Policies Health and Human Services


Policies for the Jurisdiction of the Health and Human Services Committee

Below are the policies of the NCSL Standing Committee on Health and Human Services as of the Legislative Summit business meeting, which was held on August 22, 2014.


Acquired Immune Deficiency Syndrome/HIV-Infection

NCSL supports federal initiatives that provide needed assistance to state and local governments for the treatment and care of people with AIDS and HIV-infection and considers Acquired Immune Deficiency Syndrome (AIDS) and HIV-related conditions, a high priority health concern of the nation. A coordinated and intensive effort to prevent the spread of HIV-infection, develop new treatments, discover a cure, and assist people with AIDS and HIV-infection in receiving needed medical and support services is critical and must be supported by the combined efforts of government, the private and voluntary sectors, business and individuals.

Prevention and Education

Lowering transmission rates of HIV-infection is the first of many measures that must be taken to address the enormous impact of AIDS and HIV-infection in the United States. Prevention efforts have made a measurable impact on the overall rate of transmission since the early 1990's, but have not been equally successful across all populations. Education is a critical component of the prevention effort and must be culturally sensitive, age appropriate, and tailored to be effective with a specific audience. Federally funded family life and health education and prevention programs must include accurate information emphasizing responsible sex practices. These programs should include but not be limited to the promotion of safer sex, abstinence before marriage, monogamy after marriage and discourage illegal intravenous drug use. HIV prevention programs should be included in other treatment programs (e.g. substance abuse, mental health) when appropriate.

Confidentiality and Civil Rights

NCSL supports federal efforts to sustain the privileged state of personal medical records and is particularly supportive of efforts to protect individuals with AIDS and HIV-infection from experiencing discrimination in employment, housing, insurance coverage and public accommodations. Protecting the rights of people with AIDS and HIV-infection is first and foremost, however, the rights and legitimate concerns of insurers, health care professionals, and emergency response personnel must be considered in the balance.

NCSL opposes federal legislation imposing either a mandate for or a prohibition of state partner notification requirements or contact disclosure or tracing programs. NCSL also opposes federal legislation that would require states to establish civil and criminal penalties for the knowing transmission of HIV-infection. Provisions of this sort are particularly onerous if the receipt of federal financial assistance is contingent upon their passage. Federal initiatives regarding confidentiality and civil rights should enhance, strengthen, and underscore the states' responsibility for action in these areas and allow state flexibility in such initiatives.

Counseling and Testing

 Individuals with a history of high risk behavior or suspected exposure to HIV-infection should be encouraged to be tested for HIV-infection. Unfortunately, many people who are tested never return to receive their test results. NCSL supports the promotion of rapid testing programs. Screening with the rapid testing method facilitates the immediate provision of information and prevention counseling because the individual being tested may receive the test results, accompanied by counseling in one appointment. NCSL also supports the use of rapid testing in non-medical settings when appropriate and when counseling is available and provided on-site. HIV testing is particularly important now that effective treatments are available for asymptomatic individuals with HIV-infection.

NCSL supports efforts to encourage obstetricians and gynecologists to urge patients to be tested. This is particularly important to bolster efforts to reduce HIV-infection and AIDS in children. All physicians who serve sexually active men and women should also be enlisted to encourage their patients to be tested and should be prepared to provide educational materials to patients who request them.

Health Professionals Providing HIV Treatment and Care

NCSL supports the decision by the Centers for Disease Control and Prevention (CDC) to continue to permit state and local health officials establish guidelines regarding procedures that health care workers infected with HIV or Hepatitis B should be permitted to perform. NCSL also supports the Blood-Borne Pathogen Standard rule promulgated by the Occupational Safety and Health Administration (OSHA) and the Needlestick Safety and Prevention Act. The Blood-Borne Pathogen Standard rule mandates the use of universal precautions in infection control and requires employers to provide workers with training, protective clothing, engineered safety devices, puncture-proof containers for contaminated needles and medical waste, and vaccination against the Hepatitis B virus. The Needlestick Safety and Prevention Act requires employers to solicit input from employees responsible for direct patient care in the identification, evaluation, and selection of engineering and work practice controls.

Ryan White CARE Act

Federal grants supporting state efforts to provide care and treatment to people with AIDS should provide maximum flexibility to states to enable them to develop programs that best meet the needs of their citizens. NCSL supports continued and adequate funding for states through the Ryan White C.A.R.E. Act and through cooperative agreements with the CDC. States should be permitted to demonstrate, in their state plan, that they have addressed the needs of all populations within their boundaries, in lieu of federal statutory mandates. Finally, in light of the substantial financial commitment by the states for HIV-related activities, NCSL opposes the imposition of state matching or maintenance of effort requirements in these programs. NCSL urges the federal government to ensure that adequate funding is provided for the AIDS Drug Assistance Program (ADAP). This program has become increasingly important as new drug therapies are developed. It is important that the funding for this program keep pace with the approval and availability of new drug therapies.

ADAP Counted Towards Out-of-Pocket Expenditures for Dual-Eligibles

Under current law, ADAP expenditures do not count as part of the true out-of-pocket (TrOOP) expenditures for Medicare Part D beneficiaries. NCSL urges Congress to count all or part of ADAP expenditures toward TrOOP.

Treatment and Care

The two-year total disability waiting period in the Medicare program severely limits the ability of Americans with HIV-infection and other debilitating or terminal illness from participating in the program. Under current law, persons suffering from terminal, but relatively brief illness cannot now benefit from this program. NCSL recommends that the waiting period be waived in these cases. The Social Security Administration (SSA) has promulgated regulations that make it easier for individuals with AIDS and HIV-related conditions to receive Social Security Disability Insurance (SSDI). In addition, SSA has adopted rules that will help ensure that women and children with AIDS and HIV-infection are treated equitably and compassionately. NCSL supports these initiatives. NCSL urges the continuation and expansion of the end of life/palliative care initiative for underserved populations. The program provides a wide range of palliative care services including hospice care and case management services to individuals in urban, suburban and rural areas.


NCSL calls upon the federal government to increase its support for research efforts through both basic and applied biomedical investigations to better understand, to treat and to prevent the disease. The federal government should continue and intensify efforts to develop both preventive and therapeutic vaccines. NCSL supports the Food and Drug Administration's (FDA) efforts to expedite the drug approval process and to increase the number of people participating in clinical trials and other programs designed to test the effectiveness of new drugs and treatments.

Racial and Ethnic Disparities

NCSL is pleased that the Minority AIDS Initiative (MAI), which was established in 2000 to reach out to all minority communities (Hispanic, African-American, Asian-Pacific, Native American, Alaskan Native and other ethnic and racial minorities), was permanently authorized in the 2007 Ryan White CARE Act reauthorization. NCSL urges the President to provide focused leadership domestically to reduce health disparities, particularly as they relate to HIV/AIDS and requests the Congress to increase funding for state and local grant programs authorized by the Ryan White Comprehensive AIDS Resources Emergency Act, especially to assure funding for faith-based initiatives providing culturally and linguistically competent prevention and treatment programs.

NCSL urges the Congress to provide increased funding to the Department of Health and Human Services and relevant agencies, including the Centers for Disease Control; Prevention and the Human Resources and Services Administration, and the National Institutes of Health to: (1) implement the Centers for Disease Control and Prevention’s National HIV Prevention Strategic Plan; (2) expand the Minority AIDS Initiative to provide additional support to minority-serving community-based organizations; (3) augment outreach and HIV testing efforts targeting populations including racial and ethnic minorities at higher risk of contracting HIV; and (4) develop additional evidence-based HIV prevention interventions targeting ethnic and racial minorities. NCSL urges the federal government to make every effort to include more women and minorities in clinical trials and other research initiatives.

International Initiatives

NCSL supports federal initiatives that recognized the pandemic nature of HIV-infection and AIDS and that focuses on primary prevention of HIV/AIDS, care and treatment of tuberculosis and other opportunistic infections, palliative care and appropriate use of antiretroviral medications, and infrastructure and capacity development in 25 countries.

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)

On July 30, 2008, the Tom Lantos and Henry J Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 was signed into law, authorizing up to $48 billion over the next 5 years to combat global HIV/AIDS, tuberculosis, and malaria. Through FY 2013, PEPFAR in partnership with host nations will support treatment, prevention services and care for millions of people around the world. To meet these goals and build sustainable local capacity, PEPFAR will support training of at least 140,000 new health care workers in HIV/AIDS prevention, treatment and care. NCSL supports these efforts.

Assistance to States for Emergency Care Services Furnished to Unauthorized Immigrants and Immigrants Pending Authorization under Immigrant Reform (Resolution)

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provided assistance to states to make emergency payments to eligible providers of emergency health care to certain unauthorized immigrants. The authorization for this program has expired and the remaining funds will be expended this fiscal year. NCSL urges Congress, as it considers broader immigration reform legislation, to include state impact assistance that would include funding to offset emergency health care costs for immigrants who are on track to become citizens, but are not eligible for federal health care assistance and for the costs of unauthorized immigrants.

Expires August 2015

Declaration of Youth Violence as a Public Epidemic in The United States (Resolution) (Joint with Law and Criminal Justice Committee)

The National Conference of State Legislatures (NCSL) declares youth violence as a public health epidemic and supports the establishment of nationwide trauma-informed education by Congress and the Administration.

NCSL believes youth across our nation are committing acts of violence against one another and throughout their communities causing victimization among their peers, social and psychological dysfunction, leading to in some cases, symptoms of Post-traumatic Stress Disorder.

A national survey by the Centers for Disease Control and Prevention (CDC) found that United States adults reported approximately 1.56 million incidents of victimization by perpetrators estimated to be between 12 and 20 years of age. The CDC states, "Violence is a serious public health problem in the United States. From infants to the elderly, it affects people in all stages of life. In 2007, more than 18,000 people were victims of homicide and more than 34,000 took their own life." The CDC reports that many people survive violence and are left with permanent physical and emotional scars and that violence erodes communities by reducing productivity, decreasing property values and disrupting social services.

In 1985, former United States Surgeon General C. Everett Koop declared violence as a public health issue and called for the application of the science of public health to the treatment and prevention of violence. In 2000, former United States Surgeon General David Satcher declared youth violence as a public health epidemic, and released a report that deemed youth violence as a threat to public health and called for Federal, state, local and private entities to invest in research on youth violence. Additionally, the report also states that the public health approach to youth violence involves identifying risk and protective factors, determining how they work, making the public aware of these findings, designing programs to prevent or stop the violence and calls for national resolve to confront the problem of youth violence systematically; to facilitate entry of youth into effective intervention programs rather than incarceration; to improve public awareness of effective interventions; to convene youth, families, researchers and public and private organizations for a periodic youth violence summit; to develop new collaborative multidisciplinary partnerships; and to hold periodic, highly visible national summits;.

The Pennsylvania State Conference of the National Association for the Advancement of Colored People (NAACP) Branches, through its Education Committee members, have given testimony before the Education Committee of the House of Representatives calling for attention to the impact of trauma brought about by violence and other adverse conditions on children's academic performance as well as their relationship with school and the broader society.

Due to the violence epidemic, youth suffer from either primary or secondary trauma. Primary trauma is trauma associated with the violent death of a loved one. Secondary trauma results from exposure to violence present within their community. Exposure to violence in families and communities, as well as exposure to homicidal death, can lead to youth-specific post-traumatic stress disorder with complex effects as well as homicidal grief. NCSL recognizes that trauma is not easily visible within youth because it requires proper assessment and, due to the amount of violence youth are currently exposed to, measures should be taken without delay, to properly assess the issue.

NCSL supports the CDC statement that schools provide "a critical opportunity for changing societal behavior because almost the entire population is engaged in this institution for many years, starting at an early and formative period" and "Universal school-based violence prevention programs represent an important means of reducing violent and aggressive behavior in the United States."

NCSL strongly supports a state/federal partnership to increase education in violence prevention and PTSD awareness through education.

Expires August 2015

Eliminating Health Disparities (Resolution)

The Patient Protection and Affordable Care Act and the reform of our nation’s health care system provides an opportunity for Congress and the Administration to work with NCSL, state policymakers, public, private community and faith-based institutions to develop strategies,  policies and programs to reduce health disparities among racial, ethnic and cultural populations in the United States.

 The U.S. Department of Health and Human Services and its offices, institutes and centers including the Office of Minority Health, Centers for Disease Control, National Institute of Mental Health, Substance Abuse and Mental Health Services Administration and others should work with NCSL and state policymakers to: identify the social determinants of health which lead to disparities; adopt the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards) and; develop standards for the collection and reporting by federally funded health and health care programs of data on race, ethnicity, sex,  primary language, disability status, those living in rural and frontier areas and other characteristics identified by the Secretary of Health and Human Services in order to analyze and monitor health disparity trends and develop promising practices and programs to eliminate them based on the data collected.

NCSL believes reporting requirements are important, but should be limited to requirements where there is a reasonable expectation that the data will be used to analyze trends, improve patient outcomes, improve programs and eliminate health disparities. In addition, efforts must be made to impose data collection and reporting requirements in the least burdensome way possible.

 These efforts should be supported by the President and Congress with possible increased funding and other supports to:

  • Reduce health disparities;
  • Provide quality care and efficiencies;
  • Improve health outcomes;
  • Increase cost-effectiveness and save money; and
  • Meet legislative, organizational, and accreditation standards.

NCSL urges the President and Congress to provide increased funding to the Department of Health and Human Services and relevant agencies, including the Centers for Disease Control; Office of Minority Health, the National Institutes of Health and etc. to: (1) implement the HHS Office of Minority Health’s National Partnership for Action to End Health Disparities (NPA) efforts to mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity; (2) expand funding and other resources to support the Regional Blueprints for Action that will align with the National Stakeholder Strategy to help guide action at the local, state, and regional levels; (3) augment outreach and other efforts targeting populations including racial and ethnic minorities at higher risk of chronic diseases and illnesses; and (4) develop additional evidence-based prevention and interventions targeting ethnic and racial minorities. NCSL urges the federal government to make every effort to include more women and minorities in clinical trials and other research initiatives to improve health care strategies and programs to eliminate disparities.

Expires August 2015

Child Care

State legislators have always been in the forefront of these creative approaches to child care. Federal efforts should assist our efforts and not be a barrier to state innovation. State legislators continue to examine the effects of their child care policies and use their legislative authority to appropriate Child Care Development Block Grant Fund (CCDBG) funds. In addition to state's own funding and the federal CCDBG, states are increasingly using a significant portion of TANF Block Grant funding to serve the needs of those on public assistance as well as those who have left public assistance and the working poor who may not have ever received cash assistance. Current funding levels for child care create a tension between serving TANF families and low-income working families.

To address family needs for child care services, and to increase the supply of child care facilities the state federal partnership must be flexible enough to deliver a wide range of affordable high quality child care services must be made available including, but not limited to: center-based, family child care, work-site based care, and in-home care. In addition, these facilities must be prepared to provide a full range of services including: infant, pre-school and school-age child care; information and referral services; 24-hour care; sick care and respite care.

Child Care Development Block Grant (CCDBG)

CCDBG fills an important gap in federal support of child care for low-income and moderate-income working families. NCSL strongly supports full funding for this program. Child care needs vary from state to state. NCSL believes that the CCDBG regulations must not unduly prevent states from directing funds to their particular needs, from inspections to development of providers to reimbursement. Each state's child care market is different. State legislators have the often difficult job of directing the CCDBG where the need is greatest. States balance the competing demands for high quality, affordable, available and accessible child care. Some states have waiting lists for current welfare recipients; others have trouble meeting the demands of those who have left welfare and are working. States want to ensure that former welfare recipients do not return to the welfare rolls because of a lack of child care. Also, state legislators are concerned about meeting the special needs of certain populations: children with disabilities, infants and older children in after-school care. State legislators work to meet the needs of children whose parents work off shift and non-traditional hours including nights and weekends.

 It is critical that states have the necessary flexibility to direct CCDBG funds. Earmarking the current CCDBG or earmarking further increases in funding would reduce that flexibility and may make the provision of child care more difficult in the states. NCSL urges Congress and the U.S. Department of Health and Human Services (HHS) to maintain state flexibility when they examine and revise the CCDBG.

 Specific concerns include the following:

  • States should be able at their option to pay differential payment rates for providers of higher quality service and/or providers who serve children with special needs;
  • The current portion of the CCDBG that is not earmarked should remain consistent with Congressional intent to provide flexible funds for states to use as they see fit on a wide range of activities including services, resource and referral, training and regulatory areas;
  • Rules on registration of unlicensed providers should be created at a state's discretion to include more than payment information;
  • The federal government should not be able to withhold funds from a state with stricter standards;
  • Maintenance of effort requirements make it difficult for states to take advantage of federal funds when they face difficult decisions about how to fund all human services programs.
  • Parents should be able to choose their providers within a state regulatory framework;
  • If an administrative cap is enacted, it should be limited to a strict definition of administrative funds. Services such as inspections, licensing, automation, eligibility determination, resource and referral, case management, training, and rate setting are critical to the provision of quality services and should be defined as services;
  • Proposed changes to the CCDBG must not include additional mandates;
  • Quality supply building, and system building activities must be included as acceptable expenditures in addition to reimbursement;
  • Child care services must be made available to all recipients required to participate in welfare to work programs, and adequate federal funding should be provided for these services; and
  • The CCDBG must not have burdensome reporting requirements and should have outcome-based measurement.


NCSL strongly supports expansion of the CCDBG to supplement ongoing state efforts to assist both welfare recipients and low- and moderate-income working families. State legislators oppose efforts to limit providing child care funds to families who are or have been attached to welfare. CCDBG should continue to be available to both former welfare recipients and low and moderate income working families.

The preponderance of funds for the Child Care Development Block Grant must remain an entitlement to the states. This is especially critical because under the TANF program, welfare recipients cannot be required to work if they can prove they do not have access to child care. NCSL continues to strongly support the portion of the CCDBG that is funded by discretionary dollars and subject to the Congressional appropriations process. However, any additional funds for the CCDBG must be an entitlement to the states. A state match may prevent some states from accessing badly needed child care funds. Child care is critical to meet increased work participation rates. NCSL opposes initiatives to add additional earmarks as not providing the needed flexibility for states to address the condition in their own markets.

NCSL believes that states should have the flexibility to extend the age of eligible children beyond age 13, especially children with special needs, to give states more flexibility to use these funds for out of school time care for older adolescents.

NCSL believes that the federal government must provide technical assistance to states to improve the coordination and financing of child care programs.

TANF and Child Care

NCSL strongly believes that child care is a legitimate use of the Federal TANF block grant and state maintenance of effort funds. It is critical that states continue to be allowed the flexibility to transfer up to 30% of TANF into the Child Care and Development Block Grant.

We urge the Administration and the Congress to eliminate the distinction between how child care is treated for working families based on funding stream. There are different rules for working family child care funded by TANF, non-working families funded by TANF and child care funded by CCDBG. NCSL appreciates that HHS signaled the importance of child care for working families by not considering it assistance, thus allowing families to have this vital service without having it count against their time-limited assistance. NCSL urges the federal government to reconsider the distinction in TANF regulations that counts child care and other work supports for the unemployed as assistance. This will be particularly important for families who receive Unemployment Insurance benefits. We want these families to have a reliable source of child care support while they look for another job rather than offering an incentive for them to return to cash assistance. Having this child care support count toward the time limits also raises equity issues and confusion since different rules apply to different funding sources. Additionally, research suggests that having a consistent child care provider is important to children's early development.


State governments should retain the authority to regulate child care facilities, and the federal government should not intrude in this area. The federal government should provide financial and technical assistance, and develop model standards for state guidance. This assistance could be used for the training of providers, or to conduct a study on how to raise salaries for providers while maintaining affordability. States should continue to establish and enforce minimum health and safety standards and adequate child/adult ratios for all child care facilities. Should federal standards or requirements for states to establish additional standards be enacted, states should be afforded adequate time to carry out the requirements of any new child care policy.

Taxes and Benefits

  • Tax incentives can encourage creation of child care programs and help parents better afford child care services. NCSL supports:
  • Tax credits for employers that establish and/or operate child care programs;
  • Public or private incentives for a child's primary caregiver to have the option to stay at home during the child's early developing stages;
  • Tax credits for taxpayers with dependents under compulsory school-age;
  • Child care benefits as an option in employer-sponsored cafeteria plans, including pre-tax flexible spending accounts;
  • Retention of the Dependent Care Tax Credit as it exists under current law; and
  • Tax incentives to encourage individuals to establish and/or operate child care programs.


NCSL supports federal funding for liability insurance pools, as long as the establishment of such pools is a state option. NCSL opposes any attempts to preempt state law in the area of insurance.

Coordination with Early Learning

A greater attempt should be made to integrate and coordinate child care and early childhood education programs and policies. NCSL supports congressional proposals which would provide grants to states to develop innovative programs which link child care to early childhood education for children in public assistance households. NCSL's current policy on Early Learning addresses these concerns, including those specifically related to Head Start, in more detail.

Child Welfare and Family Services

The National Conference of State Legislatures (NCSL) is concerned about the welfare of our nation's families and the safety of their children. NCSL supports strengthening families through coordinated early intervention and prevention services so that they can protect and nurture their children. Flexible federal funding, including decategorized funding, is essential to address the changing needs of families and leverage state program funding.

 Child Welfare Principles

 NCSL supports federal law that:

  • promotes the goals of safety, permanence and the well-being of children;
  • increases family support services in order to maintain children safely with their families and decrease the number of children unnecessarily entering the foster care system;
  • ensures that children placed in foster care are placed in the least restrictive, most home-like environment, including placement with family members;
  • facilitates the timely and safe return of children to their functional families with supportive services and promote the timely adoption or other permanent placement of children who cannot return home; and
  • promotes educational stability for foster care children.

NCSL supports the development of family-based child welfare services. NCSL supports policy and practice which promotes a system of services that promote safety and permanence for children and support families. This system of services must: (1) protect children and support families and reduce unnecessary placement of children outside the home; (2) reunite children safely with their families when placement becomes necessary; (3) ensure a range of foster care alternatives; (4) promote timely adoption and other permanency options when it is not appropriate for a child to return home; and (5) promote kinship and guardianship placements. Child welfare services should be family-based, providing support to keep children safely in their homes with their families, limiting the need for long-term family intervention. When short-term intervention is necessary, out-of-home placements provide a safe therapeutic environment essential for healthy child development. When family reunification is impossible, permanent alternatives, particularly adoption, kinship care and subsidized guardianship as well as independent living arrangements are available to provide stable, nurturing environments for children who cannot return home. NCSL is concerned about the number of children who enter the foster care system that are victims of neglect.

