President’s Budget Proposal – In General
On February 12, the president released his FY 2019 budget proposal, which would make significant changes and cuts to many programs of importance to children and youth with special health care needs (CYSHCN) and their families. See the “HHS Budget in Brief.” Among other changes, the president proposes to convert the Medicaid program to block grants or per capita caps. (See HHS Budget in Brief, pp. 80-84 for Medicaid proposals.) The president also proposes to repeal and replace the Affordable Care Act with a Graham-Cassidy like bill. (See pp. 53-57.) In addition, the administration proposes certain changes to the Supplemental Security Income (SSI) program, including a reduction in SSI payments to families with more than one person receiving SSI benefits (including multiple children). (See Pres. Budget FY 2019 – Major Savings and Reforms, pp. 113-115, and the Consortium for Citizens with Disabilities fact sheet on the administration’s proposals regarding Supplemental Security Income and other changes to the Social Security program.)
For changes in program policy – such as most of those proposed for the ACA, Medicaid, CHIP, and SSI, Congress would have to amend current law. In years when Congress passes a budget resolution – and includes “reconciliation instructions” – they can use a reconciliation bill to make such changes, meaning a simple majority, rather than 60 votes, is needed to approve the legislation in the Senate. It does not look likely that Congress will pass a budget resolution this year, however. See House Budget Being Drafted Despite Nearly Insurmountable Obstacles (Roll Call, 2/16/18).
For more information about the president’s budget in general, as well as the budget process, see Trump’s 2019 Budget: What He Cuts, How Much He Cuts, and Why It Matters (Vox, 2/12/18).
President’s Budget Proposal – Addendum
On the same day the budget was released, White House budget director Mick Mulvaney sent Congress a budget addendum via a letter to House Speaker Paul Ryan. Among other things, the addendum proposes a shift of $5.75 billion from “mandatory” funding to “discretionary” funding for 15 HHS programs, including Community Health Centers, the Prevention and Public Health Fund, the Maternal, Infant and Early Childhood Home Visiting Program, several aging programs, and Family-to-Family Health Information Center (F2F) program. (See letter, attachment pp. 7-8.)
Individual discretionary programs (e.g., the Maternal and Child Health Block Grant) must be funded each year through appropriations legislation, and overall spending for discretionary programs is subject to specified caps (which were raised for two years in the recent budget law). In contrast, “mandatory” programs – like the F2F program – are automatically funded for as long as they are authorized, without going through the annual appropriations process.
If the president’s proposal to shift some programs from mandatory to discretionary funding were adopted by Congress, the shifted programs would have to compete with all other discretionary programs for the limited pot of discretionary money available to appropriators.
Many of the programs that the administration proposes to shift from mandatory to discretionary, including the F2F program, were reauthorized/funded – with “mandatory” dollars – through FY 2019 when the Bipartisan Budget Act was enacted on February 9. Therefore, it does not seem likely that Congress would want to use some of its limited discretionary funds for mandatory programs that have already been funded, when those funds could be spent for the discretionary programs that still need to be funded for FY 2018 and will need to be funded next year.
The ADA Education and Reform Act of 2017
On February 15, the House approved the “ADA Education and Reform Act of 2017”
(H.R. 620) by a vote of 225-192. Although the bill is bipartisan, it is opposed by disability advocates because it would weaken the Americans with Disabilities Act (ADA). The bill’s supporters are concerned about frivolous lawsuits against businesses that allege non-compliance with the ADA’s requirements regarding physical accessibility. If the bill were enacted, it would reduce incentives for businesses and other entities to comply with the ADA’s requirements. See the Judiciary Committee’s report on the bill, dissenting views (House Report 115-539 (pp. 17-27); and HR 620- Myths and Truths about the ADA Education and Reform Act (ACLU). At this time there is no companion bill in the Senate, and it will likely be difficult to get the 60 votes that would be needed in the Senate to advance the bill. See House Passes Bill Critics Say Would Undermine Disability Rights (Roll Call, 2/15/18).
