible for Medicaid if
they are:
. . In a family receiving Aid For Families and Dependent
Children (AFDC).
. . In a family with incor:ne at or near poverty (varies by state) .
. . Disabled and poor enough to qualify for Suplemental
Security Income (SSI) .
. . In some states, impoverished by rnedicar expenses or
·living in a medical institution.
6
�Health Care For People
With Disabilities
• Medicaid will cover 6 million people with disabilities in 1995.
• Medicaid is the primary insurer for people with disabilities,
since private insurance is not affordable for people with
pre-existing conditions.
• Persons with disabilities can get Medicaid if they:
.. In some states, have been impoverished by medical expenses .
. . Reside in an institution and cannot afford the full cost of care .
.. Are poor enough to qualify for SSI .
. . Are entitled- to Medicare as a S9cial Security beneficiary and have
income at or slightly above poverty.
7
�Lon -Term Care and
"Me igap" for the Elderly
· • Over 4 million older Americans will be covered by Medicaid
in 1995.
• Although most elderly are covered by Medicare, its benefits
are limited. Because_ of high deductible-s and copayments
and no prescription drug coverage, the Medicare benefit is in
the 20th percentile of benefit packages i·n the country.
• Medicaid pays for the services not covered by Medicare by
paying for premiums and cost-sharing for all elderly at or
slightly above the poverty threshold.
• Medicaid also covers long-term care for older Americans
_ who have spent most of. their resources and income on
health care.
8
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Lon -Term Care and
"Me igap" for the Elderly
• Older Americans can get Medicaid if they:
. . In some states, have been impoverished by medical
· expenses .
. . Reside in an institution and cannot afford the full cost of
care .
... Are poor enough to qualify for SSI.
... Are entitled to Medicare and have income at or slightly
above poverty ..
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Medicaid Coverage and
Spending ·
• States and the federal government will spend an
average of $3,700 per person _on Medicaid in
1995.
• However, spending varies for the different people
and types of coverage in the program. Medicaid
spends about:
·
• $1 ,4oo·per child.
• $8,300 per person with disabilitie,s.
• $9,800 per elderly recipient.
10
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Medicaid Coverage and
Spending
• Only 28 percent of the people enrolled in
Medicaid are. elderly and disabled, but they
account for 69 percent of the spend-ing.
• Conversely, whi~e 72 percent of the people on
Medicaid are children and_ their families, they
account for only 31 percent of the, spending.
• These contrasting statistics are due to the fact
that health care costs for the elderly and the
disabled are much more expensive than· costs for
chil-dren and their families.
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11
�Medicaid Beneficiaries
and Expenditures: 1.995
Beneficiaries
Expenditures
Millions of People Percentage
Billions of Dollars Percentage
18
51%
Children
$25
18%
Elderly
4
12o/o
Elderly
$43
32%
Disabled
6
16%
Disabled
$50
37%,·
21%
Adults.
$18
13°/o
Children
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Adults
8
.
TOTAL
36
Source: CBO estimates for fiscal year 1995..
* Excludes disproportionate share and administrative costs ($20 billion).
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TOTAL
$136
,
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�What Medicaid Covers:
States' Flexibility
·• All states cover a minimum set of services, including
hospital, physician, and nursing home services.·
• States have the option of covering an additional 31
services, including prescription drugs, hospice care and
personal care services.
• States' flexibility in designing their Medicaid program is
highlighted by the fact that over 50 percent of Medicaid
benefit payments in 1993 were for optional services and
populations selected by the states.,
13
�What Medicaid Covers:
Long Term Care
• Medicaid is the largest insurer of long-term care for all Americans,
including the middle class. Medicaid covers 68 percent of nursing
home residents and over 50 percent of nursing home costs.
~
• Medicaid covers skilled nursing facility care, intermediate care
facilities for the mentally retarded and developmentally disabled,
and home~and-community-based services.
• Although most long-term care spending is for ,institutional care,
Medicaid has made great strides in shifting the delivery of services
to hom~ and community settings.