NCSL believes that the provision of support services, including in-home family services to at-risk families, is key to reducing the number of children in the foster care system. NCSL encourages the federal government to continue to seek cost effective alternatives to foster care. The efforts of the states have been hampered by inadequate funding, confused federal guidelines, and tardiness for reimbursement to the states for mandated program expenditures. NCSL urges Congress to provide states with additional federal financial support and technical assistance in their efforts to implement a comprehensive service system that helps institute more effective child welfare and adoption policies and practice to promote the safety, permanence and well-being of children.

Families and children in the child welfare system often face complex problems such as homelessness, substance abuse, and HIV-infection that require interdisciplinary and interagency solutions. To combat service fragmentation, the federal government should provide increased flexibility enabling states to better coordinate service delivery among the public and private child welfare systems, child mental health, and juvenile justice systems as well as TANF, education and health agencies. Interagency collaboration including public/private partnerships should be encouraged to further integrate and coordinate services.  NCSL supports special efforts by the federal government to work with courts to improve their processes in child welfare cases and better collaborate for improved outcomes for children. State flexibility must be maintained in these programs to provide interagency training, budgeting, planning and conflict resolution as well as integrated data systems.

Promoting Safe and Stable Families Program (Title IV-B, Subpart 2)

The Promoting Safe and Stable Families entitlement program, which NCSL strongly supports, is a critical step toward changing the inequity between funding for out-of-home placement and funding for protecting children by strengthening families. This guaranteed level of federal funding, while modest, will enhance state efforts to develop additional family preservation, family reunification and family support programs.  NCSL supports efforts to create a continuum of care for families from prevention of abuse and neglect through family support programs to intervention for families in crisis through family preservation. State legislators have long been the innovators of these programs, using predominantly state, local and private funds. NCSL believes that family support programs also can play an important role in preserving adoptive families.

There must be respect for the enormous variation between states in implementing family preservation and family support programs. States should be given maximum flexibility in designing their programs, without preemption of existing state laws. The federal government should provide state legislatures with technical assistance that includes peer to peer discussion. Intensive staff training will be needed in order to deliver these services as well as broader training of relevant agencies. Training should not be limited to an administrative expense. HHS should communicate directly with legislators. NCSL is concerned about the lack of uniform interpretation of federal law and regulations by federal regional offices.

NCSL is strongly opposed to efforts to limit state flexibility in the distribution of entitlement funds. The federal law calls for significant portions of the funds to be divided between family preservation and family support programs. NCSL is strongly opposed to efforts to earmark these funds and urges HHS to recognize that states should determine where these funds can best be spent in the community. NCSL's concerns were heightened when the law was changed to require "significant" portions must be used to promote time limited family reunification and adoption promotion and support services.

Child Welfare Services (Title IV-B Subpart I)

The child welfare services program authorized under Title IV-B of the Social Security Act provides for federal matching grants to states for three types of services relating to child welfare: direct services, training, and research and demonstration grants. NCSL urges and encourages full funding of Title IV-B and expansion of funds for child welfare services. This will encourage the provision of services aimed at supporting families, rather than out of home placements.

Any cap on administrative funding must be carefully constructed so that vital work done by caseworkers is not considered administrative. NCSL is opposed to possible restrictions on states’ ability to use Title IV-B, Part 1 funding on child care necessary for parental employment, foster care and adoption assistance and states’ ability to use such expenditures as match.

Family Unification Program

 Homelessness and other housing problems are often barriers to family stability and children are unnecessarily separated from their families due to these problems. The Family Unification program allows certain states to provide housing assistance through the Section 8 program to families who meet the regular Section 8 eligibility criteria and whose children are at-risk of placement in out-of-home care or delayed in returning from care because of homelessness or severe housing problems. NCSL urges the U.S. Department of Housing and Urban Development to fund programs and inform state legislatures of the availability of funds and the results of this program.

Foster Care

The federal Foster Care program, an open-ended entitlement program that is permanently authorized under Title IV-E of the Social Security Act, provides payments to states to reimburse a substantial portion of the maintenance costs of licensed or approved out-of-home care, administrative costs, and training for state agency staff and adoptive and foster care parents. While some provisions of foster care are nominally classified as "administration," in reality, they constitute activities in support of children and their families and are necessary to meet the mandates in federal law. NCSL strongly opposes efforts to cap these Title IV-E expenditures. Further technical assistance efforts are needed to help states understand the complicated reporting system, find effective ways to maximize federal dollars and enhance revenues for innovative service techniques.

 Specifically, NCSL urges the federal government to:

  • Promptly appropriate and pay prior year state claims;
  • Oppose more stringent time limitations for the collection and submission of state claims;
  • Continue a monitoring and review system that fairly assesses state performance and gives states tools for improvement;
  • Continue to emphasize family support services, family preservation services, family reunification services, preplacement services and other programs designed to help children at risk of foster care placement remain with their families when safe and timely reunification is appropriate, and those in foster care to return to their families, when safe and timely reunification is appropriate. These services should continue to receive "entitlement" funding;
  • Define and separate foster care administration from child placement activities, and support the separate reporting by states of such amounts. Eligibility determination and redetermination, preparation and participation in judicial hearings, child placement, case management (plan development, reviews and supervision), recruitment of foster homes and institutions, rate setting and training costs are critical child placement activities that are essential to the provision of quality services and must continue under the  Title IV-E entitlement;
  • Support and provide technical assistance to states to use the federal waiver authority;
  • Support the concept that grandparents, or other immediate family members, who are caring for children who cannot safely remain with their parents, should be given priority for such custody and placement over placement in a foster home with a non-relative, unless the court determines that placement with any of these relatives is not in the best interest of the child or children. Additionally, kinship foster care placement and/or subsidies should not be contingent on physical removal of a child from his or her relatives. Subsidized guardianship with relatives may be an appropriate permanency option for children who cannot safely return home. Federal funds should be made available for this option and for support services for caretaker relatives. NCSL opposes efforts either by legislation or by regulation that would eliminate federal reimbursement for relative foster care that is non-licensed. If a state chooses to allow a relative to care for these children, the state should be able to receive federal funds for their care;
  • Continue the federal financial participation for states that choose to provide assistance to youth ages 18-21 who are preparing to transition from foster care to self-sufficiency. In these difficult fiscal times, states should be allowed to expand services to different ages for foster care adoption and relative guardianship;
  • Increase recruitment of and training and respite care for foster care and special needs adoption providers;
  • Provide quality, appropriate health, mental health, drug and alcohol abuse treatment and services, education, and job training services and coordinate with existing programs for children and families who come to the attention of the child welfare system; and
  • Promote policies that keep children in their own communities and schools.

State legislators are very concerned about the child welfare workforce. Child welfare agencies face daunting challenges recruiting, retaining and supporting caseworkers and supervisors. NCSL supports federal efforts to help the workforce meet these challenges, including student loan forgiveness, funding to expand and improve staff training, and financial assistance to states to reduce caseloads. NCSL is concerned about the denial of plans where states have used Medicaid for targeted case management and Deficit Reduction Act changes to targeted case management.

Information Services

NCSL supports HHS efforts to develop a national information system to track data on families in the child welfare system in order to solicit critical child welfare data particularly with respect to outcomes for children and the impact of particular problems such as substance abuse and the effectiveness of treatment options.

Independent Living

Congress authorized and increased the capped entitlement funding to assist older youth in the foster care system to aid their transition to life as an adult outside of the foster care system. NCSL urges the Congress to fully fund the John H. Chafee Foster Care Independence Program, and to appropriate funds for education and training vouchers for youth aging out of foster care

Adoption Assistance

Adoption subsidies are a valuable resource in finding permanent homes for children with special needs as defined by the states. Special needs children include those who are: physically, mentally, or emotionally disabled; members of minority groups; older; or siblings needing to be placed together. Adoption assistance increases the number of homes available to these children by subsidizing their medical and other special expenses and by easing the costs of child-rearing in general. NCSL urges HHS to reimburse states immediately for program expenditures in a timely fashion and to pay claims currently owed to states.

However, NCSL continues to oppose federal efforts to restrict state authority to determine the criteria for termination of parental rights. Post-legal adoptive services are critically needed for families who adopt these children, many of whom may have health and mental health problems as they mature. Respite services are critically needed as well.

In some cases, interstate adoption may present the only opportunity to place a child. Differences in state law and policy create special concerns with respect to the apportionment of legal and financial responsibilities. For adoption subsidies to be effective, adoptive parents must be assured that coverage will be provided, regardless of their state of residence. The Interstate Compact on Adoption and Medical Assistance helps facilitate the provision of medical and other support services for these adoptions and incentives should be provided for states that join the compact.

Adoption incentive funds have provided states the ability to build on their success in increasing adoptions. Adoption incentive funds have been very important to states for implementing a range of programs including support for foster and adoptive parent and other child welfare services. Any discussion of changing incentive criteria must keep in mind that special needs children cannot be defined in terms of age alone.  NCSL urges Congress and the Administration to avoid any unintended consequences in any changes to how funds are apportioned. States should be permitted to use such adoption incentives toward the matching rate for Title IV-E, especially for the use of post adoption services.

Social Services Block Grant

NCSL has a policy directive on the Social Services Block Grant (SSBG) that details the importance of SSBG in providing critical services to protect children and prevent child abuse and neglect.

Flexible Funding for Children's Services

When states have attempted to reform service systems serving children and families, they are often unable to meet local service needs because of the inflexibility of the major federal funding streams and the wasteful administrative structure they require. To meet the challenges facing the children and families in our communities it will take more creativity and flexibility at the state and local level, not greater restriction at the federal level. The use of funds are sometimes so restricted that states cannot use these funds to meet locally-determined needs. States attempting major service reform often face regulatory barriers that impede their efforts, require creative financing and contradict service priorities.

States need the option of using a portion of their funding for foster care maintenance payments for child welfare and family services, especially when utilization of foster care funds is reduced. States adopting this option would develop a statewide plan for the use of these funds and to conduct broad-based community planning incorporated into its submission. The federal government would (1) eliminate the requirement that funds go to a single state agency payee, (2) identify specific quantifiable outcomes the plan must address, (3) and develop basic procedural regulations including timelines, formats and procedures for approval of the plan based on meeting outcome goals. NCSL continues to oppose reduction or limitation of the funding including capping of Title  IV-E for these programs as a condition of any such children's services proposal. We urge Congress to consider delinking foster care eligibility from AFDC eligibility as of July 16, 1996 for all states and move toward reimbursement for all children in care, as the states determine.

NCSL applauds the Administration for recognizing the importance of flexibility in child welfare financing and welcomes the discussion of more options in Title IV E funding. Proposals are currently being developed in Congress under which states could choose to accept a fixed amount of Title IV-E Foster care funding in return for the ability to use these funds more flexibly, including using these funds for prevention activities in addition to maintenance payments. The details of such proposals are not yet final. NCSL notes that such an option would not be the solution for all states. The NCSL urges Congress to not mandate a child welfare block grant. However, should a child welfare option be considered, there are a number of issues that must be dealt with before any state, at their option, could feel comfortable accepting a fixed amount of funding for IV-E in return for the ability to use these funds on prevention activities and flexibility in determining eligibility for federal reimbursement including the elimination of the look back requirement. The issues include: establishing the baseline on which the fixed amount of funding would be based, clarifying what expenditures would fall under an MOE requirement, and including state legislators in decision making about applying for and accepting such an option.  A state’s decision to accept fixed funding for a number of years is both a fiscal and a policy decision which state legislators must approve. Any block grant should be subject to state legislative appropriation. States would need to be assured, when choosing to cap an open ended entitlement, that such a capped program would not be cut by the federal government. Any state coordinating or advisory body required by federal statute must include, at a minimum, a representative of each chamber of the state legislature selected by the presiding officer.  While we welcome the discussion of child welfare financing, NCSL continues to oppose any mandate to block grant open-ended funds for foster care and adoption for all states.

Child Abuse and Neglect

NCSL supports early identification, intervention and treatment of victims of child abuse and neglect. Recognizing the relationship between child abuse and neglect, juvenile delinquency, and adult crime, NCSL believes that it is important to make every effort to reduce the incidence of child abuse including, but not limited to, physical, sexual, and emotional abuse and any neglect relative to a child's health or welfare.

NCSL strongly supports the federal Child Abuse Prevention and Treatment Act and urges that it be fully funded at the levels authorized by Congress in order to assist states to respond to increased incidents of abuse and neglect.

Child abuse and neglect cases can be complicated and involve the child protective services, criminal justice, education and court systems, among others. In our state federal partnership to combat child abuse and neglect, NCSL encourages the federal government to support states in training mandatory reporters. NCSL opposes federal preemption in defining who is a mandatory reporter or unfunded federal mandates to combat the tragedy of child abuse and neglect.

Drugs and Alcohol

Widespread addiction by women has been a hidden problem which has led to policies which ignore rehabilitation and family assistance while supporting criminal sanctions. State legislators are concerned that many women who abuse drugs and alcohol are pregnant but current treatment programs have been designed almost exclusively to serve male addicts. Federal law has strict timelines for state decision making. Significant federal support is needed to meet the treatment needs of families who come to the attention of the system. This is critical to keeping children safe and in permanent families.

NCSL supports:

  • Rehabilitation programs that include appropriate child care for children and addicted mothers and federally-funded programs that do not deny access to drug and alcohol programs on the basis of pregnancy;
  • Federal incentives for partnerships between substance abuse and child welfare agencies including cross system training of staff, improved screening and assessment procedures, comprehensive treatment and prevention programs, after care services and improved data collection;
  • Federally-funded programs that recognize that women avoid seeking essential prenatal care when public policy utilizes criminal penalties regarding their substance abuse rather than rehabilitation and collaborative efforts of schools and community providers. These necessary interventions must be properly funded and implemented to prevent the use of harmful substances by women before they become pregnant; and
  • The use of Employee Assistance Professionals at the worksite to help impaired employees become more productive in the workforce and in society.

Family Violence

 Family violence is a barrier to safety and permanence for children. Unfortunately it is not uncommon for child abuse and domestic violence to occur in the same families. NCSL is particularly supportive of the Family Violence Prevention and Services Program which is designed to assist states in their efforts to prevent family violence and to provide immediate shelter and related services to victims of family violence. It also provides for training and technical assistance to state and local agencies on family violence program administration. NCSL supports federal incentives for coordination between child welfare systems, domestic violence agencies, and juvenile courts.

NCSL supports services to at-risk households, including emergency crisis services, 24-hour services, in-home services, parent and family counseling, child care services, parent education, and employment assistance. NCSL supports federal efforts to provide demonstration grants to increase the number of supervised visitation centers as a neutral location for protective temporary transfers of custody and on-site supervised visits of children.

Community Services Block Grant (CSBG)

In 1964, The Economic Opportunity Act established the Community Services Block Grant (CSBG) and Community Action Agencies (CAAs) as part of the historic "war on poverty."  CAAs deliver a number of important programs including Head Start, the Low Income Home Energy Assistance Program (LIHEAP), low income weatherization, homeless programs under the Stewart M. McKinney Homeless Assistance Act and Meals on Wheels.

The National Conference of State Legislatures supports full funding and reauthorization of the Community Services Block Grant Act as funds are available. State lawmakers oppose any unnecessary reduction in present funding, which, in turn, provides funding for CAAs. CAAs are a valuable resource to state and local governments’ participation federally funded human resource programs, particularly in rural areas isolated from information, and their ability to provide adequate means of service delivery.

State legislators support programmatic increases but are disturbed by proposals to fund programmatic increases at the expense of adequate administrative funding. Furthermore, state legislators find it contradictory to fund certain programs that the CAAs deliver while reducing the funding of the CSBG as a whole. The CAAs provide numerous administrative services for these programs. Congress must pay vigilant attention to continue to find ways to adequately fund this program. The CSBG Act should reaffirm coordination with state and local government. In addition, NCSL asks Congress to include "isolated rural" to the demographic designation for eligibility for receiving federal funds. The traditional designations of "urban" and "rural" do not allow appropriate delivery of services in 23 states with long distances between small population clusters.

NCSL believes that the current formula block grant structure is appropriate and that all states should continue to receive CSBG funding. The current formula block grant respects current state structures and the state legislative process. NCSL does not support turning the CSBG block grant into a competitive grant process. Additionally, NCSL encourages the federal government to provide opportunities for states to use outcome based performance measurement for the local CAAs, while maintaining state flexibility in administering CSBG.

Federal Funding to Assist States to Improve Services to Underserved People and Areas to Address Health Profession Shortages

National Health Services Corps

The National Health Services Corps (NHSC) provides medical scholarship and loan repayment assistance to health professionals in exchange for primary care service in underserved rural and urban areas after graduation. In addition to this financial assistance, state offices of rural health are funded through the NHSC and health programs such as community and migrant health centers rely on NHSC to help recruit health care professionals. The National Conference of State Legislatures supports the NHSC program and encourages Congress to continue to make the NHSC a priority program and to appropriate funds necessary to continue its important work.

The goal of NHSC is to educate and recruit primary health care professionals for service in communities experiencing critical shortages of health care providers. Many of these communities consist largely of individuals with specific cultural experiences or ethnic backgrounds. These communities can present special challenges in recruiting and retaining health care providers sensitive to the particular needs of the community. The NHSC recognizes the importance of training culturally-competent and responsive primary health care providers. NCSL urges Congress through the NHSC programs to: (1) develop additional mechanisms to recruit and retain minority participants; (2) augment informal efforts to match communities with specific cultural traditions with health care providers with shared cultural experiences, or who are specifically trained in culturally diverse community-based systems of care; (3) increase and formalize efforts to recruit and place health professionals who represent racial and ethnic minorities in communities who request them; (4) improve training to encompass cultural competency that considers geographical/regional differences that may affect the health delivery system; (5) more directly involve communities in the recruitment, selection and retention of health care professionals through community sponsorships; (6) increase the emphasis on public/private partnerships, including faith-based institutions, to enhance community involvement and contractual arrangements with independent health care providers; (7) develop programs to assist remote communities, those too small for community health centers, but large enough to need assistance in obtaining primary health care for its citizens; and (8) provide technical assistance to states and local communities in implementing NHSC programs and maximizing resources.

The Conrad 30 State J-1 Visa Program

The Conrad State 30 J-1 Visa Waiver program is the most common method of obtaining a J-1 visa waiver for physicians and other health professionals willing to enter into a 3-year employment contract in a designated health professional shortage area (HPSA) or medically underserved area (MUA). The program provides for the approval of up to 30 J-1 visa waivers for each state.

 NCSL urges Congress to:

  • Permanently authorize the Conrad 30 State J-1 Visa program;
  • Make additional waivers in states for academic medical centers;
  • Increase the current cap on the number of visa waivers per state;
  • Allow physicians who work in underserved areas for five years (three of which could be through the Conrad 30 program) would be eligible for a green card through the physician National Interest Waiver (NIW) program and exempt from the worldwide cap on employment-based green cards;
  • Allow physicians who serve in Conrad 30 "flex" spots to be eligible for the National Interest Waiver (NIW) green card program.
  • Allow physicians who enter the country on a J visa to receive graduate medical education or training with the intent to immigrate permanently; and
  • Allow spouses and children or physicians on J visas to be exempt from the two-year home country return requirement.

HRSA Health Professions Grants and Cooperative Agreements

The Health Resources and Services Administration (HRSA), through a number of grants and cooperative agreements, supports innovations and targeted expansions in health professions education and training. Most of these programs focus on: (1) increasing the diversity of the health care workforce; (2) preparing health care providers to serve diverse population; and (3) preparing health care providers to practice in the nation's medically underserved communities. NCSL urges Congress to continue to support these important programs.

Community Health Centers, Rural Health Centers and Federally-Qualified Health Centers

Community Health Centers, Rural Health Centers and Federally Qualified Health Centers and similar and related facilities play critical role in the health care safety net. NCSL urges Congress to continue to support these facilities.

Liability Protection for Health Professional Volunteers at Community Health Centers and Rural Health Centers - NCSL urges Congress to adopt legislation that amends the Public Health Service Act to deem a health professional volunteer providing primary health care to an individual at a community health center or rural health center to be an employee of the Public Health Service for purposes of any civil action that may arise from providing services to patients. This protection would apply when: (1) the service is provided to the individual at a community health center or rural health center through offsite programs or events carried out by the center; and (2) the health care practitioner does not receive any compensation for providing the service, except repayment for reasonable expenses.

Rural Health Programs and State Rural Health Offices

Discretionary rural health programs such as the rural health outreach grants, the rural health research program, rural hospital flexibility grants, the telehealth program and related grant programs provide important health service support and resources to rural and remote areas of our nation. NCSL urges Congress to continue to support these programs. The State Office of Rural Health Grant Program, first established in 1991, has spurred the development of 50 state offices by providing matching funds for their creation and by providing forums for exchanging information and strategies among states. Today's state offices provide an institutional framework that links small rural communities with state and federal resources and develops long-term solutions to rural health problems. States have become a major agent for change in rural health policy and service delivery, due in part to the work performed by the state rural health offices. NCSL urges Congress to continue to support this important program.

Federal Legislation to Strengthen the Pharmaceutical Supply Chain and to Improve the Regulation of Compounding Pharmacy (Resolution)

Congress has enacted legislation to strengthen the regulation and oversight over the pharmaceutical supply chain and to improve the regulation of compounding pharmacies with a particular emphasis on the “non-traditional pharmacy compounding” that has become important to our overall health care system, but has also has caused harm to a number of individuals across the country. NCSL urges the Food and Drug Administration to work closely with state legislators, state public health officials, state boards of pharmacy and other important state and local officials, providers and industry representatives to develop procedures and systems that retain state regulatory authority where appropriate and that will improve the overall safety of the nation’s pharmaceutical supply chain.