|MEDICAID/CHIP NEWS, INFORMATION, AND RESOURCES
On February 1, the Centers for Medicare and Medicaid Services (CMS) approved a Medicaid waiver request from Indiana that would impose work requirements on some Medicaid beneficiaries, among other measures that would likely restrict eligibility. See Indiana’s Waiver Approval Adds More Barriers to Medicaid Coverage (Georgetown Center for Children and Families Blog, 2/2/18). While most of the attention about recent waiver requests has focused on work requirements, there are other aspects of these proposals of concern to patient advocates, including requests to impose lifetime limits on Medicaid eligibility. See Trump’s Historic Medicaid Shift Goes beyond Work Requirements (Stateline, Pew Charitable Trusts, 2/16/18); HHS Chief: No Decision Yet on Lifetime Limits for Medicaid (2/15/18).
Both Members of Congress and patient advocates have expressed strong opposition to work requirements. For resources on work requirements, see Summary of Posts and Resources on Medicaid Work Requirements (National Disability Navigator Resource Center, 2/15/18). To learn about the legal challenges to work requirements, see Will Federal Courts Uphold Trump Administration Medicaid Waiver Approvals? The Case For Skepticism (Health Affairs blog, 2/15/18).
From our friends at the Colorado Consumer Health Initiative.
The Majority of Colorado Medicaid recipients who can work do work.
- The Department of Health Care Policy and Financing found that 76% of non-elderly adults and children enrolled in Medicaid in Colorado live in a family with at least one part-time or full-time worker.
Non-working Medicaid recipients are either looking for work or face substantial barriers to employment.
- A Kaiser Family Foundation study found that among unemployed adults who are likely to gain Medicaid coverage in Medicaid expansion states:
- 29% were not working because they were taking care of home or family,
- 20% were looking for work,
- 8% were in school,
- 17% were ill or disabled, and
- 10% were retired.
- In Colorado, the Medicaid expansion offered health coverage for the first time for disabled people on the Aid to Needy Disabled (“AND”) program. Participation in AND requires a determination of disability by the Colorado Department of Human Services.
- 41,000 veterans in Colorado rely on Medicaid; the total number of veterans on Colorado Medicaid increased by 65% following implementation of the Medicaid expansion.
- A Medicaid work requirement could prevent people with substance use disorders such as opioid addiction from getting care – care that could allow some people to improve their health and join in the workforce.
Medicaid can help those who can work keep their job or search for employment.
- An Ohio study found that 8% of those who were unemployed stated that enrollment in Medicaid made it easier to seek employment and 52.1% of those already employed reported Medicaid coverage made it easier to continue working.
- A University of Michigan study found that 55% of those covered under Medicaid expansion that were out of work said job seeking improved after coverage, and 69% of those already working reported doing better at work after gaining health insurance.
- A Medicaid work requirement could block people with hourly and seasonal jobs from keeping their coverage. Many low-wage workers have variable hours, and an inflexible work requirement could cost them their coverage if their hours drop — which could make it difficult for them to continue working.
- Research demonstrates that being insured improves health outcomes and a person’s ability to work. In fact, one study that CMS cites explains that “income does not have a causal effect on life expectancy.”
The data and experience with work requirements in other programs does not support work requirements as an effective tool.
- The Urban Institute and the Center on Budget and Policy Priorities conducted two different studies on the effectiveness of work requirements in other federal public assistance programs – the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and federal housing assistance – and found that for each program, most people were already working whether they were subject to work requirements or not, and for those who were out of work, the work requirements did not improve their employment status, and most recipients actually either remained poor or became poorer.
Work requirements reduce low-income families’ access to care and jeopardize children’s health.
- Parental loss of health insurance caused by work requirements could cause financial and social stress that would have a negative impact on child health and development.