• Cost-effective community-based long-term care ·increased from 13
to 21 percent of long-term care spending between 1990 and 1995.
.
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�_;
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A Critical Safety Net ·
• Medicaid has slowed the rapid increase in the number
. of people without health insurance_.
• Medicaid coverage is especially important since
employer coverage has been declining. Between 1988
and 1994:
,., The percentage of Americans covered by employer-sponsored
health insurance fell from 67 percent to about 61 percent.
~
Medicaid coverage increased from 9 ·to 13 percent.
~If
Medicaid coverage had not increased, there would be
more uninsured, more uncompensated care, and rnore
cost~shifting.
15
�.J
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•
Changes in Insurance
Coverage: 1988 to 1994
1988
1994
Employer 61%
Employer 67%
*
*
Other 9°/o
Uninsured 15°/o
Other 10%
Uninsured 16%
Source: The Urban Institute, February 1995. Includes only the non-elderly, non instutionalized population.
* Includes individually purchased insurance and other public insurance.
�Medicaid Spending
Growth
• CBO projects that aggreg·ate Medicaid spending will
grow at an average rate of 10.2 percent between 1996
and 2002.
~
This is lower than the growth of expenditures in the early
1990s, when the average rate was cl·oser to 20 percent.
• Medicaid spending growth results from three different
pressures: increases in the price of health care, utilization
and intensity of health care, and the number of people
covered.
17
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Enrollment Growth Drives
Medicaid Spending
Growth
• ·Medicaid growth is largely driven by enrollment growth, especially
_among the elderly and _disabled. According to CBO, about 45
percent of the total spending increases results from a rising number .
of people in the program.
• The number of Medicaid beneficiaries is projected to grow by 3.0
percent a year between 1996 and 2002 -- more than three times
the general population growth, and twice the growth in the number
of Medicare beneficiaries.
• Medicaid enrollment growth reflects the fact that the popu_lation is
aging. The number of aged and disabled beneficiaries is growing
at 4.6 percent per year-- almost twice the rate for adults and
children, wh.ose projected average growth rate is 2.4 percent.
18
�•
r-- --
J
•·
Medicaid Spending . .
Growth Per Person 1s Low·-.
• Since Medicaid enrollment growth is hig-h, it distorts the
overall Medicaid spending growth. Thus, when
·
comparing Medicaid to other health programs, it should
be done using Medicaid growth per beneficiary.
• Medicaid spending per beneficiary is projected fo
grow at 7 percent per year between 1996 and 2002.
• This growth rate is the same as the projection of the
private health insurance spending per insured person
under the CBO baseline.
19
- --- -- - -
�~
Jl
..
.
.
The Republican Budget Resolution:
·Unprecedented Cuts
.
• The Republican Budget Resolution would cut Medicaid
by 20 percent-- $182 billion over the next 7 years.
• The Republicans would achieve these savings by
imposing a 4.5 percent average annual growth rate cap
on aggregate spending. That is less than enrollment
growth plus inflati-on.
• Taking enrollment growth into account, ~he
Republican Budget would limit growth in Medicaid
spending per person to only 1.4 percent annually.
20'
�,. -. - - - - - - - - - - - - - - - - - I
•
J
-
---- ·----
•
The Republican Budget:
Unprecedented Cuts
• Republicans say their Medicaid proposal is not a
cut. However, a 1.4 percent cap on growth per
beneficiary is a cut in real terms. It is:
-~
80 percent below the projected private health spending
per person (7 .1 percent).
~
75 percent below projected medical inflation (5.3
percent).
~
50 percent below the projected consumer price index (3.3
percent).
·
·
21
�.
~----------------------
•
J-
-
•
-
--------------
-
Medicaid Growth Per Beneficiary:
Effect of the Republican Proposal
..
1996-2002
10.0% , . . . . - - - - - - - - - - - - - - - - - - - - - - - .
7.0%
7.1%
8.0%
6.0%
4:0%
2.0%
O.O%
L...---
Current
Medicaid
Source: CBO Projected Baseline for Fiscal years 1996-2002.