Expires August 2015

Federal Regulation of Interstate and Internet Tobacco Sales

Regulation of Interstate and Internet Sales of Tobacco Products

Illegal interstate, tribal and internet sale of tobacco products affects the health and safety of the nation’s citizens and has a particularly negative effect on state revenues. Tobacco sellers that evade state tobacco taxes: (1) use the profits of these sales to finance other illicit activities; (2) undermine state efforts to reduce youth access to tobacco products by making lower cost products available to them through the mail; and (3) reduce state revenue. In addition, many of these sellers fail to comply with the provisions of the Master Tobacco Settlement Agreement, endangering state compliance with the Agreement and reducing state payments under the agreement by illegally gaining market share in cigarette sales by offering lower prices made possible by their failure to pay the appropriate state taxes.

The Prevent All Cigarette Trafficking (PACT) Act became effective in June 2010. NCSL supports the PACT Act and the continuing partnership between the states and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) to implement this important law. The law:

  • Imposes improved recordkeeping requirements to implement these recommendations;
  • Prohibits the commercial importation of tobacco products, including smokeless tobacco products, into any state in violation of state or federal law;
  • Increases the penalties for noncompliance with the federal laws regulating interstate and internet sale of tobacco products;
  • Authorizes states to enforce tobacco tax collections through the Jenkins Act;
  • Permits states to collect triple damages in any suit against entities selling tobacco in states in violation of the laws of the state and make debts incurred in the purchase of these products uncollectible through actions in courts;
  • Prohibits interstate tobacco sellers from doing business in a state that is party to the Master Settlement Agreement if the seller is not in full compliance with the Model Statute or the Qualifying Statute enacted by the state; and
  • Preserves existing agreements between states and tribal governments regarding cigarette taxes.

FDA Regulation of Tobacco and Tobacco Products 

The Family Smoking Prevention and Tobacco Control Act of 2009 establishes the Food and Drug Administration (FDA) as the agency responsible for the regulation of the manufacturing, marketing and sale of tobacco products. In summary, the law: (1) Restricts the sale and marketing of tobacco products to young people;(2) Authorizes the FDA to restrict tobacco marketing;(3) Requires tobacco manufacturers to disclose information about the ingredients of their products and any changes they make to the ingredients; (4) Authorizes FDA to require changes to tobacco products to protect the public health; (5) Authorizes the FDA to regulate “reduced harm” claims;(6) Requires more prominent health warnings; and (7) Funds FDA regulation of tobacco products through a user fee imposed on tobacco manufacturers. The law does not permit states to regulate the content of tobacco products, tobacco labeling or advertisements. The law does preserve some important state and local government regulatory authority. Specifically, states may adopt laws or regulations related to the sale, distribution, possession or exposure to tobacco products and may restrict the time, place and manner of tobacco product advertising. The law also does not preempt most state-based civil claims. The preservation of state authority permits states to actively support and enhance FDA initiatives.

Food & Drug Administration Regulation Health Programs

The Food and Drug Administration Safety and Innovation Act

The National Conference of State Legislatures supports efforts to improve the safety and quality of our drug supply included in the Food and Drug Administration Safety and Innovation Act.  Key provisions of the law include:

  • Reauthorizes user fees paid by medical device companies and prescription drug manufacturers and establishes new user fee programs for generic drugs and biosimilar (or follow-on biologic) drugs to augment funds provided to the FDA by Congressional appropriations;
  • Enhances the safety of the drug supply chain;
  • Provides incentives to drug manufacturers to develop new antibiotics by providing an additional five years of market exclusivity;
  • Permanently authorizes the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA);
  • Takes initial steps to address drug shortages; and
  • Provides for expedited development and review of drugs for the treatment of serious or life-threatening conditions.
  • In addition, some of the provisions are of particular interest to states.

State Prescription Drug Monitoring Programs – Authorizes the U.S. Department of Health and Human Services Secretary, in consultation with the U.S. Attorney General, to facilitate the development of recommendations on interoperability standards for state prescription drug monitoring programs, to inform and facilitate the exchange of prescription drug information across state lines. The law requires the Secretary to consider the following in the development of recommendations:

  • Open standards that are freely available, without cost and without restriction, in order to promote broad implementation;
  • The use of exchange intermediaries, or hubs, as necessary to facilitate interstate interoperability by accommodating state-to-hub, hub-to-hub, and direct state-to-state communication;
  • The support of transmissions that are fully secured, using industry standard methods of encryption, to ensure that protected health information and personally identifiable information are not compromised at any point during transmission;
  • Access control methodologies to share protected information solely in accordance with state laws and regulations; and
  • Model interoperability standards developed by the Alliance of States with Prescription Drug Monitoring Programs.

Regulation of Internet Pharmacy – The Ryan Haight Online Pharmacy Consumer Protection Act, enacted in 2008, (1) established disclosure standards for internet pharmacies; (2) prohibited the dispensing of prescription drugs over the internet to individuals who have not be seen by a physician, but have merely filled out an on-line questionnaire; and (3) authorized state attorneys general to shutdown non-complying sites across the country by using the federal court system. Unfortunately, the provisions of the Act have not been sufficient to control rogue websites. The law directs the U.S. Government Accountability Office (GAO) to identify problems posed by internet pharmacy websites that violate state or federal law and to identify potential actions that may improve compliance.

Treatment of Synthetic Marijuana, “Bath Salts” and 2c Substances – The law permanently classifies synthetic marijuana, “bath salts”, and 2C substances as Schedule 1 Controlled Substances, making it a federal crime to prescribe, administer or dispense them. Schedule 1 Controlled Substances are substances considered to have a high potential for abuse and are not accepted for use in medical treatment.

Finally, the Congress discussed, but did not agree on a federal law to establish a national drug pedigree system and stronger standards for pharmaceutical wholesale distributors. State pedigree laws should not be preempted unless a workable, national standard is adopted that provides at least the same level of protections as the state laws. The Food and Drug Administration should assign a high priority to initiatives to both identify quantities and assure the quality of raw drugs entering the United States that are then remanufactured for retail sale to consumers here.  The potential for human error in processing or acts of terrorism and the serious consequences that may result from either call for a vigorous and vigilant response by the federal government.

Access to Affordable Prescription Drugs

Importing Prescription Drugs - The National Conference of State Legislatures (NCSL) believes that it should be a national priority to expand access to affordable prescription drugs. More and more people have become interested in exploring the feasibility of importing prescription drugs from other countries to move toward this goal.

Personal Use Policy - NCSL is opposed to the “criminalization” of drug importation and the effect it may have on individuals with limited options. The current federal policy on drug importation is confusing at best. NCSL urges the Food and Drug Administration (FDA) to clarify its “personal use” policy and how the policy is to be enforced. Ultimately if it is determined that drug importation is not the right approach, NCSL urges Congress will make it a priority to explore ways to: (1) increase the number of individuals with health insurance, thereby increasing access to prescription drug coverage; and (2) increase the affordability of prescription drugs.

FDA Regulation of Tobacco and Tobacco Products

 The Family Smoking Prevention and Tobacco Control Act of 2009 establishes the Food and Drug Administration (FDA) as the agency responsible for the regulation of the manufacturing, marketing and sale of tobacco products. In summary, the law: (1) Restricts the sale and marketing of tobacco products to young people;(2) Authorizes the FDA to restrict tobacco marketing;(3) Requires tobacco manufacturers to disclose information about the ingredients of their products and any changes they make to the ingredients; (4) Authorizes FDA to require changes to tobacco products to protect the public health; (5) Authorizes the FDA to regulate “reduced harm” claims;(6) Requires more prominent health warnings; and (7) Funds FDA regulation of tobacco products through a user fee imposed on tobacco manufacturers. The law does not permit states to regulate the content of tobacco products, tobacco labeling or advertisements. The law does preserve some important state and local government regulatory authority. Specifically, states may adopt laws or regulations related to the sale, distribution, possession or exposure to tobacco products and may restrict the time, place and manner of tobacco product advertising. The law does not preempt most state-based civil claims. The preservation of state authority permits states to actively support and enhance FDA initiatives.

General Guiding Principles: Federalism and Health Programs

The partnership between the states and the federal government on health care is complicated, yet critically important. The underlying goal should be to achieve mutually agreed upon goals that produce improved outcomes and achieve program efficiencies and savings for federal, state and local governments. It is equally important that the basic tenets of federalism carry throughout the partnership. NCSL urges Congress and the Administration to avoid:  (1) the imposition of unnecessary uniform standards; (2) unfunded mandates in discretionary and entitlement programs and cost-shifting; (3) restricting state taxing authority and other means of generating revenue; and (4) preemption of state laws and regulations, unless there is a compelling national goal that cannot be achieved another way. NCSL also urges the Congress and the Administration to seek the counsel and expertise of state legislators as key health care initiatives are being developed. It is particularly important that state agencies take the state consultation requirement seriously when implementing health care programs. It is equally important that the agencies consider and detail the impact of federal regulations on state governments. Finally, we strongly urge the Congress, when drafting legislation, and the Administration, when implementing laws, respect the state budget and legislative process and provide adequate time for states to comply with federal requirements.


 In these challenging times, it is still important to provide stable and adequate funding for priority health programs and to increase state flexibility and reduce program requirements when sufficient funding is not available. Every effort should be made to fund programs in a way that is equitable across the states, but also recognizing and addressing the different circumstances among the states and the varying needs of their constituents. In discretionary block grant programs, NCSL urges Congress to avoid imposing set-asides within the block grant. Each new set-aside decreases state flexibility. NCSL supports accountability and transparency and welcomes public feedback and participation. NCSL supports a strong role for state legislatures in program oversight and urges the federal government to give states the flexibility with regard to public notice and the solicitation of public input related to program proposals, program design and benefits, administration and implementation. Too often, legacy states, innovative states that take the first step on a new approach, are disadvantaged when federal programs mirroring their own are enacted. These states should receive special consideration and not be penalized for being innovative.

Medicaid Funding

NCSL strongly opposes proposals to reduce or cap federal matching funds provided to states for Medicaid services, provider reimbursement or program administration. Proposals to cap the Medicaid program fundamentally change the relationship between the states and the federal government by inappropriately transforming a full partnership into a limited partnership, and shifting both costs and responsibility to state governments without adequate authority to manage costs.

NCSL urges the Administration to continue and to expand state flexibility in the Medicaid program through demonstration programs and 1115 waivers. Successful demonstration and waiver programs should be replicated. NCSL urges the Administration to permit bold, innovative programs to be tested and to provide technical support to states as needed.

Emergency Assistance and Countercyclical Assistance - NCSL urges the Congress to study options to include a provision establishing emergency and countercyclical assistance to states within the Medicaid statute. The provision would upon some triggering event, such as an economic downturn, natural disaster, act of terrorism, pandemic or other public health emergency, provide additional financial assistance to states through an enhanced federal match or some other mechanism that would revert back to the regular federal-state cost sharing formula when the triggering event has been resolved. This is a complex, but critical component to fiscal security for the Medicaid program. NCSL looks forward to working with Congress and the Administration to identify options and to establish and implement a program.

State Implementation of Federal Health Programs

State Sovereignty – When federal law requires a declaration be made on the part of the state, the law should simply require “the state” to take the action and allow the state to determine the appropriate state entity to fulfill the requirement. Alternatively, when a federal agency implements the law, the agency should also let the state determine the appropriate entity or individual instead of making its own determination.

State Flexibility – States should be afforded maximum flexibility when implementing federal programs. This flexibility must be accompanied by accountability and transparency on the part of states. Unnecessary uniformity compromises the effectiveness of programs by making it impossible for states to respond to local conditions.

Reporting Requirements and Data Collection – Reporting requirements are important, but should be limited to requirements where there is a reasonable expectation that the data will be used to further program goals. In addition, efforts must be made to impose data collection and reporting requirements in the least burdensome way possible.

Judicial Reforms

State Medicaid dollars are increasingly tied up in costly federal litigation. NCSL urges the Administration and the Congress to work with state officials on developing strategies to reduce the volume of litigation by clarifying and simplifying Medicaid statutory provisions that are too vague or too prescriptive for states to properly administer. NCSL also urges the U.S. Department of Health and Human Services to provide technical assistance to states regarding Medicaid services/issues that are the subject of litigation in several states so that states may find ways to successfully provide the services in question without litigation.

Federal Consent Decrees: Impact on Medicaid

Civil lawsuits filed against public schools, transit systems, and other state and local government agencies often result in consent decrees. Consent decrees can remain in place for decades, locking in policies that were agreed to by officials who are no longer in office, reflecting concerns no longer relevant to the current times and imposing requirements on states that do not meet the current needs of their citizens. Under current law, it is extremely difficult for states to vacate or modify the terms of these consent decrees which means policymakers are hobbled in their ability to govern responsibly.

NCSL supports federal legislation that allows for periodic reexamination of consent decrees to which the state is a party, other than consent decrees addressing school desegregation or other actions brought under Titles VI or VII of the Civil Rights Act of 1964, upon motion of the state and which would make it easier for states to vacate or modify consent decrees as current state circumstances may require.

General Guiding Principle: State-Federal Relations in Human Services Programs

The National Conference of State Legislatures (NCSL) supports a continued partnership between the states and the federal government to provide human services assistance to children, families and individuals who need it. State flexibility, in addition to being an effective tool for curbing costs, provides an opportunity for state legislators to shape the way programs are run and to integrate federal, state, and local programs into a coordinated system. This flexibility is not intended to provide the opportunity for states and the federal government to absolve themselves of the responsibility to meet those human service needs and is an integral component of the state-federal partnership.

State discretion to establish and administer human services should not be replaced by inflexible federal mandates and restrictions. Unless a clear and compelling case for national uniformity exists, every effort should be made to permit state and local governments to respond to local conditions. Since many legislatures meet part-time or biennially, NCSL urges Congress and the Administration to provide adequate time for state legislatures to make necessary changes to state law to implement federal initiatives.

Cost Shifting

NCSL opposes federal initiatives that would shift costs to states by: (1) imposing unfunded mandates on states; (2) requiring states to adhere to existing requirements while reducing the level of federal assistance; (3) reducing the level of federal financial participation for services or administration in state administered programs; or (4) placing an arbitrary spending ceiling on entitlement programs.

Program Consolidation

Congressional or Administration proposals to consolidate categorical social service programs into block grants to states, should:

  • provide maximum flexibility to states with respect to program implementation and administration;
  • include legislative language stating that block grant funding should be expended "according to state law”;
  • authorize states to determine the branch of state government responsible for carrying out public participation requirements;
  • make explicit that the kinds of activities funded in the past under categorical programs need not function as limits or requirements on the kinds of activities funded under the corresponding block grant;
  • direct federal agencies to continue to provide technical assistance to states and to facilitate information exchange among the states;
  • eliminate requirements which have the effect of creating categorical programs within block grants;
  • insist that federal reporting requirements not be burdensome or require the use of funds that would otherwise be used for service delivery; and
  • provide adequate federal funding to assure the continuation of service.

Capping Entitlement Programs

NCSL opposes the imposition of arbitrary spending caps on funding provided to states for services, provider reimbursement, or state administration of entitlement programs. If federal funds to state and local governments for means-tested entitlement programs are capped, included in a program consolidation of categorical programs, or if growth in federal funds is substantially reduced, states must be authorized to reduce or limit services, eligibility and/or payments to beneficiaries and service providers. If statutory and regulatory changes are not made, state and local governments must be absolved from the legal obligation to provide services to entitled individuals.

Health Insurance Portability and Accountability Act

Under the provisions of the Health Insurance Portability and Accountability Act of 1996, federal law supersedes state law, except when the Secretary determines that the state law is necessary: (1) To prevent fraud and abuse; (2) To ensure the appropriate state regulation of insurance or health plans; and (3) For addressing controlled substances, or for other purposes. NCSL supports a broad interpretation of this provision that would result in limited preemption of state laws.

Medical Records Privacy

  • Scope of Law - No patient identifiable medical information may be released without written and oral informed consent of the patient, unless otherwise exempted. A federal privacy statute should define a range of health care conditions and services and protect patient identifiable information, including demographic information, collected during the health care process. A federal privacy statute also should define "information" to include records held in whatever form possible -- paper, electronic, or otherwise. Strong protections for individuals from the inappropriate disclosure of their medical records should be established. Anyone who provides or pays for healthcare or who receives health information from a provider, payer, or an individual should be required to conform to the provisions of the law. Health care providers that do not have direct relationships with the patient must also abide by the same standards. A payer should not be required to provide a benefit or commence or continue payment of a claim in the absence of protected health information, as set forth in each state's statutes, to support or deny the benefit or claim.
  • Consumer Rights - Individuals should have the right to: (1) Find out what information is in their medical record; and (2) How the information is used. Practices and procedures must be established that would: (1) Require a written explanation from insurers or health care professionals detailing who has access to an individual's information; (2) Require insurers or health care professionals to tell individuals how that information is kept; (3) Inform individuals how they can restrict or limit access to their medical records; (4) Inform individuals how they can authorize disclosures or revoke such authorizations; and (5) Inform individuals of their rights should an improper disclosure occur. In general, individuals should be permitted to inspect and copy information from their medical record. Finally, a process should be developed for patients to seek corrections or amendments to their health information to resolve situations in which coding errors cause patients to be charged for procedures they never receive or to be on record as having conditions or medical histories that are inaccurate.
  • Accountability/Security - Severe penalties should be imposed on individuals who knowingly disclose medical records improperly, or who misrepresent themselves to obtain health information. Civil monetary and/or criminal penalties should be imposed on individuals who have a demonstrated pattern or practice of unauthorized disclosure. Any individual whose rights under the federal privacy law have been violated should be permitted to bring a legal action for actual damages and equitable relief. If the violation was done knowingly, attorney's fees and punitive damages should be available. Information should not be used or given out unless either the patient authorizes it or there is a clear legal basis, under state or federal law, for doing so.
  • Public Health - Under certain limited circumstances, health care professionals, payers, and those receiving information from them should be permitted to disclose health information without patient authorization to public health authorities for disease reporting, public health investigation, or intervention, as required by state or federal law.
  • Research - Research protocols and confidentiality standards should be continued and strengthened.
  • Law Enforcement - Law enforcement representatives should be required to have a court order to obtain information from an individual's medical record.
  • Preemption of State Laws - Federal legislation should provide every American with a basic set of rights with respect to health information; however, confidentiality protections provided in state and federal law should be cumulative, and the federal legislation should provide a floor, not a ceiling and only preempt state laws that are less protective.

Administrative Simplification

NCSL supports the administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA). These provisions: uniform claims forms, unified transaction and billing codes, guidelines for electronic claims processing and billing, and other related initiatives will result in improvements to our health care system. It is imperative that all affected entities, however; be afforded adequate time to implement these provisions. It is equally important for the federal government to coordinate all the related rules and regulations so that changes will not have to be made after implementation has begun. Federal and state governments should share information; however, confidentiality of medical records and information must be protected.

Health Information Technology

NCSL strongly supports the development of an interoperable system of electronic health information for the United States. Such a system has the potential to: (1) facilitate the coordination of health care regardless of patient location; (2) improve both the quality and efficiency of care; (3) provide easy access to health care information to both patients and health care providers, which can contribute to more informed decision-making on the part of patients; and (4) reduce medical errors and some of the fraud and abuse that plagues our health care system.

The potential of benefits of an interoperable health information system cannot be realized unless: (1) consumers trust the system and want to participate in it; (2) the full range of health care providers trust the system and find it affordable and easy to use; and (3) employers support the system and believe that it is cost-efficient and improves quality of care.

The key to the development of a successful interoperable electronic health information system is the development of a system that is secure and protects patient privacy. The Health Insurance Portability and Accountability Act (HIPAA) set important privacy standards that must be retained in such a system. It is critical that the current HIPAA law and regulations and subsequent laws and regulations enacted to facilitate an interoperable electronic health information system continue to establish a floor, but not a ceiling when it comes to protecting patient privacy and to the permissible use of stored data. Uses of stored health information data should be limited to treatment, payment, public health and research. Interoperability, not uniformity should be the focus of initiatives to get this important system in place. The security of the data must be a priority. Severe penalties should be established for individuals or entities that compromise information in the system. Every effort must be made to make the system available and affordable to the widest range of providers and consumers.

NCSL also supports the establishment of grant, loan and demonstration programs to provide financial and technical support to health care providers, state and local governments, and other entities that will play a key role in the development and successful operation of an interoperable health information system. States should be permitted to supplement federal financial support to physicians and hospitals with state grant or loan programs for up to 100 percent of costs. Finally, it is critical that publicly financed programs such as Medicaid and Medicare become active participants in the system and that creating this capacity be a priority within the federal budget.

Health Insurance Marketplaces (Resolution)

The Patient Protection and Affordable Care Act (ACA), requires the establishment and operation of an American Health Benefit Exchange, currently referred to as a Health Insurance Marketplace, in each state by January 1, 2014. Each state may either create a state-operated exchange certified by the Secretary of the U.S. Department of Health and Human Services or defer to the federal government to create and operate a federally-facilitated exchange, which includes the ability to partner with the federal government on plan management and consumer assistance in a “state partnership” arrangement. NCSL urges the U.S. Department of Health and Human Services to continue to work with state legislators during the implementation process and to provide additional flexibility to states to improve functionality, cost effectiveness, service delivery and health outcomes.

Expires August 2015

Human Trafficking

The National Conference of State Legislatures (NCSL) condemns the trafficking of persons. Combating human trafficking requires a strong partnership between the federal government and the states. Regardless of the form trafficking takes, it is the exploitation of innocent victims, both domestic and foreign born, who require protection and separation from their traffickers.

Services may also be necessary to help assist victims with reintegration into society. Victims of trafficking are often misidentified and treated as criminals rather than victims, especially commercially sexually exploited children, and do not receive adequate services. The federal government should provide resources and capacity to provide assistance to victims of both sex and labor trafficking.

NCSL encourages improved coordination among the federal agencies responsible for trafficking in persons. There must be improved consultation and coordination with the states and territories, especially state lawmakers. Such consultation and coordination should be conducted with an eye toward establishing and strengthening state/federal partnerships and not preempting existing state laws and policies.

The United States is seeing an increase in trafficked persons who are foreign born and smuggled or brought in under false pretenses. The federal government needs to assist victims whose traffickers have destroyed or withheld their documents as a means of coercion. NCSL supports the use of T and U visas to reduce barriers in the prosecution of traffickers. State legislators commend the Office of Refugee Resettlement (ORR) at HHS for work with states to assist victims, particularly minors. NCSL encourages ORR to provide additional technical assistance to the states and include state legislators in their outreach and consultation efforts. ORR should take the lead in sharing its expertise in assisting trafficking victims with DOJ, HHS and the states.

