NCSL POLICY DIRECTIVES AND RESOLUTIONS

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.

Aging Services (Older Americans Act)

The Administration on Aging and the programs authorized and funded by the Older Americans Act are extremely important to the states, their senior citizens, and their families. The National Conference of State Legislatures (NCSL) strongly supports Older Americans Act programs and believes that the services funded through this act should be both cost effective and responsive to the special needs of the elderly. NCSL appreciates the support of Congress and the Administration for the Older Americans Act (OAA) and the National Family Caregiver Support Program.

Recognizing the challenges our country faces in providing services for the increasing number of elderly citizens, NCSL urges Congress to continue its support for the programs of the OAA by appropriating sufficient funding for them, especially the National Family Caregiver Support Program.

NCSL supports the National Family Caregiver Support program, which recognizes the need to support both those caring for older individuals and older individuals caring for children. States must be given the flexibility to establish standards in this program and decide how program funds will be distributed.

NCSL supports increased efforts in the reauthorized Act to ensure that Older Americans Act programs do reach low-income, minority and rural elderly households and to inform them about services available to them under the Older Americans Act and other state and federal programs. The authority of state government through designated State Units on Aging should be strengthened to ensure that service funds under the Act are used to support independence in older populations and the most vulnerable members of the population- the very old, the frail, the isolated, and limited English-speaking individuals, with particular attention to low-income minority persons. States must have the authority to distribute these funds based on their own criteria.

NCSL believes that states should continue to be afforded considerable flexibility in the administration of the OAA. NCSL supports permitting states to transfer funds between the nutrition program and the social services program according to a state's need and to transfer funds between congregate and home delivered meals. States should also continue to be able to determine if Area Agencies on Aging (AAA)'s should directly provide services and to determine which services AAA's can provide.

NCSL supports efforts to put additional resources into the ombudsman program. In addition, NCSL supports Congressional proposals to fund programs on elder abuse, home care, and programs to provide special assistance to the elderly. Provisions should be developed which strengthen the capacity and expand the resources of State Units on Aging and Area Agencies on Aging. This is critical on a wide range of elder rights issues: quality of long term care, elder abuse, consumer protection, guardianship, age discrimination, and beneficiary rights in entitlement programs. NCSL supports the importance of nutrition education and counseling for seniors, which recognizes the unique needs of the elderly.

NCSL believes that participants with incomes below 125 percent federally established level of poverty, should not be subject to cost sharing. Fees collected through this mechanism should provide for expanded services and increased availability of services to those elderly with the greatest economic and social need. This will also enhance the coordination and equity between OAA, the Social Services Block Grant, and state-financed programs that are often funded on a sliding fee scale.

Finally, NCSL continues to support the Senior Community Service Employment Program (SCSEP). NCSL calls for increased cooperation between the states and the national contractors. NCSL supports Congressional proposals to provide states and national contractors more flexibility on administrative costs while keeping these costs to a minimum.

Federal Policies on Aging

NCSL urges that Congress: (1) preserve the financial integrity of the Social Security system; (2) eliminate all forms of age discrimination against older workers;  (3) provide funds for direct services for the elderly; (4) fund the development of integrated, coordinated, community-based continued care systems to help prevent the unnecessary institutionalization of the elderly; and (5) provide additional support for gerontological research, education and training; (6) and ensure the flexibility for states to use TANF funds to support programs that serve grandparents raising grandchildren.

 

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

  • 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.
  • NCSL supports and encourages the continuation of state flexibility with respect to needle exchange programs and hopes to continue to work with the federal government to develop best practices regarding the prevention of new cases of HIV/AIDS, hepatitis C and other blood borne conditions that arise from individuals with substance use disorders, mental health conditions and HIV/AIDs and other blood borne disease sharing needles.

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 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 prevention, care and treatment to people with at risk of or living with HIV/AIDS should provide maximum flexibility to states to enable them to develop programs that best meet the needs of their residents.

NCSL supports:

  • Continued and adequate funding for states through the Ryan White C.A.R.E. Act and through cooperative agreements with the CDC and federal partners,
  • permitting states to demonstrate, in their state plan, that they have addressed the needs of all populations within their boundaries, in lieu of federal statutory mandates, and
  • ongoing federal resources to provide for the development and distribution of prevention and treatment medications. It is important the funding keep pace with the approval and availability of new prevention drugs and treatment therapies.

NCSL opposes:

  • The imposition of state matching or maintenance of effort requirements in these programs.