Private
Sector
_
Republican
Medicaid
22
�----------------------------. .
.
----.
·--
-
~
Republican Medicaid Spending Limits
Don't Keep Up With Inflation
Growth Rates
12% .------------~---.--.....--~r---~--r--~--..
ap
10%
8%
6%
4%
2%.
0%
1996
1997
1998
Enrollm~nt
2000
1999
2001
.2002
and CPI Medical CPI GOP Bu_dget
1~1
I
CBO projected annual increases, fiscal years 1996 - 2002.
I
•
23
.
--
�•
.A
•
The Republican Budget Resolution:
Options for Reaching this Level of Cuts
• There are three ways for states to cut this much (20
percent) from Medicaid:
... Reduce benefits or provider payments .
... Eliminate coverage for people on Medicaid .
... Find savings through increased efficiency and productivity.
24
�1··
~.The Republican Budget
Resolution:
Efficiency Can Only Go So Far
.
.
• States have already constrained the growth of Medicaid .
spending per beneficiary to the same growth rate as the ·
private sector.
• While states can improve productivity and efficiency,
savings from these activities do not come close to $182
billion that the Republicans are seeking.
25
�'
A
•
The Republican Budget Resolution:
Managed Care Savings Are Limited
• CBO estimates a one-time, 5 to 15 percent savings from managed
care for non-disabled, non-elderly adults and children.
• States have already aggressively pursued managed .care. About
one-third of Medicaid adults and children are currently enrolled in
managed care. And, under current law, states are expected to
enroll 50 percent of this population in .managed care by 2000.
• There is little Medicaid experience with managed care for the
elderly and disabled -- who account for almost 70 percent of
Medicaid spending. Therefore, it is unlikely that CBO will score
significant savings from this part of the program.
• Thus, managed care cannot be expected to achieve the 1.4
Budget.
percent growth cap per
beneficiary in the Republican
.
.
26
�•
A
•
The Republican Budget Resolution:
People Will Lose Coverage
• The Urban Institute estimates that even if states were able
to achieve half the needed savings from reducing services
and reimbursement to providers, states would still be
forced to eliminate coverage for 8.8 million people in 2002 - .
alone, including:
.
.
... Families: 6.3 million adults and children.
_ ... Elderly: 920,000 older Americans .
... Disabled: 1.4 million persons with disabilities.
• This translates into a 19 percent cut off of current
projections. In other words, almost one iri five
beneficiaries would lose coverage.
27
�•
,a
•
The Republican Budget Resolution:
Children Will Lose Coverage
• Currently, 20 percent of the nation's children rely on
Medicaid for their basic health needs .
. • Medicaid pays for immu-nizations, regular check-ups,
and intensive care in case of emergencies for over 18
million low-income children.
• Under the Republican Budget, 4.4 million children
would lose Medicaid coverage in 2002.
28
�•
..3
4
<
· The Republican Budget Resolution:
.Nursing Home Residents Will Lose
Coverage~.
• Over two-thirds of nursing home residents rely on ··
Medica-id to pay the staggeri~g costs of nursing home
care.
• On average, families pay $38,000 .per year for nursing
home care..
• A deep cut in Medicaid would mean that about 350,000
residents of nursing home could lose coverage in 20028
• For many of these residents, there is _nowhere to turn.
Two-thirds of nursing home residents are elderly
women, and a majority have no spouses. .
29
�.-.
Nursing Home Care Expenditures:
·
By Payer, 1993
.
Medicaid
52%
Private 4%
Medicare
9%
Other Public 2%
Out-Of-Pocket
33o/o
SOURCE: Health Care Financing Administration
30
�. ... .
The Republican Budget Resolution:
~
States at Risk
• States could on,ly avoid these actions by increasing
their spending by 40 percent in 2002 -- by raising taxes
or cutting other critical state spending.
• States At Risk From Inflation And Recession. When a recession
occurs, the number of working people who lose health insurance-and
apply for Medicaid can rise dramatically, increasing program costs. ·An
aggregate growth cap would not respond to this change in state need.