NCSL supports bipartisan Congressional efforts to establish voluntary grant programs and demonstration projects to assist victims of trafficking. NCSL urges Congress to fully fund the pilot projects authorized under HHS to provide safe and therapeutic shelters for minor victims.

NCSL supports the enhancement of The National Criminal Information Center (NCIC) relative to children who are missing and exploited including children at high risk for sex trafficking. Federal funding will be necessary to ensure that states do not face an undue administrative burden. However, NCSL cannot support any federal legislation that would contain an unfunded federal mandate.

NCSL urges the Congressional Human Trafficking Caucus to discuss the intergovernmental issues surrounding human trafficking with state legislators. NCSL supports the creation of a multi-governmental Blue Ribbon Commission on combating human trafficking on U.S. soil.

The Crime and Justice policy directive details NCSL’s views on the role of law enforcement and other criminal justice personnel in identifying, prosecuting, and enforcing trafficking laws.

Immigration (Joint with Law and Criminal Justice Committee)

The National Conference of State Legislatures (NCSL) recognizes the challenges facing our country in matters related to immigration. Federal immigration policy must strike a balance among core principles of our democracy: preserving the safety and security of our nation, encouraging the economic strength of our states and communities, and recognizing our history as a nation of immigrants. The impact of the federal government’s immigration policy decisions are directly felt by the states who not only implement programs required by federal law but also encourage the integration of immigrants into the economic, social and civic life of their adopted communities. States often bear the costs of immigration, especially in our education, health and law enforcement systems, with limited federal reimbursement.

Immigration Reform

State legislators call on Congress and the Administration to pursue immigration reform that enhances our border security and addresses the imbalance in the state-federal relationship. Immigration reform and implementation requires true collaboration between state and federal leaders. Our nation’s immigration laws must not contain unfunded mandates nor preempt areas of existing state authority. Federal immigration reform will not be comprehensive unless it addresses the fiscal impact of immigration on the states.


Border Security & Enforcement

Securing all of America’s borders, ports, and airports is essential to preserving our national security and maintaining the safety of all Americans. NCSL urges the federal government to fulfill its responsibilities with regard to border security and encourages a renewed state-federal cooperation in countering human trafficking, weapons and drug smuggling. NCSL urges the federal government to increase its enforcement of these crimes.

NCSL supports full, federal funding for increases in Department of Homeland Security border enforcement personnel where they are most needed and necessary improvements in facilities, technology and infrastructure.

The Role of State and Local Law Enforcement

NCSL is strongly opposed to any efforts to shift enforcement of civil immigration law to state and local law enforcement agencies. State legislators believe that enforcement of federal civil immigration law is a federal responsibility and that state involvement in immigration enforcement activities should only be a state option.

NCSL opposes efforts to criminalize violations of civil federal immigration law in an effort to shift federal enforcement responsibilities to state and local law officers. State and local government law enforcement and public safety personnel must already incarcerate, detain and transport illegal immigrants who have committed crimes, without adequate federal funding. NCSL strongly supports full reimbursement to states for the State Criminal Alien Assistance Program (SCAAP). The current SCAAP program only provides 17% reimbursement of current costs, according to a recent General Accountability Office study. NCSL also opposes any effort to coerce state participation in enforcement of federal immigration law by withholding SCAAP program funds.


Worksite Enforcement

NCSL believes that employment verification is a critical component of enforcement requiring federal reforms. NCSL supports the rights of states to provide incentives and sanctions to encourage compliance. The U.S. Supreme Court case in Chamber of Commerce v. Whiting agreed with this view. NCSL opposes efforts to treat state governments differently from the private sector in meeting federal employment verification requirements.


NCSL supports E-Verify in its current voluntary form. NCSL urges Congress and the Administration to improve the program to handle the interfaces between the Social Security Administration and Department of Homeland Security databases and to eliminate discrepancies and backlogs. NCSL opposes any efforts to mandate E-Verify until the system is adequately funded and performs to the benefit of all parties without imposing unfunded liabilities on the states.

Enforcement efforts should be focused on bad actors – employers and employees alike. NCSL is deeply concerned about identity theft and counterfeit documents. NCSL encourages the DHS to test approaches that confirm the identity of the individual as part of the verification process. NCSL urges the federal government to tighten its enforcement surrounding counterfeit documents. DHS needs to improve its education and training for employers regarding worksite verification.

SAVE (Systematic Alien Verification for Entitlement)

NCSL strongly believes that the federal government should pay for the cost of SAVE and/or new verification requirements. Unfunded verification requirements for state programs or federal programs that states administer are a cost-shift to states and violate the Unfunded Mandates Act.

Enforcement Activities

NCSL believes that federal enforcement activities – at the worksite or in communities - should be coordinated with state and local government. NCSL urges the federal government to be mindful that the states bear the primary responsibility for the children who are separated from their families as a result of federal enforcement activities. NCSL supports federal coordination with child welfare agencies to guarantee that children are not endangered and that their best interests are protected.


State Impact Assistance

The 1996 federal welfare law established a five year bar on SCHIP/Medicaid, Supplemental Nutrition Assistance Program (SNAP), TANF and SSI for legal immigrants. Yet, state governments continue to bear significant costs for essential programs and services such as education and public health that promote public safety, reduce community tensions and integrate newcomers into our communities. This could include those who may be here on a temporary basis. State governments fund critical services including: emergency health care, public health, safety and education and English language instruction.

NCSL urges Congress to include in immigration reform a funding stream to address the entire fiscal impacts on state governments of any guestworker program, earned legalization and/or increases in the number of immigrants. Such funding must be subject to appropriation by state legislatures so that it can be best targeted to the state’s individual needs including government, faith-based or nonprofit institutions. These grants must take into account the fact that some states have existing high levels of noncitizens and some states have recent high growth in the number of noncitizens. Grants must be allocated in a way that assists both categories of states.  NCSL opposes any measure that does not contain state impact assistance.


Temporary Worker Program

 NCSL supports the creation of a temporary worker program. Providing a legal channel for those that want to come to our country for work will reduce illegal border crossings and enable federal law enforcement agents to focus their efforts on individuals attempting to enter or already in the country for the purpose of doing our nation harm. A temporary worker program for critical industries will also strengthen many sectors of our economy by providing a legal workforce. NCSL believes that Congress and the Administration should work together to develop a system that responds to the nation’s needs effectively and efficiently.

Temporary worker visas help to fill labor shortages in seasonal and specialized occupations that have been caused by changing demographics and a need for expertise. NCSL urges the Administration and Congress to consider demonstration projects in health and education and work with states to develop sound policies that will prevent cost shifts to states. The federal government should work with states who wish to streamline and improve efficiencies in temporary worker and investor visa processing, and identify areas of needed flexibility for exchange visitor programs.

Earned Legalization

NCSL affirms the right and responsibility of the federal government to determine federal immigration policy, including the existence and form of an earned legalization program. NCSL supports the creation of an earned legalization program for illegal immigrants currently in the country. NCSL opposes amnesty. Earned legalization should include appropriate fines and penalties that are proportional to the violation. A mass deportation or crackdown on illegal immigrants currently in the country would have detrimental impacts on our communities because immigrant workers and entrepreneurs contribute to the economic vitality of our nation and citizen children in mixed-status households would be adversely impacted.

Legal Immigrants

NCSL opposes federal efforts to deny benefits to legal immigrants and to citizens who are foreign born. This shifts the cost of taking care of needy legal noncitizens to the states and localities. Eliminating federal benefits to noncitizens or deeming for unreasonable amounts of time does not eliminate the need, and state budgets and taxpayers will bear the burden. NCSL supports:

  • the extension of deadline for those elderly and disabled refugees so that they can continue to receive SSI benefits while pursing citizenship;
  • making affidavits of support legally binding so that sponsors of immigrants will live up to their commitment to support them;
  • requiring voluntary agencies to live up to their commitment to refugees;
  • enforcing Department of Labor certification process for employer sponsorship for both temporary and permanent foreign workers; and
  • a limited period of alien to sponsor deeming.

NCSL supports the HHS regulation limiting the definition of a means-tested benefit to Temporary Assistance to Needy Families (TANF), Medicaid, Supplemental Security Income (SSI), State Children’s Health Insurance Program (SCHIP) and Food Stamps.

Refugee Assistance

NCSL supports federal efforts to assist individuals and families forced to flee their native land in fear for their personal safety. The problem of political refugees is an international one, and consequently demands the cooperative efforts of many countries.

While refugees, Cuban and Haitian Entrants, and asylees continue to be accepted, federal support which provides income and medical assistance, social services, education, employment and training and other needed support has continued to be reduced, shifting these costs to state and local governments. The existing federal domestic assistance program appropriately provides 100 percent federal funding for income and medical assistance after settlement. States should be reimbursed for cash and medical assistance during the resettlement period for 36 months as provided by law. States have been willing to accept refugee policy decisions that are made by the federal government; to continue this coordination, the federal government must provide adequate financial assistance to aid refugees in resettlement. NCSL believes that funding should be more flexible to allow states to respond to changing needs. The cost of resettlement must not be shifted to the states.

The federal government should not raise the admissions ceiling without adequately compensating states for resettlement costs. NCSL is disturbed by the recent trend to admit refugees under "refugee-like" categories that are not eligible for federally reimbursed services.

The primary goal of the federal domestic assistance program is to assist refugees and entrants to become independent and self-sufficient members of the community. NCSL urges the federal government to improve the track record of the domestic assistance program in meeting the goal of self-sufficiency and independence for refugees.

The federal government should provide English and citizenship instruction as well as job training to refugees, where possible, before they arrive in the United States. This up-front investment should reduce costs in the domestic assistance program and should result in a more successful effort in producing self-sufficient and independent citizens. NCSL asks the Office of Refugee Resettlement(ORR) to assist states with efforts to strengthen refugee integration services. It is also critical for the federal government to support English and citizenship instruction to refugees already in the United States who, according to federal law, will lose access to public benefits unless they become citizens within seven years.

 In addition, NCSL strongly urges the federal government to avoid further placements in areas that are already heavily impacted with refugee or Entrant populations, experiencing a shortage of rental housing for low-income households, and experiencing overcrowding in the local school system. NCSL urges the federal government to continue to work with states on the issue of secondary migration.

NCSL urges the federal government to continue the health screening that is currently provided to the refugees, where possible, before they arrive in the United States and to improve follow-up. Follow-up should include, but not be limited to, providing instruction for continued medical care to refugees in the home. Improved outreach and orientation to our health care system is critical especially in light of language and cultural differences. State health screening support is critical and should not be eliminated.

NCSL urges the federal government to coordinate and consult with state and local governments is an integral component of a successful placement policy and we urge the federal government to improve its efforts in this area. It is equally important to have the voluntary agencies and organizations representing refugees participate in this coordinated effort. NCSL supports extended protection to victims of trafficking, victims of domestic violence, and unaccompanied minors.


Naturalization and Integration

NCSL supports the promotion of citizenship as a national priority. Delays in citizenship applications are unjustified. The federal government should allocate sufficient resources to a for more efficient citizenship adjudication and integration processes. The costs of becoming a citizen are excessive and a barrier to those working families who seek citizenship. NCSL strongly urges the federal government to assist the states in their efforts to promote naturalization and to address all barriers to naturalization.

Low Income Home Energy Assistance Program (LIHEAP)

The cost of energy fuels makes it difficult for low income households to adequately heat or cool their homes without assistance from federal, state, and local governments. NCSL believes that the development of an efficient and effective energy assistance program is dependent upon coordination and cooperation on the part of all levels of government and the private sector.

The federal energy assistance program should have two major components: a cash assistance program to help low income households meet their immediate financial obligations to their energy supplier and a weatherization assistance and conservation education program to help low income households lower energy consumption and costs. In addition, NCSL supports the use of interest subsidized loans to assist households to weatherize their homes.

NCSL believes that the low income energy assistance programs should: (1) include all states in the funding allocation formula; (2) afford states the flexibility to shape the program in a way which best suits the needs of its citizens and maintains strong state oversight of such programs; (3) target assistance to households with the lowest incomes and to households with infant, elderly, and/or disabled members; (4) authorize states to draw down program funds on an as needed basis; (5) prohibit counting energy assistance payments as income for the purpose of determining eligibility and/or benefit levels in the public assistance programs. NCSL supports funding at the highest authorized level for this program.

Maintaining the Solvency of Social Security

The National Conference of State Legislatures (NCSL) strongly believes that the federal government has an obligation to preserve the financial integrity of the Social Security system and assure the long-term solvency of the program. State legislatures believe Social Security must ensure a safety net for low-income older retirees as well as provide survivor benefits and disability insurance. It is critical that all workers paying into the system have confidence that Social Security will continue to be available to them at retirement or to provide for their survivors after their death. NCSL believes that efforts to assure solvency should strengthen the existing program upon which so many beneficiaries and their families rely. Social Security reform should continue to encourage private savings and employer-provided pension plans as important components of retirement savings.

The Administration and Congress face difficult choices in maintaining the solvency of Social Security. As Congress considers alternatives to maintain Social Security solvency, it must analyze and understand the impact of these proposals on states, taxpayers, state budgets, and state laws. Social Security reform will have major impacts on state employees, teachers, local government, private employers and taxpayers. The National Conference of State Legislatures opposes reform proposals that finance this shortfall by shifting federal costs to state budgets. If Social Security does not continue to provide a stable form of assistance to the elderly, state low-income programs and budgets would be severely impacted. A sudden loss of promised Social Security benefits would likely impose financial hardship on many dependent American seniors and families. It replaces lost income for workers and their spouses and children when a worker becomes disabled, dies or retires. NCSL strongly opposes any efforts to reform Social Security that create unfunded mandates for the states or preempt state laws and authority. NCSL also opposes the expansion of mandatory Social Security coverage to state and local public employees who are not already covered. Additionally, state legislators recommend the following for the solvency of the Social Security program:

Congress and the Administration should continue to study various combinations of federal policy adjustments that would avoid negatively impacting any one sector of the population and keep costs to wage earners as low as possible;

Congress and the Administration should continue to provide the expected benefits promised by Social Security and the important role of Social Security in alleviating poverty should not be lost in the efforts to restore solvency or reform the program.

Any effort to balance the federal budget or reduce the federal debt shall not be accomplished by reductions Social Security benefits.

Medicaid and Children's Health Insurance Program, Legislative, Regulatory, and Administrative Initiatives (2014-2015) (Resolution)

Legislative Initiatives

Children’s Health Insurance Program (CHIP) – NCSL continues to support CHIP and urges the Congress to ensure continued funding and state flexibility in the operation of the program.

Continuation of the Incentive Payment Program for Primary Care Services – NCSL urges the Congress to ensure continue to fully fund the Medicaid Incentive Payment Program for Primary Care Services for an additional calendar year through December 2015.

Deficit Reduction – NCSL supports efforts to put the federal government’s budget on solid footing and NCSL anticipates reductions in federal support for some state and local government programs as part of that effort. The reduction of the federal deficit should not be achieved by shifting costs to state governments. Elimination or reduction of federal assistance programs and financial assistance must be accompanied by: (1) greater program flexibility; (2) relief from unfunded legislative and regulatory mandates; (3) relief from maintenance of effort requirements; and (4) continued support for safety net programs during economic downturns. The Medicaid program represents a significant portion of states' economies and any changes should avoid further damaging already weakened economies.

Blending Medicaid Matching Rates – NCSL is pleased that the Administration is no longer proposing to blend the matching rates for Medicaid and the Children’s Health Insurance Program (CHIP).

Provider Tax Limitations – Extensive changes to the Medicaid Voluntary. Contributions and Provider-Specific Tax amendments of 1991, as amended, were adopted in recent rulemaking. NCSL opposes further restrictions on states’ ability to impose provider-related taxes. Emergency Assistance and Countercyclical Assistance - NCSL urges the Congress to study options to include a provision establishing emergency and countercyclical assistance to states within the Medicaid statute. The provision would upon some triggering event, such as an economic downturn, natural disaster, act of terrorism, pandemic or other public health emergency, provide additional financial assistance to states through an enhanced federal match or some other mechanism that would revert back to the regular federal-state cost sharing formula when the triggering event has been resolved. This is a complex, but critical component to fiscal security for the Medicaid program. NCSL looks forward to working with Congress and the Administration to identify options and to establish and implement a program.

Regualtory Initiatives

Medicaid Expansion Options – NCSL urges the Secretary of the U.S. Department of Health and Human Services to support and explore a broad range of alternative approaches in addition to the provisions in the Patient Protection and Affordable Care Act to provide affordable coverage for low-income people through the Medicaid program.

Restrictions on States’ Ability to Reduce Medicaid Provider Rates – NCSL opposes the provisions in the proposed rule, Methods for Assuring Access to Covered Medicaid Services, which would severely limit the ability of state legislators to propose and carryout rate reductions for Medicaid providers. The rule ignores the state budget process and imposes requirements that would favor the federal and state executive branch over the state legislature.

Program Integrity Initiatives – NCSL is pleased that the Administration has proposed to coordinate and consolidate some of the existing program integrity programs enacted over the last several years to address duplication of effort and conflicting elements of the programs. NCSL urges the Congress and the Administration to make the necessary legislative and regulatory changes to improve the cost effectiveness of the federal program integrity initiatives, to lessen the administrative burdens associated with them, and ultimately to improve our collective effort to eliminate fraud, waste and abuse in the Medicaid program.

Data Collection Requirements – Data is important and necessary to assure program integrity and to improve program quality. NCSL urges the Congress and the U.S. Department of Health and Human Services to carefully consider data collection requirements imposed on state and local governments. The costs, both financially and in staff time, must be commensurate with the contribution the collected data will make to overall effort to improve access and quality.


Federal Coordinated Health Care Office (Medicare-Medicaid Coordination Office) – The establishment of the Federal Coordinated Health Care Office within the Centers for Medicare and Medicaid Services (CMS) is an important first step in improving coordination between Medicaid and Medicare services for people who participate in both programs. NCSL supports the establishment of the office and looks forward to working closely with its staff to improve access, care and services to this important group of Medicaid and Medicare beneficiaries.

State Demonstrations to Integrate Care for Dual Eligible Individuals - NCSL strong supports the new State Demonstrations to Integrate Care for Dual Eligible Individuals. These projects will help states design and implement new approaches to better coordinate care for dual eligible individuals. The Centers for Medicare and Medicaid Services (CMS) provides funding and technical assistance to states to develop person-centered approaches to coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals. The goal is to identify and validate delivery system and payment coordination models that can be tested and replicated in other states. CMS is also making technical assistance available to all states interested in improving services for dual eligible individuals. NCSL urges CMS to continue to support these demonstration projects and to provide maximum flexibility to states to explore options that may improve the quality of life and health outcomes for dual eligible individuals.

Technical Assistance

Technical Assistance – As states continue to implement the Medicaid-related provisions of the PPACA, technical assistance in the following areas will be extremely important: (1) managed care and other service delivery reforms, particularly for special populations and services and in rural areas; (2) payment reforms; (3) successful initiatives to improve care and reduce costs; (4) workforce recruitment, training and retention initiatives; and (5) strategies for enrolling and serving single, childless adults in Medicaid.

Managing Medicaid Costs

Flexibility to Manage Costs - States should be given flexibility to manage Medicaid costs by modifying certain sections of the Social Security Act, such as:

  • Section 1927 that prevents states from using drug formularies to constrain the cost of prescription drugs. The section should be modified to remove the requirement that states cover every drug for which a manufacturer signs a rebate agreement.

Expires August 2015


NCSL Supports National Health IT Week - September 15-19, 2014 (Memorial)

National Health IT Week 2014 will take place September 15-19. Key public and private healthcare constituents – representing the full spectrum of healthcare interests – will convene in Washington, DC and around the country to address implications for ongoing healthcare reform initiatives and promote understanding and implementation of ARRA now.

Initiated in 2006 by The Healthcare Information and Management Systems Society (HIMSS), National Health IT Week has emerged as a landmark occasion for bringing together diverse national healthcare stakeholders, who partner in developing neutral, common ground for the advancement of health IT adoption with "One Voice, One Vision."

This September, nearly 400 public and private sector organizations throughout the nation will participate in the Ninth Annual National Health IT Week.

The National Conference of State Legislatures (NCSL) has worked closely with HIMSS and other stakeholder organizations to promote understanding among state policymakers of the contributions of health IT to improving the quality and safety of healthcare delivery and containing healthcare costs. National Health IT Week presents an opportunity for NCSL and other stakeholders to recognize the value of information technology and management systems to transform the United States healthcare system, improving the quality and cost efficiency for all Americans.

NCSL encourages its members to observe "National Health IT Week 2014" in appropriate ways in their respective state capitals as well as in the Nation's Capital. NCSL also encourages its members to urge their respective delegations to the United States Congress to join in recognizing the benefits of health information technology as they act to improve health care for all citizens during National Health Information Technology Week.

Nutrition Assistance

The National Conference of State Legislatures (NCSL) strongly supports the state/federal partnership to provide nutrition assistance to those in need. State legislators are concerned about the vast numbers of hungry persons, particularly the severity of childhood hunger. The Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamps Program), Emergency Food Assistance, WIC and Child Nutrition programs alleviate and prevent hunger and enable families to improve their health and be more productive at school and at work.  

SNAP: Supplemental Nutrition Assistance Program/Food Stamps

SNAP designed to assist needy families meet their nutritional needs, has improved the health of millions of families and moved toward eliminating malnutrition in the United States.

NCSL supports continued federal financing of the SNAP program at levels sufficient to provide assistance to all that are eligible. Especially in times of economic hardship, this program, along with other nutrition assistance programs, offers a vital safety net for low-income Americans.

NCSL opposes proposals that would impose costly administrative burdens and mandates on state governments and that remove state flexibility that is critical to cost-effective administration of SNAP. NCSL also opposes proposals to raise federal funds by capping or restricting the state entitlement to administrative funds. NCSL will not support a cap on administrative funds without a commensurate limitation on federal requirements. NCSL supports a permanent restoration of the historic 50% SNAP administrative match.

