Policies for the Jurisdiction of the Health Committee

American Health Benefit Exchanges

The Patient Protection and Affordable Care Act (ACA), requires the establishment and operation of an American Health Benefit Exchange 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.

Expires August 2013

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.
 
Research
 
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.

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 J-1 Visa Program
 
The Conrad State 30 J1 Visa Waiver program is the most common method of obtaining a J1 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 J1 visa waivers for each state. NCSL urges Congress to permanently authorize this program and to provide for a periodic review and evaluation of the program’s goals and objectives.
 
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 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.
 
Funding
 
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.

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.

Medicaid Expansion of Options

On June 28, 2012, the U.S. Supreme Court upheld the individual mandate provision of the Patient Protection and Affordable Care Act, but found that the Medicaid expansion provision was unconstitutionally coercive. It then prohibited the Secretary of the U.S. Department of Health and Human Services (HHS) from imposing the penalty for noncompliance with the Medicaid expansion, the withholding of all state Medicaid funds. Further, the Court provided that each state has the option of continuing its existing Medicaid program or implementing the Medicaid expansion. The Court provided no additional guidance on how the new option should be implemented.
 
NCSL urges Congress to afford maximum flexibility to states and to permit states to implement some, but not all of the expansion provisions without penalty. NCSL looks forward to a continued dialogue with Congress on this matter.

Expires August 2013

Medicaid Legislative, Regulatory, and Administrative Initiatives

Legislative Initiatives
 
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 assistances 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 when demand increases. 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 concerned about proposals to blend the matching rates for Medicaid and the Children’s Health Insurance Program (CHIP), particularly if they would lower the enhanced matching rates, established in the Patient Protection and Affordable Care Act (PPACA), for individuals who become eligible for Medicaid under the new expanded eligibility categories that become effective in January 2014. Any administrative simplification that would be achieved by the blending of the rates could be dwarfed by the impact of reduced federal financial assistance, unless the blended rate holds states harmless.

• 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. If Congress decides to cap further expansion of the provider tax program, then it must provide states with increased flexibility by converting the existing programs to a grant with appropriate annual inflators, thus eliminating costly administrative activities in the current programs.

• 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.

Regulatory Initiatives
 
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. Some states have been unable to reduce rates due to recent federal court rulings. While states are awaiting a US Supreme Court decision on whether providers and clients have a private cause of action under the Supremacy clause, NCSL urges Congress to address this issue by making appropriate statutory changes.
 
Program Integrity Initiatives – NCSL urges the Congress and the U.S. Department of Health and Human Services to coordinate and consolidate the various program integrity programs enacted over the last several years to address duplication of effort and conflicting elements of the programs. These actions would improve the cost effectiveness of the initiatives and lessen the administrative burdens associated with them.
 
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.
 
Dual-Eligibles
 
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; and
• Section 1903(m) that sets constraints on actuarial soundness for Medicaid rates. The section should be modified to permit states to define contract requirements and use market competition to drive down rates.

Expires August 2013

NCSL Supports Health IT Week

National Health IT Week 2012 will take place September 10-14. 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."
 
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 2012 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 by during National Health Information Technology Week.
 

Expires August 2013

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.  
 

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.
 
PUBLIC HEALTH AND THE ENVIRONMENT

• 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.

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  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.
   

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  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.

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  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 t :  (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.

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    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 Veteran’s 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.
     
    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.