•
S~ates
At Risk For Cost Of Aging Population. As the population
continues to age, the growing need for long-term care services will put
increased stress on the Medicaid program. Under an aggregate
growth cap, states with large elderly populations will bear a ·
disproportionate burden.
31
�. ...
_.
The .President's Plan
• The President seeks $54 billion in Medicaid ·
•
sav1ngs over seven yearsa
• The President's plan results in a more realistic
growth in spen_ding per beneficiary qf 6.3 percent.
• This rate is much closer to the private sector
growth rate of 7.1 percent-.
• The President's savings from Medicaid are less
than one-third of the reductions called for by the
Republicans.
·
32
�. ......
The President's Plan
~
The President's plan constrains Medicaid growth
through a mix of policies, including:
• Eliminating unnecessary federal strings on states by allowing
states to pursue service delivery innovations without seekin_g
federal waivers and by restructuring the Boren Amendment.
• Reducing and better targeting federal payments to states for
hospitals that serve a high proportion of uninsured people.
ar Limiting the growth in federal Medicaid payments to states for
each beneficiary (i.e., a per capita cap), so that states do not
need to reduce coverage to achieve savings.
33
�••••
"'
The President's Plan
• The. President's Medicaid plan is preferable to the
Republicans' plan because:
... It protects states from changing economic and demographic
conditions·.
.
.
... It gives states flexibility to manage their programs efficiently and
responsively.
- ... It protects against increases in the number of uninsured, thus
avoiding increases in uncompensated care and cost-shifting .
... Together with the President's health reform initiative (insurance
reform, small business purchasing cooperatives, and insurance
assistance for the temporarily unemployed), it protects and expands
health care coverage. ·
·
34
�Tuc. oas:p.ws:~
IALSO IN WASHINGTON
.
.
I
Senator revives ill
man
EN·
~~e::._~:=~!fcb!s. ~ -~t-,5._
PACKWOOD -DIARIES: The SeDate ethics
.. · ··\
.
=~~':::e:::s:tS:..~
·Gramm intended to send GOP money to Packwood in
Sen. William Frist, R· violation of contribution ilmit& "The committee bas
Tenn., did . the ultimate in reviewed this matter and bas concluded that no fur·
constituent service Thursday ther action· will be taken by the committee," conclud-
~:~.:1:th~::, ~e~~li=TifaE:
Congress. Tbe man, idenu~
signed last week after the ethics panel voted to expel
tled as Graeme Sieber, was him for sexual and omcial misconduct.
·
on bis way to Frist's omce to FBI CRIME LAB: Attorney General Janet Reno· ·
talk about budget cuts in chil· Said Thursday •e bas ordered the Justice Depart·
dren's services when he col- menrs inspector general to investipte allegations that
lapsed. Frist, a heart surgeon, FBI testimony on crime lab evidence, in 50me cases,
USA TODAY .· was .in bis oflce when an
is slanted to help the prosecution. Special Agent Fr&
FRIST: Is also a aide
another senator's deric Whitehurst's charges came to pubUc attention
heart surgeon
. omce summoned him. Frist after O.J. Simpson's defense lawyers wanted him to
_ · _cleared the man's airway · testify againSt another FBI analyst. Whitehurst bas acand inserted a tube so rescuers could get him breath· cused analyst Roger Martz, who testUled in the Sim~
iDg. Sieber was listed in critical condition late Tb\u's- son case, of slanting lab tlndinp in other cases. A reday at George Washington Hospital Center in Wash- view of 250 cases bas fo~d no problems, the FBI said.
..
·.J~---_
.'-~-CLP-_•·_·r£
-_
-_-_-ftA·_
.•_.-_·-_:_- _-__
_ _
from
...
..
;.,..
·.•·
,--1'.
lit N.C., 'Baby .Love'' program .t+!L ·....:.
gi~~~
· ··~ a goo(r name . \f~h!:0;
By Richard Wolf
..•::..r.\i~i·?:.--. . ·._. : .
moststudiespredictonlymodestsav·
-H\~-~.:::· . .-:_~~-
inp. In North.Carolin8, a state pro-
USA TODAY.