NCSL appreciates the administrative flexibility that USDA has created through the waiver process to allow states to implement efficiencies in administrative processes such as telephone interviews, Combined Application projects, and projects that allow partnerships with non-profit agencies to assist in the application process. NCSL supports making successful processes that were developed under waivers states options. State Legislators are concerned that benefits to recipients not be reduced, that benefits be adjusted to reflect the increased costs of food and other basic necessities and that barriers to participation be removed. NCSL would also urge the Congress and the Administration to continue to work toward making SNAP and Temporary Assistance to Needy Families (TANF) block grant more compatible.

SNAP Benefits and Program Design

NCSL recommends that Congress and the Administration incorporate the following issues regarding SNAP benefits and program access into future action:

  • eliminate the cap on excess shelter deductions which would allow families to deduct high shelter costs;
  • adopt the pre-1996 formula that each October set the benefits at 103% of the Thrifty Food Plan for the previous June;
  • exclude the first $50 a month paid as child support from consideration as income in determining the SNAP allotment;
  • expand employment and training (E&T) programs to help recipients become self-employed;
  • promote program simplification and coordination between TANF and the SNAP program to make them more compatible and less costly to administer.
  • periodically reevaluate the rules concerning the value of a vehicle that a recipient may own and still receive SNAP benefits;
  • adopt administrative improvements and ensure that coordination occurs where welfare reform changes impact SNAP policy and other means of simplification;
  • maintain federal funding and technical assistance to reach eligible families, especially those who have left TANF, and working poor families;
  • undertake initiatives to improve access to SNAP and support USDA's efforts to improve outreach;
  • allow senior citizens and the disabled to apply for SNAP at Social Security offices, allow use of joint applications and improve minimum benefits;
  • support USDA's efforts to create a web-based screening tool to determine SNAP eligibility and expand technical assistance on applications; and
  • maintain state option regarding child support cooperation as a condition of eligibility for SNAP. NCSL remains opposed to the federal government imposing a mandate requiring such cooperation. Additionally, NCSL supports the elimination of the fee for SNAP recipients child support collection efforts as a further incentive toward child support enforcement participation.
  • continue to support current state options regarding categorical eligibility and "heat and eat.”

SNAP and Legal Immigrants

 NCSL congratulates the Administration and Congress for the 2002 restorations of SNAP to eligible legal immigrant children and families. NCSL strongly opposed the provisions of the 1996 law that denied SNAP assistance to certain legal immigrants. State legislators identified the 1996 denials as a cost shift to the states and state lawmakers strongly supported these restorations. Many states created their own food assistance programs or increased state funding for food banks to try to ameliorate the impact of the federal denial of food assistance to legal immigrants. NCSL commends USDA's outreach efforts to these newly eligible legal immigrants including the efforts to translate materials into more than 34 languages. State lawmakers should continue to be included in these efforts. NCSL continues to support restoring eligibility to the small number of legal immigrants who were not covered under this historic restoration.

SNAP Employment and Training Program

NCSL is committed to assisting in efforts to make the Employment and Training (E and T) program a successful one and will work closely with USDA and Members of Congress to encourage self-sufficiency among SNAP recipients. NCSL urges Congress to allow states flexibility to create, fund and integrate SNAP E and T programs in order to complement similar programs particularly TANF and the Workforce Investment Act (WIA) and other state programs. At a minimum, a coordinated policy must be developed between this program, welfare reform and the new comprehensive workforce law. In addition, NCSL appreciates the USDA's willingness to grant states waivers of the three month rule in areas of high unemployment and USDA's technical assistance to states.

SNAP Program Quality Control/Judicial Waiver

 State legislators fully support the original intent of quality control -- to provide states with a management tool to identify problems in public assistance administration and to facilitate corrective actions. However, many problems in the current system have been documented including statistical flaws and the levying of excessive financial penalties on states. NCSL applauds the move away from a system based on error rates to one that awards bonuses for accuracy. NCSL also urges improvements in the ability to appeal waiver decisions, the placement of statute of a state's right to reinvest claims and the broadening of quality control's scope to include outcome measures of other program goals. State legislators urge Congress and the administration to find more appropriate means of judging program success and measuring program outcomes. State lawmakers continue to support the funding for bonus payments for state performance. NCSL would support efforts to focus on measurement through positive incentives and urge Congress to reexamine the funding level. State legislators urge USDA to continue the sound practice of settling QC claims through state reinvestment in program improvement.

Electronic Benefit Transfer and Automated Systems

Electronic benefit transfer (EBT) is a system of using electronically-encoded cards (such as magnetic-striped ATM cards, "smart cards" or laser technology) to provide recipient benefits through store checkout machines and ATMs. When properly administered, EBT systems can reduce administrative costs, eliminate benefit trafficking and facilitate multi-program benefit issuance systems. NCSL supports the regulation that establish the implementation of EBT systems as a normal administrative option for states and supports the widespread interest and planning for SNAP EBT implementation nationwide, and support allowing the card to be used for multiple programs, as a state option.

NCSL believes that states should be allowed to negotiate the terms of Electronic Benefit Transfers (EBT) with both food marketers and financial institutions. Additionally, the federal government must not preempt state laws that govern financial institutions in their goal of a nationwide EBT system. As additional income support programs are added to EBT systems that are state-only or state-federally governed, the federal government must not preempt state benefits law. State legislators are also concerned about the overestimation of savings by EBT systems. Currently, the federal government recoups savings by eliminating the creation, handling and storage of paper coupons and by fraud reduction. NCSL cautions the federal government from over-promising savings to the states, especially those from fraud reduction, and urges further studies of the impact of EBT on states, including costs and savings from its fraud reduction. NCSL congratulates the federal government for eliminating the cost-neutrality requirements in the EBT system. NCSL continues to support enhanced match. Many of the current systems are obsolete and barriers remain for states to combine their information systems across programs to increase efficiency of program delivery. This is especially problematic given current state fiscal conditions

SNAP Program Flexibility and Waivers

NCSL strongly believes that the federal waiver process should be reevaluated. States need flexibility for further innovation and state legislators would prefer to have options, rather than waivers for policy changes that are not in need of further evaluation. State legislators need to be included in the waiver process prior to the waiver being granted. Plan approvals and the results of demonstrations should be shared with state legislators.

Emergency Food Assistance and Commodity Distribution

 NCSL urges the Congress to fully fund The Emergency Food Assistance Program (TEFAP) at its authorized level. In addition, the Congress should provide for adequate administrative funds to facilitate the efficient distribution of food and should include sufficient safeguards to prevent program abuse. NCSL urges the Department of Agriculture to make additional surplus commodities available to states, upon request, when additional surplus food becomes available. We also urge USDA to provide administrative funding support for sorting, packaging, processing and transporting donated food. NCSL supports current federal programs that deliver commodities through farmer's markets and the child nutrition commodity program. NCSL also supports the USDA Fruits and Vegetable pilot program aimed at increasing consumption by school children.

Child Nutrition

 In 1946, Congress enacted the National School Lunch Act, which provides cash grants and commodity donations to public and private non-profit schools to subsidize the operations of school lunch programs. Since that time, Congress has enacted the following additional child nutrition programs: School Breakfast, Special Milk, Summer Food Service (SFP), Child and Adult Care Food, Nutrition Education and Training Program (NET) and the Special Supplemental Feeding Program for Women, Infants and Children (WIC). Good nutrition is fundamental to the physical and mental development of children. Recent research on early childhood brain development underscore that adequate nutrition is essential for cognitive development. Moreover, as more parents leave welfare and enter the workforce, the CACFP and SFP are especially critical to the provision of quality child care and after-school services. These programs augment our successful welfare reform efforts. The National Conference of State Legislatures believes that adequate federal support for these programs is essential.


 NCSL urges Congress to fully fund the WIC program at the levels authorized by Congress. The WIC program provides supplemental food, nutrition education and health care referral services to pregnant women, infants and young children from low-income households who are determined by competent medical professionals to be at nutritional risk. The importance of this program cannot be overemphasized. Nutritional deficiencies during pregnancy or early childhood can result in lasting damage to a child's mental and physical development. The WIC program has been proven effective in reducing the incidence of low birth weight. In addition, this program reduces the need for extensive medical care and thus yields savings in the Medicaid program. NCSL supports providing women participating in the WIC program education and information on the best sources of nutrition for their babies in the first year, starting with breastfeeding, including infant formula if needed, followed by the introduction of solid foods. This program deserves continued financial support and priority status by the Congress and the Administration. NCSL supports broadening adjunct eligibility to maximize WIC coverage for women, infants and children in need.

NCSL believes that additional technical assistance for the development of EBT systems  is critical to streamlining the administration of the WIC program. This will enable states to better monitor program expenditures. NCSL supports Congressional efforts to improve program administration by authorizing limited borrowing between fiscal years for the WIC program and by requiring the timely apportionment of WIC funds to the states.  NCSL supports funding to allow technological improvements to WIC and to allow the implementation of WIC EBT.

School Breakfast and Lunch Programs

NCSL strongly supports the National School Lunch and the School Breakfast Programs (NSLP and SBP) as critically important to the well-being, education and ultimate future self-sufficiency of young children. State legislators are concerned about proposals to eliminate the cash subsidies to schools for moderate and high income children under the provisions of the school lunch and school breakfast programs. The provision of federally-funded start-up grants would enable many schools with large numbers of low-income children to initiate the school breakfast program. Under the current financing structure for the programs, elimination of the subsidy may force many schools to drop their lunch and breakfast programs. NCSL believes that these programs are important and that schools should be encouraged to continue providing these nutritional meals. Ultimately, the existing financing structure may need to be altered. NCSL recommends that a study be conducted that would consider alternative financing scenarios that would retain program universality. NCSL urges USDA to pay attention to nutritionally-appropriate foods avoiding those high in sugar, fat and sodium. School breakfast programs are also an important part of ensuring that children have proper nutrition and are ready to learn, and NCSL supports federal initiatives in this area.

NCSL notes that accurate eligibility determination is important in any federal program, but efforts to ensure that only eligible children are served must not have a chilling effect on program participation for hungry children. NCSL supports the USDA proposal to create a pilot program for school districts to enable them to provide more nutritious alternatives and would allow such experimentation without risk of financial loss to those schools.

Summer Food Service Program For Children

 Children who qualify receive 1/3 to 1/2 of their total early nutrient intake from the school lunch program, yet only one in five of those children who receive lunch at school have the opportunity to receive a summer lunch. NCSL believes that there is value for these children to receive nutritious meals throughout the year. The Summer Food Program is especially valuable as more mothers leave welfare to return to work full-time. The program serves as an additional resource for summer programs to ensure that children are not left unattended and hungry. NCSL supports the Summer Food Service Program for Children( SFSPC) and the restoration of meal reimbursement rates that will make it possible for low-income children to receive a nutritious lunch in the summer. NCSL supports policies that will make it easier for non-profit community groups and public entities to sponsor the program, and will allow the program to be available in more neighborhoods and rural areas.

Child and Adult Care Food

The Child and Adult Care Food Program (CACFP) provides assistance to child and adult day care providers so that nutritional meals are provided to children and seniors. State legislators recognize the importance of these programs. These feeding programs are the major federal support of child care and are critical support to low-income children. Proposals to eliminate or reduce this program ignore its valuable contribution to the expansion of child care and reduction of childhood hunger. NCSL strongly supports efforts to expand this program to older children in after school programs, and to ensure that the program is available in more neighborhood and rural areas. Additionally, NCSL supports state options to expand this critical program to suppers in after-school programs.


NCSL believes that nutrition is important and that both childhood & adult obesity are a social and public health problem. NCSL supports federal efforts to find solutions to this problem without any new federal unfunded mandates. NCSL supports a proposal to fund a pilot program for the states with the greatest incidence of childhood and adult obesity to develop policies and procedures to reduce obesity.

Nuturing Responsible Families and Child Support Enforcement

The National Conference of State Legislatures (NCSL) believes a stable household with adequate financial resources to provide for basic needs of children should be the goal of every parent. The role of government should be to encourage individual parental responsibility in meeting that goal and to assist in providing support for children whose parents are unable to do so.

Child Support Enforcement

NCSL believes that enforcing parental support obligations is an integral part of a comprehensive income security program for our nation's families. The federal child support enforcement program, authorized under Title IV-D of the Social Security Act, was established to enforce support obligations owed by non-custodial parents to their children by: (1) establishing paternity; (2) locating non-custodial parents; and (3) obtaining support payments.

NCSL believes states and the federal government should ensure that child support is fair, equitable, and timely. In reviewing the current system, NCSL concludes that child support enforcement can be enhanced through better coordination of purpose at the state and federal level, through a renewed commitment to interstate cooperation, and through the application of intellectual and financial resources to attack the problem with creativity, innovation, flexibility, and strength.

NCSL supports improved coordination of all programs and organizations working on child support enforcement, including but not limited to: state policy makers, state courts, local and state bar associations, district and state attorneys, local and state child support directors, local law enforcement officials, educational institutions, family and child support advocacy groups, tribes, and programs that work with both parents.

NCSL believes that the federal child support audit process would be improved by focusing on performance outcomes rather than administrative procedures and processes. A revision of the process would allow for more innovation and adaptability to individual state needs, while still providing oversight. NCSL also urges the federal government to allow states to reinvest their child support penalties in the child support system as a more effective way for states to come into compliance. Similar penalty reinvestment practices are followed in other human services programs. State investments in technology-related expenditures, which are necessary in order to come into compliance with federal requirements, should be taken into account in the penalty process.

Program and System Improvements

The increasing effectiveness of state child support enforcement programs performs an important service for children. Federal financial participation has created the base for these effective and increasingly successful programs. However, as more families leave welfare and go into the workforce, the program no longer provides the financial return to the state and federal government. The states and federal government need to re-examine the financing of this program.

NCSL urges the federal government to continue to support technical assistance to the states with respect to exemplary practices, procedures, and legislation that has been effectively implemented.

New child support initiatives from the federal government should allow maximum flexibility among states, reward new initiatives and encourage state experimentation and innovation.

NCSL is pleased with the progress the Office of Child Support Enforcement (OCSE) has made in focusing on program outcomes and assistance to states to maximize the effectiveness of state child support systems and collections. NCSL encourages OCSE to regularly communicate with state legislators, particularly through the regional offices and relevant action transmittals.

NCSL supports an incentive approach for a permanent enhanced federal administrative match for states that implement a minimum package of innovative procedures to increase program effectiveness.

NCSL realizes states need to make significant improvements in the number and timeliness of paternity establishments, as this is the cornerstone to an effective child support enforcement program. Currently, states are rewarded for improving paternity establishment. Federal funds should accompany federal paternity mandates.

NCSL supports proposals that would put states on a phased-in schedule of improvement that would use current year levels of paternity establishments as the base and would require a reasonable schedule for improvement.

NCSL recommends that if any additional mandatory program requirements are adopted as amendments to the existing Child Support Enforcement program, Congress should provide for: (1) a reasonable transition period; (2) waivers to permit states to address state specific problems with program requirements; and (3) flexibility for states to implement innovative alternatives that still meet the goals of the program.

NCSL supports the federal parent locator service but opposes a mandate that would charge states for the use of the service.

Payment of Child Support in the TANF Program/Child Support Pass through

 NCSL supports the option for states to use a disregard as a minimum financial incentive for recipients of Temporary Assistance to Needy Families (TANF) to participate in the child support program and believes that states need flexibility to use disregards innovatively. NCSL also supports allowing states to permit families to keep more of the money collected on their behalf whether on or off public assistance. However, NCSL insists that the federal government share in the cost of this forgone revenue. NCSL opposes a federal mandate to pass through child support as a cost-shift to states. Additionally, NCSL supports more efficient outreach efforts to include a greater number of recipients receiving child support enforcement assistance. State innovations in this area are important to children and families, particularly those transitioning from welfare to work and ultimate self-sufficiency. States must have the flexibility necessary to continue these innovations to meet the need of children and families in each state. NCSL also urges the federal government to provide states with MOE credit if states choose to pass-through child support to families.

Noncustodial Parents

Historically, states have taken the lead in issues pertaining to family law. State legislators support innovative programs that reach more absent parents, especially young fathers. However, the issues of custody and visitation are under the purview of the states and NCSL would strongly oppose any effort to preempt state laws in this area. If the federal government establishes block grants to states to examine ways to involve noncustodial parents in the lives of their children, state legislatures must have the authority to appropriate these funds.

Poor fathers have a difficult time keeping up with child support payments, and there is evidence that these fathers are unable, not unwilling to pay. These fathers try to provide some informal support directly to the mothers of these children. NCSL believes that supporting efforts to help low-income fathers be better parents and providers will result in increased financial support and stronger connections with their children. Improving the employment prospects for non-custodial parents is essential so parents will provide regular, on-going cash support to their children. This is a critical component for the long-term success of welfare reform as the combination of earnings and child support makes low-income families self-sufficient.

NCSL believes that a new federal fatherhood program should:

  • Provide funds to all states on a formula basis;
  • Ensure state legislative authority (often referred to as the "Brown amendment");
  • Count state contributions to fatherhood toward their state MOE requirements under the 1996 welfare law;
  • Provide states flexibility in determining eligibility of program participants;
  • Provide state flexibility to create or support programs at the local level;
  • Encourages collaboration on the state and local level,
  • And provide states the opportunity to use government, non-profit or faith-based providers as the state determines best fits the needs of their communities.


NCSL urges OCSE to encourage flexibility and creativity in addressing arrearages. NCSL also urges that OCSE continue to work with policymakers to clarify the usage of current policy regarding arrearages. While states cannot retroactively modify awards, it is possible for states to forgive arrearages for those noncustodial parents who are working to meet current obligations but are genuinely unable to pay arrearages. These arrearages are often barriers to participation in fatherhood programs and to family reunification and marriage. The federal government should clarify and provide state technical assistance regarding the current options for states to deal with child support arrears owed by an absent parent who later married or remarried the custodial parent, a non-custodial parent living in the household, or parents in fragile families. NCSL urges the federal government to provide assistance to the states on the usage of current policy toward compromising of arrearage.

Family Formation

The National Conference of State Legislatures (NCSL) supports policies that nurture responsible families. Any policies regarding the role of parents must take into account that not all families are intact and stable. NCSL believes that children deserve two involved parents. To that end, NCSL has an interest in policies that support intact families, encourage marriage and provide opportunities for fragile and fractured families to parent their children together. NCSL recognizes efforts to salvage some relationships may not be appropriate and there needs to be special awareness of the prevalence of domestic violence and abuse. NCSL supports efforts to assist parents with parenting skills, even in the absence of marriage, in order to have as stable a support system for the children involved as possible.

NCSL supports policies that encourage the formation of two parent households. Many single parents are successful in raising children in a single parent household. However, there is growing evidence that children who grow up with two involved parents are less likely to be poor, have contact with the criminal justice system, and become teen parents, and are more likely to graduate from high school. Children need a strong family bond and support system, including the positive influence of fathers even when they do not live in the home.

One of the four goals of the Personal Responsibility and Work Opportunity Act of 1996 is to encourage the formation and maintenance of two parent families. Some states are now using federal Temporary Assistance to Needy Families (TANF) block grant funds and state Maintenance of Effort (MOE) funds to create fatherhood programs including education and training, employment assistance, anger management, peer support, parenting classes, relationship building and marriage skills. NCSL continues to support elimination of the separate higher work participation rate for two-parent families in the TANF program.

Child Support Assurance

Child Support Assurance provides a guaranteed level of child support payment. NCSL supports maintaining the option of states to develop pilot programs for the assurance concept that can be rigorously analyzed and evaluated.

Appropriate Federal and State Roles

Federal efforts should first be directed to helping states do a better job. The federal commitment to child support enforcement has been to elevate and strengthen OCSE so that it will be a more effective partner with the states. This should include attempts to improve cooperation between IV-D agencies, state revenue agencies, and the state and local courts. Federal dollars should be used to create incentives to develop innovations, to replicate successes, and to provide improved training. Incentives should be structured in a manner that is supportive of and not coercive to states. State and local courts should retain power and discretion over establishing and modifying child support orders. The federal government should not create criminal sanctions.


 Several proposals to improve the child support system begin with a premise that centralizing the system should be the driving force for change. Federalization of the child support system, however, would disrupt state efforts to integrate family support services and further diminish the sense of community that is required for government to be responsive to the needs of its citizens. NCSL rejects the assumption that transferring the program to the federal government and funding, creating, and training a new bureaucracy at the national level will offer immediate improvement. Instead, NCSL supports sorting of responsibilities in a reasonable and rational fashion. Federal responsibilities should be expanded only where compelling reason to do so exists. Any other actions should be considered violations of the 10th amendment.

Federalization raises problems for an uninitiated and overworked federal court system and poses great risk because of the absence of a national system or model. Proposals to use existing mechanisms within the Social Security System and the Internal Revenue Service, while intriguing, must be rigorously tested and evaluated before exposing the entire system to enormous cost and risk. Overlapping responsibilities would create new disorder with federal administrative law judges interfering with settled state authority in family law.

Child Support Incentive Program

NCSL strongly supports the current incentive system for child support enforcement. The current incentive system must reward performance and recognizes our changing caseloads. As states succeed in their welfare reform efforts, the child support caseload is changing from mostly welfare recipients to include more working families.  Most states easily reached the maximum incentive for non-welfare cases and the system should be revised and updated.

NCSL strongly supports federal legislation to remove the provision in the Deficit Reduction Act of 2005 that prohibited states from using child support incentive funds to match federal funds for the program. This action, reversing existing law encouraging states to use funds in this manner, was identified by the Congressional Budget Office as an intergovernmental mandate that exceeded the threshold of the Unfunded Mandate Reform Act.   The federal funds states matched with incentive funds were used for integral parts of the child support enforcement program, such as establishing and enforcing child support obligations, obtaining health care coverage for children, and linking low-income fathers to job programs. Reduction of child support funding inevitably leads to lower child support collections, leaving families less able to achieve self-sufficiency. States are put in the unenviable position of reducing services or finding state funds to make up for this federal cost-shift.

Concerns about the incentive system have been a long-standing component of NCSL policy. NCSL continues to believe that the increasing effectiveness of state child support programs provides a financial return to both states and the federal government, while performing an important service for children and families. Federal financial participation has created the base for these effective and increasingly successful programs.

The 1996 welfare reform law required the Department of Health and Human Services to report to Congress with suggested revisions to the current incentive system. In response to the Administration's proposal and pending Congressional action, state legislators:

  • Support a base matching rate of no less than 66 percent. This is critical in light of the extensive federal mandates in the welfare law;
  • Support enhanced funding for automated data systems required by federal law;
  • Support the development of clear, understandable criteria for a new incentive system;
  • Believe that these criteria should be based on performance outcomes rather than administrative procedures and processes;
  • Oppose efforts to require that incentives received by the state be reinvested in the child support program. This ignores state priorities and preempts state authority over these funds, and
  • Support a more flexible approach to reinvestment. NCSL supports state flexibility to reinvest in programs that serve children and families.

Medical Child Support Enforcement

The federal government regulates health insurance covered by self-insured companies under the federal Employee Retirement Income Security Act of 1974 (ERISA); state laws do not apply to these companies. NCSL continues to urge Congress to close a loophole in ERISA that allows self-insured companies to refuse to acknowledge state medical child support orders and effectively block access to medical child support for thousands of children. As ERISA companies refuse to acknowledge transferred orders, states must return to court and get a new order if a noncustodial parent changes jobs. ERISA companies also set highly individualized criteria which, absent a standardized medical support notice, are barriers to the Congressional goal of a uniform and efficient enforcement system. A change in ERISA is needed so that these companies will comply with state medical child support orders and children of the fathers employed by these companies will no longer remain on Medicaid.

To effectively manage welfare costs, states must have access to the necessary tools. Absent a change in ERISA clarifying that there is no preemption of state laws and procedures for medical child support, state medical costs will continue to rise. Particularly given the rigid child support mandates of PRWORA, the federal government should take efforts to remedy these problems in ERISA so that states can effectively manage costs and insure that children of noncustodial parents working for ERISA companies have adequate health insurance. NCSL also urges OCSE to continue to discuss the linkages between medical child support and the use of the State Children's Health Insurance Program (SCHIP).

NCSL urges the federal government to continue collaborative efforts and to consider the cost to states of any policy changes. Continuing discussion is especially needed regarding state flexibility to determine the “reasonable cost” of insurance. The current federal definition is very problematic because of changes in insurance coverage available through employers.


The child support enforcement system relies on accurate, working information systems. Unfortunately, implementation of these computer systems has been difficult and fraught with problems and delays. NCSL encourages Congress to convene state elected officials, welfare commissioners, vendors and the U.S. Department of Health and Human Services to review child support automation services and to develop realistic recommendations for the next phase of implementation. NCSL supports efforts to allow for corrective action plans for states in the disallowance process.

Principles for Federal Health Insurance Reform

States should regulate insurance and should continue to set and enforce solvency standards to provide oversight on insurance matters. NCSL opposes any proposals that would expand the preemption of state laws and regulations beyond those already established in the Employee Retirement Income Security Act of 1974 and the Patient Protection and Affordable Care Act. Federal remedies, that more closely resemble remedies available at the state level, should be adopted for consumers in ERISA plans. Federal health insurance legislation that establishes mandated benefits or uniform standards, should establish a floor, not a ceiling. The federal government should continue to give deference to state, local and tribal governments regarding the regulation of state, local and tribal government employee health plans. Finally, NCSL strongly opposes proposals to exempt any insurer, plan or entity from state insurance standards and laws if they are permitted to operate in the state market. 

Implementation of Federal Health Insurance Reforms

When federal insurance reforms are adopted, the consumer should easily understand the implementation process and an intensive community education effort must be an integral part of program implementation. The federal government should fund and support federal laws that require state enforcement. Any federal legislation requiring state action to comply with the law must allow a reasonable period of time for state legislatures to adequately debate and enact the legislation. Where states already have similar legislation in place, a process for declaring "substantial compliance" should be developed. Great deference should be given to states in the application of the "substantial compliance" doctrine.

Federal Demonstration Authority for States to Experiment with Innovative Health Care Reform Initiatives

NCSL supports federal initiatives to provide financial assistance and to authorize states to experiment with innovative approaches to: (1) increase access to health care services to the uninsured, (2) improve the quality and cost-effectiveness of our health care system, to increase access to the broad range of long term care services, especially home and community-based services, to individuals who need them and (3) explore a broad range of approaches and financing mechanisms to improve our health care system.

Proposed Regulations Implementing the States Long-Term Care Ombudsman Programs (Resolution)

The Older Americans Act (OAA) authorizes a broad array of critically important programs for seniors. NCSL is a strong supporter of the OAA, including the concept of a state long-term care ombudsman program. The ombudsman program is designed to make certain that there is an advocate in every state for seniors who are in nursing facilities, and other vulnerable seniors. Unfortunately, the law authorizing the ombudsman program includes provisions that may actually undermine state initiatives to protect these most vulnerable individuals. The 1988 OAA rules do not address changes to the program made in 1992 and 2006 related to the ombudsman program. Over the years, some of the shortcomings of the underlying law have become apparent. NCSL urges the Administration to delay promulgating rules for the state long-term care ombudsman program to provide an opportunity for the Congress to address state concerns in the upcoming OAA reauthorization.

Under current law, state long-term care ombudsmen offices are federally-funded and state administered. The provisions of the law that most concern states are:

  • Provisions that prohibit the state long-term care ombudsman from sharing critical information regarding neglect and abuse with law enforcement and state social services staff who also have responsibilities to assist and protect these vulnerable individuals, which may preempt existing state law and regulations; and
  • Provisions that authorize the state long-term care ombudsman to lobby state officials which conflicts with existing federal law regarding the use of federal funds to lobby state or local officials and state lobbying laws.

There is certainly a place for state long-term care ombudsmen programs, but it is important that these offices and individuals supplement state efforts to protect these vulnerable individuals.

Expires August 2015

Public Health

The U.S. Department of Health and Human Services (HHS), particularly through the Centers for Disease Control and Prevention and the National Institutes of Health (NIH), plays an important role in supporting the state and local public health infrastructure. HHS provides national surveillance of infectious disease, applied research to develop new or improved diagnoses, prevention and control strategies, and helps strengthen state’s capacity to respond to outbreaks of new or reemerging disease. The CDC provides a global health perspective and assists states in detecting new and emerging diseases. Federal support through grants and cooperative agreements, research and technical assistance is key to the stabilization and effective operation of the nation’s public health system and provides critical support for the state and local public health infrastructure.

NCSL urges Congress to continue: (1) to support grants and cooperative agreements to states and local governments for a broad range of public health activities; and (2) to support research and technical assistance, which aides states in the development and implementation of effective programs. In addition, NCSL wishes to foster the development of public and private sector partnerships to increase community accessibility to public health information and public health programs.

Health Promotion and Disease Prevention

An informed public is an important component of a healthy society. NCSL urges the Congress to continue to support public health education initiatives that are culturally sensitive, age appropriate and written at the appropriate educational level for the audience. It is imperative that these public health education initiatives integrate healthy lifestyle choices and disease prevention messages and strategies targeted for children, young adults, men, women, the elderly as well as other specifically identified populations within the community who have special healthcare concerns, needs and risks.

Healthy and Responsible Lifestyle Choices - NCSL supports programs that promote healthy lifestyle choices, reducing high-risk behaviors through education, counseling and treatment. NCSL urges the federal government to provide adequate funding for these.

Preventive Health and Health Services Block Grant - The Preventive Health and Health Services Block Grant provides funds to states for preventive health and health promotion activities and is the primary federal source of funding to states for health education and risk reduction activities; cholesterol, hypertension, and cancer screenings. States are given maximum flexibility to design and implement programs that meet the needs of their citizens. NCSL urges Congress to continue to support this program.

Preventive Health Screenings and Check-Ups - NCSL urges Congress to increase support for initiatives to promote regularized preventive health screenings and check-ups. NCSL is particularly supportive of efforts that provide information about and promote screening for: cardiovascular disease, dental disease; obesity, asthma, diabetes, and cancer. We also support efforts to ensure that children receive age appropriate check-ups and screenings that include recommended childhood immunizations; and dental, vision and hearing screenings; and recommended follow-up treatment.

Chronic Disease Management - NCSL urges Congress to continue to support initiatives that promote the management of chronic conditions such as obesity, cardiovascular disease, dental disease, diabetes, asthma, kidney disease, mental health disorders and a wide range of autoimmune diseases. Management of these conditions improves the quality of life of the individuals and their families and is more cost efficient for the health care system. NCSL is particularly supportive of initiatives that provide case management services to children with one or more chronic conditions. Early diagnosis, treatment and management is key to helping children with chronic conditions such as asthma and diabetes to stay on grade level at school and to become healthier adults.

Oral Health - NCSL supports federal initiatives to promote oral health by encouraging individuals to have regular check-ups and to practice good oral hygiene. These initiatives should include educational activities that emphasize the importance of good dental hygiene and care to overall good health. While some of the best dental care in the world is available in the United States of America, many people are unable to access dental care because they lack dental coverage and the means to afford the out-of-pocket cost of care. In addition, many areas both urban and rural have concerns about the distribution of dental professionals. NCSL supports efforts to increase access to quality, affordable dental care, including initiatives to improve public and private sector coverage of dental services, improve oral health literacy within the public, and provide states flexibility to develop innovative Medicaid dental programs to increase access to and utilization of oral health care services.

Health Education for Health Care Professionals - Health care professionals need to become better informed on health care promotion and disease prevention strategies so that they can better inform the people they serve. NCSL supports efforts to encourage institutions that train health professionals to include in their curriculum a greater emphasis on culturally competent health promotion and disease prevention.

Access to Health Screenings and Disease Treatment - NCSL supports efforts to encourage insurers and other third party payers, including Medicare and Medicaid, to cover cancer-screening tests. NCSL supports federal initiatives to improve coverage of cancer screenings, tests and treatments that have been shown on the basis of evidence-based evaluation to be beneficial for the population served.

Vaccines and Immunizations

Childhood Immunizations - NCSL supports initiatives designed to increase the overall number of children immunized. We are particularly supportive of efforts to increase federal funding for the Section 317 program to more closely match the increasing costs and number of recommended childhood vaccines. NCSL also supports initiatives that would use alternative sites such as schools, community health centers or other community settings to deliver vaccines to children when appropriate, cost effective and convenient. NCSL urges the federal government to continue and to increase public education initiatives designed to provide parents with the most up-to-date information regarding recommended immunizations for children. NCSL also supports continued research to improve the safety and efficacy of childhood immunizations. NCSL urges the Congress and the Administration to work with states to make certain that every child receives the recommended childhood immunizations and to improve immunization funding and policies to help meet that goal. Finally, NCSL urges Congress to continue to allow states to set child vaccine coverage policy.

Adult Immunizations - NCSL urges the Congress to continue efforts to increase the number of adults who receive recommended immunizations. NCSL supports the special efforts being made to encourage high-risk adults to receive flu shots.

Vaccine Supply - NCSL urges the Congress to appropriate sufficient funds to maintain a reasonable stockpile of pediatric vaccine, seasonal influenza vaccine and vaccines that may be used during a flu pandemic so that everyone who needs an immunization can be served.

Workplace Safety and Health Care Workers

Occupational Hazards/Workplace Safety - NCSL urges the federal government to support efforts to increase awareness of occupational hazards and ways to avoid accidents in the workplace. Information must be provided to employers and employees and should be included in the national effort to emphasize health promotion and disease prevention.

Health Care Workers - NCSL supports the decision by the Centers for Disease Control and Prevention (CDC) to continue to permit state and local health officials establish guidelines regarding procedures that health care workers infected with HIV or Hepatitis B should be permitted to perform. NCSL also supports the Blood-Borne Pathogen Standard rule promulgated by the Occupational Safety and Health Administration (OSHA) and the Needlestick Safety and Prevention Act. The Blood-Borne Pathogen Standard rule mandates the use of universal precautions in infection control and requires employers to provide workers with training, engineered safety devices, protective clothing, puncture-proof containers for contaminated needles and medical waste, and vaccination against the Hepatitis B virus. The Needlestick Safety and Prevention Act requires employers to solicit input from employees responsible for direct patient care in the identification, evaluation, and selection of engineering and work practice controls.

Pandemic and All-Hazards Preparedness

State and local governments are the first line of defense against acts of bioterrorism and other public health emergencies. State legislators are committed to enhancing their states’ ability to prepare for and respond to these events. A strong partnership between and among the states, the federal government, and other public and private non-profit entities is the best way to accomplish this goal. NCSL urges the federal government to: (1) Provide states, territories, and the District of Columbia with direct, sufficient and stable funding to enable them to continue to build and maintain an infrastructure to support on-going efforts to respond to bioterrorism and other public health emergencies; (2) Pass federal funds through the states for distribution to local governments, hospitals and other entities, permitting state officials to take the lead in planning on a regional and statewide basis, utilizing federal funds in the most efficient and effective way; (3) Require grantees that receive direct funding from the federal government to collaborate with the state and to coordinate all of their activities with the state plan; (4) Afford states the flexibility necessary to meet their diverse needs and priorities; (5) Build upon existing national and state efforts; (6) Ensure that regulations and requirements imposed on states are accompanied by sufficient funding to support implementation, both immediately and in the long term; and (7) Authorize the appropriate federal official to temporarily waive or modify the application of federal laws that may impede implementation of state plans during a bioterrorist attack or other public health emergency.


Lead Poisoning - NCSL supports federal efforts to prevent and detect lead poisoning in children. NCSL urges the federal government to continue to assist state and local health officials in addressing this serious health care problem.

West Nile Virus - NCSL supports the Mosquito Abatement for Health and Safety Act which provides grants to states to: (1) coordinate mosquito control programs; and (2) assist localities to conduct need assessments and to develop plans for the implementation of a mosquito control program.

Maternal and Child Health

The National Conference of State Legislatures (NCSL) continues to support the Social Security Disability Insurance (SSDI) program which provides needed income and medical support for disabled Americans. NCSL is particularly supportive of: (1) initiatives to accelerate the disability determination and appeals process and to assure that people with intellectual disabilities have effective access to the appeals process; (2) the Compassionate Allowance process that identifies conditions that are almost certain to qualify an individual for SSDI coverage, shortening the eligibility process; (3) continued improvements to the Ticket to Work program. With only a few exceptions, individuals who become eligible for SSDI due to a severe disability must wait two years before they become eligible for Medicare. These are very sick people with almost no health care coverage options. The provisions of the Patient Protection and Affordable Care Act that become effective in 2014 may help some SSDI beneficiaries receive coverage, but coverage gaps are likely to continue for many. NCSL recommends that the Congress consider waiving the waiting period in some cases.

Special Disability Workload - The Social Security Administration erroneously enrolled thousands of people in the Supplemental Security Income (SSI) program instead of the Social Security Disability Insurance (SSDI). As a result, these individuals were also enrolled in state Medicaid programs. SSI recipients are categorically eligible for Medicaid. The Special Disability Workload (SDW) project is a federal effort to correct the errors and to restore cash benefits that should have been received. According to recent estimates, states spent over $4 billion dollars over the years providing Medicaid coverage to these beneficiaries. Several attempts have been made to address this issue administratively and through Congressional legislation. None has been successful. NCSL urges Congress and the Administration to develop a plan to address this longstanding issue.

Maternal and Child Health (MCH) Block Grant - The MCH block grant provides funds to states to meet a broad range of health services for mothers and children. In addition to formula grants to states, the set aside for special projects of regional and national significance (SPRANS) continues to help states to identify and address special needs. NCSL supports the MCH block grant and urges Congress to continue to provide adequate funding. NCSL opposes efforts to transfer program responsibilities to the MCH block grant without the funding to accompany it, thereby reducing the funding available to functions currently funded through the block grant.

Universal Newborn Hearing - The Universal Newborn Hearing Screening program provides competitive grants to states for the implementation of a national program of universal newborn hearing screening that consists of: (1) physiologic testing prior to hospital discharge; (2) audiologic evaluation by three months of age; and (3) entry into a program of early intervention by six months of age. NCSL supports this program and urges Congress to continue to provide adequate funding.'

Rewarding Work and Reducing Poverty

The National Conference of State Legislatures (NCSL) believes that the federal government should continue to support the partnership between the federal government, the states, local government, non-profit organizations and the private sector to reduce poverty. Those with little experience and those with low-skilled jobs are often the first to be fired and the last to find employment. The long-term effects of poverty can be devastating, especially for children. Children in poverty are at higher risk for placement in foster care, of beginning school behind, remaining behind, and dropping out. Girls raised in persistent poverty are more likely to become a teen parent and boys are more likely to spend time in prison.

States are facing significant budget shortfalls and many of the policy solutions are federal. Too often, states are left to address the symptoms of poverty through their child welfare, mental health and criminal justice systems. NCSL believes that the federal government should encourage and support state efforts to address the underlying causes of poverty and support prevention strategies that improve outcomes for children living in poverty. Federal policies must recognize the impact of economic stress on low-income families, especially in an economic downturn, and has a direct effect on children’s emotional and social wellbeing and educational attainment.

State legislatures around the country have been grappling with poverty and focused on helping families leave poverty by helping parents get jobs and providing education and training to help them get better jobs. These strategies require a new level of coordination and collaboration among a broad range of federal, state and community-based programs—Temporary Assistance for Needy Families (TANF), workforce, schools, community colleges, health care, business, foundations, community and faith-based organizations. Substantial state and federal efforts and resources are already devoted to general anti-poverty efforts, but often not in a focused and coordinated way. NCSL believes that federal policy should facilitate and inform state efforts.

State legislators support a new federal partnership to foster state-based and/or community and local comprehensive strategies. Information about successful approaches to reducing poverty that reach across state and federal agencies should be shared among all levels of government as well as business and community-based organizations.

Measures of Poverty and Child Wellbeing

 It is critical that anti-poverty efforts use measures of poverty and wellbeing that accurately capture families’ levels of need and accurately track the effect of government programs in meeting those needs. An accurate federal poverty measure is important because it can draw attention to the poverty issue and the consequences for families, children, workforce, economy and society. Improved information about ongoing and new initiatives that work in combating poverty is needed both in programming efforts and in strategic, governance approaches. NCSL supports efforts to create new measures alongside the current poverty measure which was created in the 1963 by Mollie Orshansky based on food expenditures. While the current measure is a useful longitudinal tool, it does not count the value of non-cash benefits nor tax-credits. It also does not count costs for health care, transportation, child care, housing and utilities. It does not reflect geographic cost of living differences.

Most importantly, it does not give state policy makers the ability to accurately measure the effectiveness of ongoing and new initiatives to combat poverty. However, any new poverty measure should not be used to determine eligibility or level of assistance.

 While supporting efforts to change or add new measures of poverty, NCSL emphasizes the importance of strategies and actions that address the needs and opportunities of families and individuals rather than getting caught up in long debates about the “perfect” measure.

Currently, state lawmakers lack reliable data on many aspects of child wellbeing in their states. Data is collected infrequently or released many years after collection and focuses only on children who participate in particular programs (such as Medicaid). Positive behaviors are rarely tracked. A state level child wellbeing survey would provide timely state specific information. NCSL supports the bipartisan bicameral effort to provide for a comprehensive child well-being measure that documents the effect of growing up in poverty.

Anti-Poverty Efforts

 Any new federal initiative on poverty should identify key goals for state efforts, but allow states flexibility in deciding which goals to emphasize and how to harness state and community efforts to address those goals. Part of this framework should include outcome-based (well-being measures based in family and community conditions) measures that federal and state efforts measure and report. Accountability should be focused on these outcome measures, rather than program structure and rules.

States need flexibility to restructure their human service, workforce, health care and educational programs to address poverty strategically and in ways adapted to their particular goals and circumstances. Federal programs and funding streams reach across a variety of federal agencies and congressional mandates. Federal efforts should be designed to avoid shifting costs to the states. Federal policy should foster and enable state-based initiatives and strategies that reach across the full range and government, business and community based efforts to effectively reduce poverty, alleviate the effects of growing up in poverty, and build states’ workforce training and economic development efforts. Supporting these innovative state-based efforts requires a broad-based federal options and/or waiver authority that reaches across agencies and programs. Supporting these efforts also requires flexible outcome-based accountability measures rather than the current program process measures.

The poverty agenda is broad and NCSL recognizes that it includes efforts in many kinds of programs including:

  • Parenting programs, fatherhood efforts, and other family preservation efforts
  • The Earned Income Tax Credit
  • Improving work opportunities and returns to work for low-income parents and individuals
  • Reentry and Employment Programs for Offenders and Outreach Programs to the Children of those Incarcerated
  • Transitional jobs and career pathways
  • Temporary Assistance to Needy Families
  • Early childhood care and education
  • Home visiting
  • Access to education and
  • Early learning initiatives as a key poverty prevention strategy.

Earned Income Tax Credit (EITC)

NCSL supports the federal EITC as a means of reducing poverty among working poor families, and ensuring that the benefits of work surpass the benefits of public assistance. Increasing public awareness is essential to the success of this program. NCSL strongly urges the federal government to work with states as partners to develop new and creative methods to inform eligible families about the following:

  • They must file a federal return even if they pay no federal taxes in order to receive the refundable credit;
  • They can use the toll-free IRS hotline;
  • They can receive free tax preparation assistance through the VITA (Volunteer Income Tax Assistance) program; and
  • They can file a W5 form with their employers to receive their credit benefit throughout the year.

Because an expanded EITC supplements the wages of low-income working families without decreasing work incentives, NCSL supports federal efforts to increase the value of the credit, adjust it for family size, and eliminate the marriage penalty. Research has shown that the EITC increased labor force participation and employment rates among low-skilled single mothers. NCSL supports expanding the EITC to single workers, especially noncustodial parents, to have the same impact on low-skilled fathers. However, NCSL objects to increases to the credit that result in cost shifts to the states. NCSL supports continuation of federal practice that allows states to use TANF and MOE funds for the state EITC. Such support should not count as "assistance" under the welfare law nor should federal data reporting for "assistance" programs apply. Such a requirement for a state EITC program is overly burdensome. Further, NCSL encourages the Administration to provide states the maximum flexibility to administer their own EITC programs. NCSL urges the federal government to simplify the application for the federal EITC and reduce the paperwork burden on filers. NCSL believes that such an effort will reduce errors.

 Congress and the administration have implemented several error-reducing measures supported by NCSL:

  • IRS access to the Federal Child Support Case Registry which will allow the IRS to reduce filing errors on the part of non-custodial parents who are ineligible to receive the EITC;
  • Linking of Social Security numbers of parents to new numbers established for children in the Social Security database, enabling the IRS to verify parentage and thereby eligibility for the credit; and
  • Providing additional funds to the IRS, which allows the IRS to substantially intensify efforts to curb EITC errors through screening and other means.