MOUJ'ff AIRY, N.C. - If Brittany
.Semones·~ gives birth to a healthy
baby next month, she wm·have Medicald to thank.
. .
..
With one miscarriage beliind her
and considered a risk for another,
Semones quit her job. in this rural
community after becoming pregnant
· and opted for bed rest. .Husband
-~.3rty'!! ~ ~s 8 machinP. operator
comes with .health insurance- but
not nearly enough. . _
So the couple, who earn about
$15,000 a year, appUed for Medicaid
.: .' . .
'·-..
. _. ·
.;,~v!~~~~: ~cal .dau~--~-:b~ninl
. paid for surgery,. two hospital visits, caseload and more generous bene-
"== ·_
check-upS and medicines. "WWthout
;::,=:s~~:S
mother. "It does a great job."
tlts have combined to keep Medicaid
1
~ m.PP~~;~::~ii~J.r~~!:ri~~;Y::-· -
ersN:':
than Baby Love, which began in 1987... -~~;;;::_,• ~-:. =.~ ,~·-.::.: ". : .·
and covers 50,000 pregnant womeJL: ::~2\&:¢/:·.;.--;,n::< : ~
0
=~==~o:e=~- ;::~u:=n:ck
back ~~= ::i~: .:o/~13~:i(·-x·-~·J_· ·.
to .run the program, which gobbles not cut
on the needs of the unin- · : :·!.f~";t·· ,:_· · '·i.
._ But ProsrmDs Uke -Baby Love up 20% of most~ budgets.
cOuld lose funding if Congress folMost of tbat goes to the elderly
lows through on plans to cut $182 bU· and disabled, particularly for nursnon- 30% of projected spending- ing-home and lilstltutional care. Tbe ·
trom the federal-state health-care · average annual c:cst for a senior dti·
program-by 2002.
., : \ · .
·. zen under Medicaid is more than _dependent child weren't covered un- ·:
Uilllke Medicare, which is guaran- $8.000; for a chnd, $1,000.
. . der her parents' .private insurance; _,. -..~·,~, ir
·
teed to everyone in old age, the MeBudget-cutters in Congress say the Nichols qualiled for the Baby Love · \ ..::;r,o
dicaid program is designed for the cuts am be made without jeopardiz- program. She bas spUt from !dlyssa's: ::~-.
poor and disabled of any age, and iDg health care for the poor, but they father and- works part time. without·-:-...,~; .. . _ ,_.,
consisls of a variety of separate pro- would leave details to the states.
; Medicaid, she would "probably go orr.·.~~::"':
··. ·
grams such as Baby LOve. · · .
"We can't continue to let the pro- welfare." ·
· - - ·• c ~- ..,: .
. This month, GOP senators and gram grow as it has been growing,~ . But if Medicaid funding is cappf;ci,'~ ": .
· House members hope to come up . says House Commerce .Committee most state oflciaJs agree, something
with a new formula for Medicaid Cb81rman Thomas BUley, R·Va., who will have to give..
-~ : ·• -. ., ~--·· --·.;·-.:~~~~~~'" .
that sendS le!s money to the states wants to trim Medicaid inla1:lon to · _ In:Nortb Carolina,' Medicaid infla... :._,:;;>:
with fewer ~ atlached. ·SUch a 4% annually by 2002. . · :·: .· :·., , .- .-_ .tion hit double digits in 1988, as
;~
"block grant"- apprOach faces stUr
Medicaid DOW pays to deUver one . caseload expansion. Since then, costs·,:,.·-.-~
opposition-from Democrats·and in three babies in the USA and criv· · have risen at least14% annually, to.-,,:·'•\: . . .~.
some GOP moderates.