Individual Development Account (IDA)

Individual development accounts (IDAs) are another tool to promote financial self-sufficiency. NCSL supports federal efforts to provide incentives for the creation of IDAs as a complement to state efforts to reform welfare and to support working families' efforts to move out of poverty. NCSL urges the federal government to continue to allow states to have the flexibility to use TANF funds for IDA programs. Further, NCSL supports changes in the federal tax code that would expand opportunities for IDAs including a tax credit for financial institutions that participate with matching funds and for private entities that invest in nonprofits that administer IDAs. NCSL also urges the U.S. Department of Health and Human Services to examine and eliminate barriers in the TANF program, including those associated with the Cash Management Improvement Act, to simply administration of IDAs.

Research and Technical Assistance

NCSL supports extensive technical assistance to learn about promising practices, identify effective programs at the state and community levels, and implement strategies for effective collaboration. More research is needed to understand how to improve opportunities and achievement for low income workers and their families and how different programs can successfully collaborate.

Working with faith-based organizations

NCSL recognizes the importance of religious organizations that provide vital social services to individuals who require them. NCSL continues to support giving states options, as in TANF, to collaborate and contract with religious organizations for family assistance services, within the boundaries of state and local laws. NCSL does not support any charitable choice legislation that preempts state and local laws, is retroactive in its application, undermines existing state-federal grant programs and partnerships by offsetting their funding, creates new rights for states to be sued in federal court, and mandates participation on the states according to federal guidelines.

Social Services Block Grant

Social Services Block Grant (SSBG or Title XX) funds are a vital part of the delivery of community and home-based services to the most vulnerable segments of society including the disabled, elderly, and children in need of protective services. These services often allow individuals to receive services in their homes and communities, not in more expensive residential settings. NCSL urges the federal government to fund the SSBG at the level agreed to as part of the enactment of the 1996 welfare reform act, $2.8 billion. In addition, it is critical that the amount states can transfer from their TANF grants to the SSBG remains at least 10% and is not reduced. SSBG funds programs that complement TANF's goal of self-sufficiency. States use their SSBG funds to provide protective services for children and adults, adult day care, meal preparation and delivery for the elderly, counseling services, and serve the disabled in their homes, rather than in institutions, and provide child care for low-income working families. Further reductions in funding for this grant would mean programmatic losses and service reductions. NCSL opposes earmarking SSBG for any of the populations served by the block grant.

Social Security Disability Insurance 

The National Conference of State Legislatures (NCSL) continues to support the Social Security Disability Insurance (SSDI) program which provides needed income and medical support for disabled Americans. NCSL is particularly supportive of: (1) initiatives to accelerate the disability determination and appeals process and to assure that people with intellectual disabilities have effective access to the appeals process; (2) the Compassionate Allowance process that identifies conditions that are almost certain to qualify an individual for SSDI coverage, shortening the eligibility process; (3) continued improvements to the Ticket to Work program. With only a few exceptions, individuals who become eligible for SSDI due to a severe disability must wait two years before they become eligible for Medicare. These are very sick people with almost no health care coverage options. The provisions of the Patient Protection and Affordable Care Act that become effective in 2014 may help some SSDI beneficiaries receive coverage, but coverage gaps are likely to continue for many. NCSL recommends that the Congress consider waiving the waiting period in some cases.

Special Disability Workload - The Social Security Administration erroneously enrolled thousands of people in the Supplemental Security Income (SSI) program instead of the Social Security Disability Insurance (SSDI). As a result, these individuals were also enrolled in state Medicaid programs. SSI recipients are categorically eligible for Medicaid. The Special Disability Workload (SDW) project is a federal effort to correct the errors and to restore cash benefits that should have been received. According to recent estimates, states spent over $4 billion dollars over the years providing Medicaid coverage to these beneficiaries. Several attempts have been made to address this issue administratively and through Congressional legislation. None has been successful. NCSL urges Congress and the Administration to develop a plan to address this longstanding issue.

Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant

The Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block grant provide critical assistance to state governments to help address alcohol, substance abuse, and behavior health issues using a broad range of strategies and services. The National Conference of State Legislatures continues to support these important programs. In recent months the U.S. Department of Health and Human Services has made a number of administrative changes to these block grant programs. Some of the changes anticipate the improved access to health insurance coverage for substance abuse and behavioral health conditions provided for in the Patient Protection and Affordable Care Act. Many of the changes involve more coordination between state agencies that provide substance abuse and behavior health services. Some of the changes assume a reduced need for some of the services provided through these block grants due to increased coverage through health insurance exchanges and the Medicaid expansion scheduled to occur in January 2012. NCSL urges caution in reducing resources to these programs until there is better information on the extent of the expanded enrollment in private coverage or Medicaid.

Support for Seniors and People with Disabilities

The development of a comprehensive approach to provide support services for elderly and disabled people is critical. Without the development of such a system, long-term care expenditures will continue to overwhelm state and federal health care budgets, limiting needed expenditures for primary and preventive health care. States should be given new options for setting financial and functional criteria to qualify for these services. In addition, NCSL supports the development of expanded options for private long-term care insurance, flexible life insurance products, and home equity sharing programs, such as reverse annuity mortgages. NCSL also supports initiatives to provide incentives to employers to offer and for individuals to establish health savings accounts and other innovative financing options to pay for a broad range of supportive services. Finally, much of the care provided to seniors and people with disabilities today are provided by family members. NCSL supports efforts to assist family members who are caregivers, including tax incentives and programs that provide support services, such as respite care, for family caregivers. It is critically important to acknowledge the important role of family caregivers as part of the continuum of care in the provision of long-term care services and to provide needed support to maintain this important component of our long-term care infrastructure.

Increasing Options for Home and Community-Based Care

NCSL continues to support the development of more home and community-based options under Medicaid to provide long term care services. States should be encouraged to develop innovative programs to improve the long-term care system. NCSL urges the Administration and Congress to work with states to develop assessment tools that will help states better identify what level of services individual clients need and the most appropriate settings for the client to receive care. These assessments should be made available to all elderly and disabled individuals to help them plan for their long-term care needs.

Long Term Care Insurance

Recognizing consumers can potentially benefit from the purchase of long-term care insurance, NCSL supports strong federal action to protect consumers of long-term care insurance from predatory pricing or inadequate benefit plans, and to speed the development of long-term care insurance as a viable alternative or complement to Medicaid support for long-term care services. At the same time, tax credits, partnership programs, and other incentives should not be seen as a tool for reduced funding for Medicaid. While the states will continue to take primary responsibility for the regulation of long-term care insurance, NCSL supports the development and evaluation of programs and initiatives that would: (1) provide preferential tax treatment for individuals who purchase qualified long-term care insurance; (2) provide tax incentives for private employers and a Medicaid bonus program for state and local government employers to encourage the them to offer long-term care insurance as a benefit; and (3) encourage and provide incentives to employers to offer long-term care insurance, as a condition of receiving federal benefits, such as business tax credits;

Administration for Community Living

The Administration has consolidated the agencies within the U.S. Department of Health and Human Services (HHS) that provide supportive services to seniors and people with disabilities into a new, Administration for Community Living,. The purpose of this consolidation is to: (1) reduce the fragmentation among federal programs that address the community living service and support needs of seniors and people with disabilities; (2) enhance access to quality health care and long-term services and supports for all individuals;(3) to promote consistency in community living policy across other areas of the federal government; and (4) complement the community infrastructure, as supported by both Medicaid and other federal programs, in an effort to better respond to the full spectrum of needs of seniors and people with disabilities. In addition to programs authorized by the Older Americans Act, the new entity includes the State Councils on Developmental Disabilities, the State Protection and Advocacy Systems and the Help American Vote Act program that provides grants to make polling places accessible to voters with disabilities. NCSL applauds this reorganizational effort and looks forward to continuing to work with HHS to improve community living services and supports for all who need them.

Alzheimer's Disease and Related Disorders

NCSL supports continued federal funding for research that will: (1) lead to the development of new drug treatments; (2) assist in disease management; and (3) improve the early diagnosis of these conditions.

The Administration on Aging – The Administration on Aging administers some of the most critical support services to seniors including; (1) home and community-based support services; (2) nutrition programs ---congregate and home-delivered meals and nutrition services; (3) caregiver services and supports; (4) protection for vulnerable adults, including the long term care ombudsman program; (5) consumer information, access and outreach services, including the State Health Insurance Assistance Program (SHIP); and (6) the National Clearinghouse for Long Term Care Information. NCSL supports these critical programs and services and urges the Congress and the Administration to adequately fund them.

National Plan to Address Alzheimer's Disease- The Plan proposes to:  (1) promote and effectively treat Alzheimer’s Disease by 2025; (2) optimize care quality and efficiency; (3) expand supports for people with Alzheimer’s Disease and their families; (4) enhance public awareness and engagement; and (5) track progress and drive improvement. The plan specifically calls for working with state, tribal and local governments to improve coordination and to identify model initiatives to advance Alzheimer’s Disease awareness and readiness across all levels of government. The plan directs the U.S. Department of Health and Human Services to convene a meeting of state, tribal and local government leaders to develop a more concrete agenda. NCSL looks forward to assisting in this effort.


The State-Federal Partnership in Early Learning (Joint with Education Committee)

The National Conference of State Legislatures (NCSL) supports early care and education and its benefits, especially in lessening the adverse effects of childhood poverty. Evidence shows that for all children these programs can help improve children's intellectual and social performance in school and ultimately can help children achieve greater school success and possibly greater socioeconomic success and social responsibility.

State legislators have been in the forefront of efforts to create and improve opportunities for children. Many states have maximized the use of the state and federally funded Child Care Development Fund (CCDF) and used even more of their own funds to increase the supply, quality and safety of child care. States have voluntarily supplemented the federal Head Start program, and states have created their own pre-kindergarten programs. States have encouraged parental involvement to enhance children's early learning experience. Several states have special initiatives to improve the training and compensation of early learning teachers, as well as other programs to enhance early learning. State legislators believe that a smooth transition between early learning programs and the K-12 education system is crucial to academic achievement.

NCSL supports federal efforts to improve early learning opportunities for young children. Efforts to support early learning must provide states with the flexibility to meet local needs. Constitutionally and historically, states are responsible for public education. States are accountable to their citizens for the results of public education and are committed to improving learning for all students and closing the achievement gap.

Any federal legislation must take into account current state fiscal conditions. Maintenance of effort requirements may make it difficult for states to take advantage of new federal funds when they face difficult decisions about how to fund all state services programs.

If the federal government expands its involvement in promoting early learning for young children before they enter school, these are the tenets on which such an effort should be built:

  • Preservation of state flexibility, including maintaining the states' authority to determine how the program is administered, evaluated and what population is served;
  • Preservation of state authority;
  • Avoidance of unfunded mandates;
  • Support for flexibility that allows states to use ESEA Title I funds for children from birth to school entry, including professional development for early educators;
  • Support for early learning challenge grants that assist the development of the statewide infrastructure of integrated early learning supports and services for children from birth through age five; and
  • Support for research and evaluation of new state initiatives.

To establish such programs on a broader basis than is currently available through Head Start or other state and locally initiated programs may require an enhanced commitment from and partnership with the federal government. Any proposal to create a pool of federal funds for early learning programs must:

  • Give states the opportunity to provide assistance to a range of early learning programs;
  • Give states the opportunity to support initiatives to train and adequately compensate early learning providers;
  • Allow states to supplement existing programs which already are improving children's early learning;
  • Ensure state legislative authority to appropriate the funds;
  • Use state-selected administrative structures;
  • Ensure that state legislators are included in all aspects of these programs including advisory panels;
  • Give states the opportunity to use a wide range of existing resources including, but not limited to, state and local funds that are not used to match another federal program, private funds, and in-kind contributions (facilities, equipment, and services) to match the federal funds;
  • Allow eligibility requirements to be set at the state level; and
  • Be flexible to allow states to meet the increased demand for early learning services.

It is especially important that efforts to support early learning programs complement but are not at the expense of efforts to expand CCDF. NCSL’s Policy Directive on Child Care details state priorities in CCDF.

Head Start

With the numbers of children in poverty increasing and the need for more child development/child care services for low-income families increasing, it is essential that Head Start be fully-funded to assure school readiness for all eligible children. It should be emphasized that parental involvement, which benefits both parents and children, is the critical component of Head Start. Additionally, staff development and training is critical for quality Head Start programs

 Head Start must be leveraged to support both school readiness and the needs of low income working families. NCSL supports:

  • Improving educational opportunities for disadvantaged populations through greater coordination among Head Start, early childhood and  child care programs, and elementary schools;
  • Funding for quality and access;
  • Allocating funding for training staff and enriching program curricula;
  • Improving coordination of quality efforts in Head Start with state quality improvement efforts;
  • Expanding opportunities for federal grantees to use Head Start funding to best meet the needs of communities in ways that complement state effort;
  • Disseminating  research findings from evaluations; and
  • Encouraging legislative involvement in Early Childhood Advisory Councils.

If the option arises for states to have more control over Head Start and/or the authority to coordinate Head Start with other state early childhood education efforts, NCSL must be included in such deliberations.

Family Support and Parental Involvement

 NCSL further recognizes that we cannot continue to treat family conditions as a matter separate from education and that such a focus is particularly important for younger children. Programs to support parents and family members as the first teachers of their children should be promoted and strengthened in both public and private sectors. NCSL supports efforts to expand community-based, including faith-based,state-federal partnerships to work with parents and caregivers to promote pre-literacy skills. Faith-based partnerships are an important resource to assist parents in their communities.

States continue to implement strategies to support parents with young children. A majority of states currently operate one or more home visiting programs to support parents, prevent child abuse, improve child development, identify delays or provide referral to services. In some cases states are also supporting both home visiting and center-based approaches which have proven to improve child outcomes and pre-literacy skills. NCSL supports continued federal funding for these approaches:

  • Funds should support state initiatives to implement a broad range of home visiting strategies and support new initiatives designed to make them more effective.
  • Funds should not be limited to one approach or mandate specific administration but should allow for state flexibility in both design and implementation.
  • The federal government can play an important role in supporting further research about effective programs and state pilots to test program options.

The Homeless

The National Conference of State Legislatures (NCSL) recognizes the need for a comprehensive approach to the problem of homelessness. The most significant causes of homelessness are the extreme shortage of decent and affordable housing, unemployment and the lack of community based support systems. Mental health, substance abuse, teen pregnancy, domestic violence, low wages, and catastrophic illness also play a significant role in homelessness. The solution of the problem of homelessness must stress prevention, emergency shelter, support services, transitional housing, permanent housing, and case management.

Coordination is critical among existing programs, because the homeless population may come in contact with different social service programs at different times. The federal government has a critical role to play in facilitating such coordination. There also needs to be more attention to the differences inside the homeless population. Strategies to serve the long-term homeless differ from those of families with more short-term needs. NCSL urges the federal government include homeless prevention as an allowable expenditure under the Family Preservation and Family Support Services program to prevent out-of-home placement and to allow the flexibility of TANF funds to serve this population.

The plight of homeless families with children are of special concern to state legislators. For many of these children, a homeless shelter or welfare hotel is the only home they have known. The children face multiple barriers to becoming productive and self-sufficient adults. They often do not attend school regularly, may suffer inadequate health care and poor nutrition, and can too easily become involved in crime and drug and alcohol abuse.

States have played a leading role in responding to the needs of the homeless, often investing substantial state resources to address the problem. An effective strategy to address homelessness will require a partnership among all levels of government, the private sector, and private non-profits. The federal government, in cooperation with state efforts, must assume a leading role.

The McKinney Homeless Assistance Act

 The federal government began to supplement state and local efforts to aid the homeless by implementing the Omnibus Stewart B. McKinney Homeless Assistance Act. The McKinney Act addresses the needs of homeless people by providing for emergency shelter, food, health care, mental health care, housing, educational programs, job training, and other community services. While any comprehensive homelessness strategy includes addressing permanent housing solutions, the McKinney Act provides a necessary emergency response. McKinney programs have never been funded at their authorized levels. Given the extent of the current homeless crisis, NCSL urges full funding to address mandates and more effective implementation of the McKinney Act.

McKinney Act funds should be used to augment existing state programs and to address individual state needs. States need more flexibility in both the use of funds and administration of McKinney Act programs to use limited resources in the most cost-effective and efficient way. The state role in the coordination of McKinney Act funds with current state and local efforts should be enhanced to ensure that scarce federal resources can be used effectively. States need increased predictability regarding when the various grants will be awarded to assist in their planning efforts for the homeless. A small set-aside for state administration of McKinney Act funds would greatly assist states in their coordination role.

NCSL has found that states have often been unable to implement the McKinney Act Programs or use McKinney allotted funds. Unfortunately, state efforts to implement McKinney Act programs have been disadvantaged due to a lack of information from the administration on the availability of programs including application procedures and deadlines. The Administration must take a more aggressive role in disseminating information concerning the availability of McKinney funds, providing technical assistance to states and coordinating federal program initiatives.

There should be opportunities for state and federal government to develop properties that are vacant, under-utilized or foreclosed. NCSL urges the Federal government to actively make available to states, localities and non-profit agencies under-utilized or vacant federal properties that could be used for shelter and other services. Few eligible and suitable properties have been leased for homelessness services.

The U.S. Department of Health and Human Services also administers a wide range of programs for the homeless, programs that are critical because they address important needs of the homeless population, including mental health needs. NCSL urges a coordination of these efforts with the McKinney Act Programs and state and local programs.

Veteran's Health

NCSL supports federal initiatives to improve the accessibility and quality of health care services to U.S. veterans and their families. NCSL is particularly supportive of efforts to: (1) increase access to health care services to veterans and their families; (2) improve and expand mental health services; (3) provide assistance to veterans and their families regarding the range of health care services available to them and the appropriate means of accessing the services; (4) expand and improve services to veterans who are amputees, who have traumatic brain injuries or other conditions or injuries sustained during active duty. NCSL urges the Department of Defense and the Department of Veterans Affairs to work closely with state and local governments to when they can assist in the implementation of these initiatives, including sharing information with state Veteran’s Departments regarding the status of veterans residing in the state; and (5) improve the operation of the Veterans Health Administration.

 Extension of TRICARE Prime to Veterans in the U.S. Commonwealths and Territories - NCSL supports the extension of TRICARE prime to American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the Commonwealth of Puerto Rico and the Virgin Islands and urges the Congress to move forward on efforts to determine the feasibility and costs associated with this important extension of health care benefits.

Welfare Reform

In 1996, the National Conference of State Legislatures (NCSL) supported the enactment of welfare reform. NCSL urges Congress and the Administration to ensure that welfare reform is continued as a successful bipartisan partnership between the states and the federal government. This revolution of social policy allowed state legislatures to transform a system of income maintenance to one focused on work and self-sufficiency with support for families and vulnerable children. States and territories have shown that they can use the flexibility provided in the block grant to find innovative ways to move families into jobs, off welfare, towards self-sufficiency, and address poverty. State legislators urge the federal government to continue to make flexibility a key theme in all aspects of welfare reform including Temporary Assistance for Needy Families (TANF), Maintenance of Effort (MOE), child care, child welfare and child support.

 Everyone who is able should be engaged in efforts toward self-sufficiency while he or she is receiving public assistance. The majority of states have focused on getting welfare recipients into unsubsidized jobs in the private sector - a proven strategy to increase earnings, promote family stability and end the cycle of dependence. States have succeeded with this strategy. State lawmakers urge Congress and the Administration to not make it difficult for states to continue this success. Unfortunately, the 2005 reauthorization of TANF rules and regulations, promulgated by the U.S. Department of Health and Human Services (HHS) implementing the Deficit Reduction Act changes, have limited state flexibility, constrained state policy choices, and left states facing financial penalties for not meeting federal work participation rates.

States should be able to adopt a variety of goals for their TANF programs within the broad federal structure, including moving families into jobs and off welfare and towards self-sufficiency and working with youth and low-wage workers to help them avoid welfare. Flexibility must be maintained so states can use a variety of different approaches in pursing these goals, including strong work-first efforts, comprehensive assessments and services for hard-to-employ parents, stronger sanctions and time limits, post-secondary education to prepare parents for higher wage jobs, and extended financial support for families making the transition into the workforce. States must be able to continue to use TANF funds to support other essential services for family well-being, including child care for low-income working families, child welfare, parent education and home visiting, pre-school education, and after school programs for youth.

Remaining Challenges

Many families struggle with barriers to self-sufficiency. Mental illness, substance abuse, physical challenges, low literacy, limited English proficiency, domestic violence, and learning disabilities are among the challenges faced by TANF clients, especially long-term recipients.

NCSL supports maintaining changes to regulations that would allow states to deem individuals with disabilities participating in work activities to count in the work rate even if they don’t reach the hours of work threshold or are in activities appropriate to their disability but which do not match the standard TANF requirements. In addition, individuals receiving SSI are excluded from the work rate calculation because it is recognized that they are unable to work. Individuals who are applying for SSI should also be excluded if the state has determined they meet the SSI threshold instead of having to wait for an SSA determination. Similarly, individuals with severe temporary disabilities, who are ineligible for SSI due to the temporary nature of the disability, but are unable to work, should be excluded from the work rate calculation.

State legislators also believe that welfare reform is an ongoing process of sustaining the work effort of former welfare recipients. This includes services that support job placement, retention and advancement to prevent welfare participation and improve the lives of children and families.

NCSL urges the federal government to keep in mind the requirements of the Unfunded Mandates Reform Act as policies and proposals are developed, including consultation with states regarding the impact of regulations.

State/Federal Partnership

 Any changes in the TANF program made at the federal level must be carefully crafted so as not to impede the progress made by innovative state and county programs because of the differences in the ways states have implemented programs. NCSL urges the federal government to avoid earmarks, preemption of state authority or mandates on the states as they compromise the spirit of state/federal partnership critical to our success. States still face the financial risk and have lost flexibility, especially in the use of state maintenance of effort dollars. Congressional action is needed to return flexibility to the states.

Restoring State Flexibility

 In order to meet these important goals, states need stability and certainty. States are struggling to respond to significantly tougher work participation requirements and the threat of financial sanctions for non-compliance and corrective compliance plans that could curtail state flexibility. HHS continued to change these rules, making it even more difficult for states to meet the work rates. In addition, the rules constrain state flexibility by limiting the use of diversion programs and curtailing states’ use of additional state TANF spending (MOE), to increase their caseload reduction credits toward meeting work rates.  State lawmakers’ spending choices and strategic TANF policy making and oversight have been frustrated. NCSL urges HHS to reconsider these rules and also urges Congress, where necessary, to exercise its oversight authority to preserve state flexibility.

Our income assistance program should emphasize flexibility for the states to design their own programs in accord with community needs and should include: (1) financing of the program without cost-shifting to state government and without targeting other vulnerable populations, (2) the promotion of family formation and stability, (3) parental responsibility, (4) training and education that are geared toward lifetime career opportunities as well as community and business needs as a path to self-sufficiency, (5) support services necessary to self-sufficiency such as health care, child care and transportation during education, training and subsidized employment and transitional services for those who successfully leave cash assistance, (6) short term assistance to able-bodied heads of households, (7) long term support for the disabled and the elderly, (8) strengthening child support services

NCSL's Concern for Children

 NCSL reiterates its concern for children and their well-being in consideration of welfare reform. Children will be better off with parents who are self-sufficient. However, NCSL urges the federal government to consider the impact of any new welfare strategies on other state and federal systems that serve children and their families. There must be coordination with the myriad employment and training and retraining programs. The child welfare system, including foster care, may be inadvertently impacted by welfare reform if parents are unable to support their children.

TANF Funding Issues

 States have upheld and continue to uphold their part of the welfare reform agreement. NCSL urges Congress and the Administration to resist all efforts to cut the welfare block grant (TANF), the Social Services Block Grant (SSBG), Low Income Home Energy Program (LIHEAP) or any related welfare program, to restore TANF supplemental grants and contingency fund, and preserve the full integrity of the historic welfare agreement.

With TANF and MOE funds, states can serve families who receive cash assistance and families who formerly received cash assistance, as well as families who have never received cash assistance and should continue to have flexibility to do so.

State MOE funds should retain their flexibility as originally enacted in 1996. Recent regulations that restrict their use to a narrow list of programs, eliminate their use to meet work participation rates, or attach federal requirements to separate state programs should be stopped.

State Legislative Authority ("The Brown Amendment")

A critical component of the 1996 law explicitly gave state legislatures the specific authority to appropriate their state's TANF, child care, and welfare to work funds. This authority invests state legislators fully in the TANF program and increases state oversight of TANF funds. NCSL strongly supports maintaining this language.

The TANF block grant

The TANF block grant must be fully funded, which includes TANF supplemental grants in the baseline. The TANF block grant must not be reduced. NCSL appreciates that the Administration and key Congressional proposals support full funding.

Inflationary Adjustment

NCSL urges Congress and the Administration to consider an inflationary adjustment to the TANF block grant. Congress should provide an inflationary increase in the overall block grant. This will allow us to address the increased demand for non-cash assistance, economic uncertainty and any new expectations of welfare reform. If Congress were to include increased state MOE as a condition, it should be optional for states to receive this adjustment. States are currently struggling with severe budget deficits and funding constraints. Therefore, it should be optional for states that can contribute above 75% state MOE.


NCSL will oppose any effort to earmark the TANF block grant as a limitation on critical flexibility and antithetical to the notion of devolution. Any earmarks of TANF funds will also have a disproportionate impact on states that rely on their supplemental grants or states that spent all of their TANF funds and do not have any carried over funds.

TANF supplemental grants

The 1996 law provided grants to states with historically low levels of welfare spending under the prior AFDC program and high population growth, ensuring that they were not disadvantaged under the block grant formula. Without restoration of these grants, states that received them will be hard pressed to continue innovative programs and a divisive formula fight will ensue. Already these states have had to curtail or cut programs. NCSL urges Congress to ensure that states continue to receive supplemental grants and that these grants are incorporated into their TANF baseline.

Carried-over funds

According to the April 1999 regulations, TANF block grant funds carried over from one fiscal year to the next can only be spent on assistance -- cash, food, and housing. This severely impacts state flexibility to provide services that might keep a family from needing cash assistance. Carried-over TANF funds should be as flexible as current year TANF funds.

Contingency funds

 If welfare caseloads increase, states will be pressured to spend a greater percentage of their TANF funds on cash assistance, and there will be less money available for supports such as child care and transportation that help low-wage workers keep their jobs. A contingency fund should be part of any reauthorization proposal. It must be a contingency fund with a less restrictive trigger mechanism and with less complicated requirements for state participation than the contingency fund in the 1996 law. NCSL urges the federal government to construct the reconciliation and maintenance of effort provisions so that needy states can have greater access to the fund. Additionally, the commonwealths, territories and tribes should be allowed to participate in the contingency fund. NCSL appreciates the Administration's proposal to continue the contingency fund. NCSL urges Congress to adopt a less restrictive trigger mechanism and MOE requirement than in the 1996 law that will make the contingency fund more accessible when states' caseloads and spending increase.

State contingency funds remain in the federal treasury and are considered unobligated, so it can appear that those funds are not needed or not allocated for any purpose. This issue should be addressed and is an example of the unfortunate interactions between the block grant and the Cash Management Improvement Act.


NCSL believes that work is a critical component of welfare reform. Welfare recipients want to work for themselves and their children. The goal of reform should be to enable clients to become self-sufficient, strengthen their families and work their way off welfare. The diversity of the welfare population means that states must have the ability to choose different strategies for families receiving assistance. Federal law should support state efforts to create a continuum of self-sufficiency. This would range from job search for those with skills and work histories to treatment for parents with substance abuse and mental health problems that are a barrier to employment to mandatory work for those unable to find employment. It also should include part-time work with increased earning disregards as well as work focused educational assistance including English as a Second Language and other supports for the employed so that work is always better than public assistance. State legislators urge HHS and Congress to revisit the current regulations on the definitions of job search and the ability to count the work effort of those with disabilities. Substance abuse and mental health treatment should not be limited to job search.

Part-time employment with some support is preferable to no employment. State legislators strongly believe that federal rules that create financial disincentives for work should be repealed. Subsidized employment is one of several tools that states might employ to help families during difficult times and should be supported by the federal government. Working should always improve a family's financial and economic situation.

Work Requirements

NCSL supports the current requirement that after 24 months, all families should be engaged in work, as defined by the state.

State lawmakers want to work with all families, understanding that each has different needs and barriers to employment, but all can make progress. State legislators agree that all families should have a self-sufficiency plan, which updates the employability plan under current law. However, the details of these plans, how participants are engaged and how these plans are monitored must be left up to state discretion. HHS should be required to provide technical assistance to the states on the implementation of these provisions. NCSL does not see the need for such a severe penalty - loss of TANF funds, increase in state funding to make up the difference and increase of state MOE - to ensure that states comply with this requirement. NCSL supports a program improvement provision that would allow states that are improving the work rates of TANF recipients, but do not meet newer, higher goals, to avoid financial penalties. This allows states to continue improving their programs without the burden of a reduced TANF grant.

Work Activity and Work Participation Rates

NCSL urges the following changes in the work participation rates:

  • Eliminate the two-parent work participation rate and have all families count in one consistent work participation requirement, which will help strengthen families and remove a barrier to marriage.
  • Allow states to count all recipient work effort.
  • Give states greater flexibility to define what activities count as work, especially the combination of activities such as work, job training and preparation, education and treatment for alcohol and other substance abuse, and mental illness, and activities to meet the requirements of a domestic violence plan.
  • Retain the 30 hour work participation rate as the standard.
  • Continue to give states credit for those who leave welfare. If the current caseload reduction credit is reduced or eliminated, it must be phased out so as to give states time to adjust to any changes.
  • Give states the option of including education leading to employment as part of the first 20 hours of work with the purpose of meeting state work participation rates and give states the flexibility to count post-secondary programs that lead directly to good jobs.
  •  The time limit on post-secondary education programs should be extended from 12 months to 24 months.
  • Retain 20 hour requirement for a parent with a child under six.
  • The focus on work should not come at the exclusion of necessary basic or vocational education that would enhance skills, job retention and earnings. NCSL has always urged the federal government to leave the decision on when and how education should count for each client up to the states, similar to other TANF benefit and services decisions. The current policy that limits the amount of time and caps the number of clients engaged in vocational education does not take into account state decision making. State legislators support efforts to expand the length of time a recipient can be in vocational education, and to lift or increase the cap on a percentage of the caseload that can be counted. NCSL supports giving states more flexibility to define education, and to give credit to those engaged in Adult Basic Education and English as a Second Language and post-secondary education.
  • Continue to support states ability to use TANF funds for subsidized employment programs.

State legislators are concerned about the impact of reauthorization. Tougher work participation requirements and limitations on what activities count for the core work requirements will force states to only concentrate their efforts on those receiving cash assistance and move away from supporting those who have left welfare to go to work. It will also force states to move away from putting clients into private sector jobs and force states to direct resources toward community service jobs. States will also be forced to reallocate TANF funding away from creative and innovative services including family formation efforts and mental health treatment to fund these new efforts. There are particular difficulties for finding employment and mandatory work in rural areas, where jobs may be few and access to child care and transportation services is limited. Administering these requirements in remote, rural and tribal land areas is especially costly. It will exacerbate the difficulties states face in providing child care to those on welfare and poor working families including former welfare recipients - especially if no new child care funds are included.

State welfare programs have honored and rewarded work. State legislators are concerned that if new and inflexible work requirements are added to the program, states, constrained by the fixed sum of money available from the block grant and their own economic difficulties, will be forced to establish costly community work programs for those on public assistance at the expense of those who have left or have never been on public assistance. States will have to fund administrative structures to create slots and monitor activities to meet the work participation rates. To do otherwise would leave states vulnerable to substantial fiscal penalties - losing 5% of TANF block grant, backfilling this penalty with state dollars and an increase in 5% for the state maintenance of effort requirement. Diverting program funds to pay for these new administrative structures and technological changes will compromise state success. Forcing states to allocate additional funds to administrative purposes endangers the desired results of welfare reform.

NCSL supports the adoption of credits to reward state success in moving families to employment. Such credits would benefit states that focus their efforts to get recipients into jobs that promote long-term self-sufficiency. Part time work should also be counted, as State legislators believe part time work is an achievement. Additionally, states must have the ability to account for those who are in the application process for Supplemental Security Income. States should be given credit for providing services that keep potential recipients from having to go on public assistance. This is often referred to as "diversion." Additionally, it is critical that states receive credit for providing significant child care and transportation assistance that allows people to stay on the job. This would better reflect state efforts to encourage self-sufficiency.


NCSL believes that states should retain the flexibility they currently have to define sanctions for noncompliance with welfare rules including work requirements. Federal mandates regarding the definition, occurrence and duration of sanctions are contrary to the spirit of devolution. Such decisions should be made at the local level. NCSL opposes efforts to mandate a full family, full check sanction policy. Legislators strongly believe that states should retain full flexibility on the use of state MOE funds. Therefore, NCSL opposes any efforts that would restrict a state's ability to provide state funding to serve sanctioned families including children.

Drug Testing

NCSL supports continued flexibility to address issues of drug use among TANF recipients, and opposes new federal mandates in this area. The key to success in welfare reform and any future success is continuing Congress’s clear original intent to leave such decisions to the states. States currently have a variety of innovative programs to address substance abuse issues, including screening, treatment, and testing.

Time Limits

It is important for federal policymakers to recognize that time limit policy is implemented differently across the states. Many states feel that there is sufficient flexibility under current law to exempt, delay and extend time limits as they choose for appropriate candidates, notably families facing tough challenges. However, some states with historically lower state welfare spending with resulting smaller MOE requirements report less flexibility within current time limit policy. While federal policy recognizes the ability to exempt families from time limits, it does not explicitly allow extensions of time limits. NCSL believes that federal policy should always encourage work. When a parent is working and receiving benefits, states should have an option to extend or exempt these workers and their families from the federal time limits. The current policy should continue to:

  • Give states flexibility to determine their own time limits
  • Allow states to decide to maintain separate state programs under MOE or segregate their MOE spending in an existing program to be able to use the funds with greater flexibility.
  • Maintain the ability of states to exempt 20% of their caseload, as defined by the state, from federal time limits.
  • A related issue is the definition of "assistance". Receipt of assistance triggers time limit requirements. NCSL urges Congress to continue the practice of applying time limits to only "assistance" funded by TANF and to continue to allow states flexibility to decide time limit policy for MOE funded programs. State lawmakers continue to support efforts that would distinguish cash support from non-cash support. Currently housing, food and cash count as "assistance." NCSL urges Congress to separate housing from other forms of assistance

There are some individuals with severe barriers to employment that may not be best served in time-limited assistance program. NCSL urges Congress and the Administration to carefully examine how the SSI and SSDI programs can be better coordinated with the TANF program and state efforts to help each individual achieve the maximum level of self-sufficiency possible.

Purposes of TANF

 NCSL continues to support the purposes of the TANF block grant. The current four purposes focus state attention not only on caring for children and moving families from welfare to work, but allowing states to target funds on some of the key reasons for dependency - lack of employment, job preparation, formation and maintenance of two parent families, marriage and out-of-wedlock child bearing. The focus of the TANF program should be not just on getting a recipient into the workforce, but on job retention and wage enhancement strategies and supports that allow the recipient to become truly self-sufficient.

Family Formation and Marriage

While marriage is an issue that transcends discussion of the reauthorization of the TANF program, promoting the formation of stable families is part of ensuring that the cycle of dependency on government programs is broken. Marriage provides important benefits, including economic ones, for adults and children. Government policy should be to support healthy marriages, and, perhaps as critically, not to set up barriers to marriage. Great progress has been made in reducing the welfare cash assistance caseload since the passage of the PRWORA in 1996, but state legislators recognize that much remains to be done in addressing the underlying causes of poverty. That includes strengthening two-parent families. State legislators recognize that not everyone will choose to marry or choose to stay married.

State legislators believe that any federal discussion of the issue of marriage must be based on the following principles:

  • NCSL recognizes that efforts to salvage some relationships may not be appropriate and there needs to be special awareness of the prevalence of domestic violence, family violence and abuse. Therefore, NCSL supports the family violence option;
  • Marital status must never be a condition of receiving TANF benefits or services. Great care must be taken to respect personal decisions because people approaching human services agencies are in a vulnerable position;
  • Efforts to encourage marriage should respect cultural differences and should be conducted in culturally sensitive ways;
  • States must have maximum flexibility as they utilize a range of approaches to promote marriage, especially within the finite resources of the TANF block grant. Marriage laws have been the purview of state government, not the federal government;
  • A central focus of these efforts must be child well-being. NCSL supports efforts to assist parents with parenting skills, even in the absence of marriage, so the children involved have a stable support system;
  • Rules for the TANF program and other federal programs must be examined to ensure that they do not penalize couples that choose to marry; and
  • TANF program restrictions that apply solely to two-parent families must also be re-examined, especially the two-parent family work rate. Examples of federal areas of law that can discourage couples from marriage include the tax code and federal low-income housing regulations.
  • NCSL requests that the federal government consider existing efforts and how those efforts might be strengthened. States are already working to promote marriage outside the TANF program. Some examples of actions states have taken include establishing fatherhood programs, providing incentives for marriage education, enacting earned income tax credits without penalizing marital status, enacting family law related to both marriage and divorce and creating programs to sustain the marriages of parents of children with disabilities with respite care services. State legislators urge federal policymakers to affirm the value of these efforts.
  • NCSL supports a demonstration fund for states to implement marriage and family formation initiatives. NCSL opposes any efforts to earmark the TANF block grant for the purpose of family formation or marriage.

Teen Pregnancy

Efforts must continue to reduce out-of-wedlock births. Eighty percent of teen births are non-marital and a significant percentage of teen mothers have second births out-of-wedlock.

State legislators realize that teen pregnancy occurs across all income levels, regardless of race and ethnicity, and over time teen parents have worse outcomes than other teens in educational attainment, and income expectations. Teen parents have more difficulty remaining self-sufficient and are more vulnerable to economic downturns.

NCSL believes that this national problem deserves full attention and strongly supports a nationwide campaign to prevent out-of-wedlock births. NCSL supports highlighting this issue, especially in the popular media, including a National Day to Prevent Teen Pregnancy. NCSL further believes assistance for teen parents to complete high school or obtain a GED will strengthen their futures.

NCSL recognizes that teen parents need special assistance beyond education and training programs to become self-sufficient. Programs to promote better parenting skills including nutrition and basic health must be added as well.


More attention needs to be focused on the fathers, especially low-income non-custodial fathers. As NCSL's policy "Nurturing Responsible Families" details, NCSL believes that children deserve two involved parents. States have established innovative programs to reach out to low-income non-custodial parents, and can share their successes with the federal government. Child support is an especially critical issue for many low-income fathers. NCSL cautions the federal government, however, to remember that there are 50 state systems collecting child support. Any changes in federal child support enforcement law must be carefully crafted to avoid unintended consequences.

State legislators have long supported efforts to increase paternity establishment, recognizing how important it is to have both parents emotionally and economically involved in the life of their child. Establishment of paternity represents a point at which all options, including marriage, can be discussed with unwed parents. Paternity establishment should be accomplished in the least coercive way possible. Teen fathers also must not be left out of these programs.

Data Collection and Reporting Requirements

State legislators remain concerned that the reporting requirements in the law are unrealistic and do not gather the information both the federal and state legislatures need to adequately provide oversight over welfare reform implementation. The new law should pay attention to these provisions to ensure that the data required are collectible by the states and relevant to the policy questions state legislators have. Adequate time must be allowed to provide states an opportunity to create and design systems to collect all the required data by the deadlines stipulated in the law. Additionally, state legislators question the ability of states to track the time a recipient receives TANF funds when that recipient moves across state lines. In addition, the new regulations require very specific types of verification and do not allow states sufficient flexibility in pursuing additional and accurate verification methods in programs that are multi-dimensional. Integrated programs, which combine activities and have been proven to be successful for families, are difficult to fit into the new verification structure. NCSL opposes the establishment of a national error rate for the TANF and Child Care and Development Block Grant programs under the Improper Payments Act.

Child Care

The Child Care and Development Block Grant (CCDBG) must also be reauthorized. NCSL policy directive on Child Care supports an expansion of funding for the Child Care and Development Block Grant. Child care is critical to meet increased federal work participation rates. Full funding of TANF is important for child care, as is the ability to transfer up to 30% of the block grant into the CCDBG. NCSL continues to oppose further earmarking of the CCDBG or direct TANF spending on child care.

Social Services Block Grant

NCSL has a policy directive on the Social Services Block Grant (SSBG) that details the importance of SSBG in providing critical services to low-income individual families and transferability of TANF to the SSBG.

Child Welfare

An issue that remains to be addressed is reconciling the "look back" date to a state's AFDC plan when determining IV-E eligibility. NCSL urges federal policymakers to reconsider this provision. NCSL has a policy directive on Child Welfare and Family Services that is more detailed.

Tribal TANF

 NCSL urges clarification of the welfare reform requirements as they relate to tribal options. State legislators are concerned about the implications of the tribal options on the states and urge Congress and the Administration to work with state legislators and tribal leaders. NCSL has met with tribal leaders and will continue to work to find areas of mutual agreement in welfare reform.

As Congress considers revisions to the tribal TANF program, NCSL urges inclusion of the following:

  • Continuation of and expansion of MOE credit for states who voluntarily provide state funds to tribal TANF programs;
  • Trigger mechanisms that allow flexibility in work requirements and time limits for areas in tribal lands with high levels of unemployment,
  • Provisions that would encourage state/tribal cooperation, foster a better state/tribal partnership and avoid mandates on the states,
  • Access to performance bonuses,
  • Funding for technical assistance to tribes including economic development,
  • Consider reworking current law to provide a separate funding stream for tribal TANF with provisions for tribes to contract with states, and
  • Change the period of time for tribal options to accommodate those states with biennial sessions and budgets.

Welfare Waivers

NCSL strongly believes that states need flexibility for further innovation. State legislators would prefer to have options, rather than waivers, for policy changes that are not in need of further evaluation. NCSL strongly believes that states must be able to continue current federal waivers as well as receive new federal waivers for welfare reform. The elimination of current state waivers will substantially undermine current state programs.

The Administration has proposed a new process for states to apply for waivers across programs and departments. NCSL has urged more coordination across programs and supports the creation of an expedited process to consider state requests. A new waiver process must have cost-neutrality provisions that allow states the ability to count their progress over five years, not year to year. It must include a broad range of programs. It would also be especially helpful if it allowed for data reporting across programs and agencies and allows for information technology to be adapted in a more flexible manner by states. State legislators should be given a role in the waiver application process.


Transportation is another barrier to employment. Transportation assistance must be part of any federal welfare reform plan. Too often, work opportunities are provided at a distance from where recipients live. This assistance must take into account transportation needs for child care. Transportation assistance should not be considered "assistance" for the purpose of triggering time limits.

Other Work Supports

Work expenses are an additional barrier to employment. Uniforms, tools and texts can be especially costly for those beginning employment. NCSL believes that the federal government must provide adequate funds and eligibility disallowance for work expenses. There is little coordination between the various programs that assist low-income families with their housing needs and self-sufficiency efforts. State legislators urge the federal government to link these systems so that those who return to employment are not in danger of losing their housing assistance and can earn their way out of poverty.


State legislators are extremely concerned about federal financing of welfare reform. NCSL strongly opposes federal efforts to finance welfare reform through cost-shifting to the states. NCSL opposes the following:

  • unfunded mandates;
  • transfer of support for needy populations to state government through elimination of program and benefit funding by the federal government. The federal government cannot eliminate their responsibility for legal immigrants, substance abusers, homeless families and families in crisis. This does not address legitimate needs -- it transfers the need to state-funded and nonprofit programs and public hospitals;
  • capping current open-ended entitlements; and
  • unrealistic assumptions about savings from recipients leaving welfare or receipt of child support enforcement.

Technical Assistance/Implementation

State legislators believe that there are many innovative programs around the country that should be shared. Technical assistance to state legislatures will be critical as state revisions are considered. NCSL urges that the federal government include funds for technical assistance to state legislatures as part of the national reform effort. Adequate implementation time is necessary, especially if states must make changes in state law to comply with new federal requirements. Regulations must be issued in a timely fashion and continue to promote state flexibility.

Additional Resources

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