· .. . . .eis the infantfor at least a year .:.... _at·. $3.5 blllion; the caRload grew at,·' ··,}~~--- ,~-~-~- ;:·~··~t~&
But even if' the structure of Medl· an average cost of $7;000 per child. least 13% annually until 1994. As a . . : ':";':. ':.·.:·:- ':~.::~ ·· .':: .
caid is retained, big cuts are Ukely: In most states, pregnant women and .· result, Medicaid rolls have more· .;;t,%·!,,f;'•.•,,;';':; ':.~_>:· .·
UnUke Medicare, which is staunchly children are covered up to 185% of than doubled in six years, to 1 million
:>'~ -;_ , ., .. ,
defended by the powei'ful senior dti· the federal poverty level, tar beyond · people.
_:
. .. ·
>:!'.' '< ,.. ·~: :..;· • ·
zens' lobby, Medialid is politically federal requirement& Most also of·
The population boom has been felt
vulnerable as well as lnancially un- fer enhanced maternity packages, most by those who treat pregnant
sustainable:
including education and home visits. women and children. About 42% of·.·
IJJJ>,Among its 36 million recipients,
If the· GOP· succeeds in sending all births in North Carolina are cov·
nearly three-fourths are mothers Medicaid to the states . as a block ered by Medicaid.
..
and children who quality by meeting . grant, it will be lett to people Uke
At Northern Pediatrics .in Mount
income and eligibility standards Barbara Matula, North Caronna's di· Airy, 40% of Roiand Boyd's practice
made more generous in the paSt dec- rector of medical assistance, to lnd is paid by Medicaid;
ade~ Unlike the elderly and disabled
the savi~ And there are only so
"Probably most of mine are workwho complete the Medicaid ellen- many places to look:
ing poor, and they're trYing. I like
tele, many feel this group lacks clout
IJJJ> Moving more Medicaid recipi- that," Boyd says. "For the kids. it's
"The conventional .wisdom is that ents into managed-care insurance good, because they can't decide who
nursing homes and seniors will have plans could save money, although they're born to."
·
·'? ;:
r
did:<
'·
-.
gram that matches benetlciaries to · :.r:v'::..-:·:' .'_.:
primary-care doctors already has· - . <~.;ir·
· .cut hospital costs. . . . - · ..~\.}fi~·~<::·' ,':.,·
.. IJJJ>·Reducingtheincomethresholds- .,)tr::·:<
under which famllles and children·
';'!.::-e:·..
qualify for Medicaid could trim the·: .:~if~ff;./·(.•
caseload, but some of their health·
.f;:;~~~:.- ..
care costs might be shifted to paying;_ --~~:~~-~~ ·. :, · ·
customers.
·
· . .7/!1~1;;_, ;_,.. · ·, ·. . IJJJ>·Reversing some of the expan- :·:,~~~Jt~_::~:
~
sions of recent years could remove· .,;.:.( ~·-' - :...
more poUtical.clout to protect them- gror.ps or recipients. A prime target --\·:;r~::<
selves at the state level," says. Judy could be poor children ages 12-lS,all
j{~:.:·. -.-:.\.:. WumanofFamillesUSA,agroup ofwhomarescheduledforcoverale ··:;::~W:;::,·_,·:·:·>
seeking expandf!d health lnsurance by 2002. North Carolina already cov- · ·· .,.~,.f~<'~·--~-;:-.. ,:.,-/. · , ...
..
·
.
�/
· ('u-M $u5~
c-~ ~
CcJ-(
-
c~.?~
-
�
Dublin Core
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Title
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Don Baer
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Office of Communications
Don Baer
Date
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1994-1997
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<a href="http://clinton.presidentiallibraries.us/items/show/36008" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7431981" target="_blank">National Archives Catalog Description</a>
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2006-0458-F
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Donald Baer was Assistant to the President and Director of Communications in the White House Communications Office. The records in this collection contain copies of speeches, speech drafts, talking points, letters, notes, memoranda, background material, correspondence, reports, excerpts from manuscripts and books, news articles, presidential schedules, telephone message forms, and telephone call lists.
Provenance
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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537 folders in 34 boxes
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Medicaid
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Office of Communications
Don Baer
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2006-0458-F
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Box 12
<a href="http://www.clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0458-F.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7431981" 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
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42-t-7431981-20060458F-012-003-2014
7431981