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Building Self-Reliance and Financial Independence for Low-Income Families

Temporary Assistance for Needy Families (TANF)

NCSL supports:

  • Federal stakeholders providing states with flexibility in making strategic TANF policy decisions to design their own programs in accordance with their communities’ specific needs,
  • the concept that individuals receiving public assistance should be engaging in efforts towards self-sufficiency,
  • regulations that authorize states to deem compliant individuals with disabilities who fail to meet the work threshold or activity standards which TANF requires,
  • permitting states to determine if individuals applying for Social Security Income (SSI) meet the SSI threshold for an exclusion from the work rate calculations because they are unable to work prior to a Social Security Administration (SSA) determination,
  • providing assistance to needy families so that children can be cared for in their own homes or in the homes of relatives,
  • continuing to allow Maintenance of Effort (MOE) requirements that are flexible for the use of funds in any manner “reasonably” calculated to achieve TANF’s statutory purpose,                                                                           
  • excluding individuals unable to work due to temporary disability and ineligible from SSI from the work rate calculation, and
  • allowing states options to collaborate and contract with religious organizations for family assistance services, within the boundaries of state and local laws.

NCSL urges federal partners to:

  • Continue to provide full financial support for the TANF block grant, and the contingency fund, which provides additional financial support for qualifying states during an economic downturn, and
  • Support the success that states have had with proven strategies to get welfare recipients into unsubsidized jobs in the private sector.

NCSL opposes:

  • Federal regulatory actions that would limit state flexibility, constrain state policy choices or leave states facing financial penalties for not meeting federal work participation rates,
  • Congressional proposals to reduce the welfare block grant in TANF, related block grant and welfare program, and
  • The preemption of state authority, or mandates on states as they compromise the spirit of the state-federal partnership. 

Individual Development Account (IDA)

NCSL supports:

  • Federal efforts to provide incentives for the creation of Individual Development Accounts (IDAs) as a tool to promote financial self-sufficiency that complements state efforts to reform welfare and to support working families' efforts to move out of poverty,
  • 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, and
  • Examining and eliminating barrier in the TANF program, including those associated with the Cash Management Improvement Act, to simplify the administration of IDAs.

Inflationary Adjustment

NCSL urges federal partners to consider an inflationary adjustment to the overall TANF block grant. An inflationary adjustment would enable states to respond to the increased demand for non-cash assistance, economic uncertainty and any emerging expectations of welfare reform. NCSL would oppose any imposition of an MOE requirement as a condition of receipt of funding unless the receipt of the additional funds were optional.

State Legislative Authority 

A critical component of the TANF law explicitly gives state legislatures specific authority to appropriate their state’s TANF, child care, and welfare-to-work funds through the “The Brown Amendment.” NCSL strongly supports maintaining this language.

Rewarding Work and Reducing Poverty

NCSL believes that work is a critical component of welfare reform and federal law should support state efforts to create a continuum of self-sufficiency. Federal policy should facilitate and inform and encourage state-based and/or community and local comprehensive strategies. 

NCSL supports:

  • The current work requirement, that after 24 months, all families should be engaged in work, as defined by the state, but NCSL urges the administration to make the following changes in the work participation rates:
  • eliminate the work participation standard states must meet that requires a higher work participation standard for the two-parent portion of their assistance caseload, which will help strengthen families by removing a barrier to marriage,
  • Allow states to count all recipient work effort including:
    • Providing states greater flexibility to define what activities count as work, such as, job training and preparation, education and treatment for alcohol and other substance use disorders, and mental illness, and activities to meet the requirements of a domestic violence plan,
    • retain the 30-hour work participation rate as the standard,
    • continuing to provide states credit for those who leave welfare,
    • providing 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,
    • extending the time limit on post-secondary education programs from 12 months to 24 months,
    • retaining the 20-hour requirement for a parent with a child under six,
    • allowing states flexibility to define education and give credit to those engaged in Adult Basic Education and English as a Second Language,
    • continuing to support ability to use TANF funds for subsidized employment programs, and
    • permitting states flexibility to define sanctions for noncompliance with welfare rules including work requirements.

Time Limits

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.

NCSL supports:

  • Providing states flexibility to determine their own time limits,
  • distinguishing cash support from non-cash support and separating housing from other forms of assistance,
  • examining how the SSI and SSDI programs can better coordinate with the TANF program,
  • allowing states to decide to maintain separate state programs under MOE or segregate their MOE spending in an existing program with greater flexibility for funds and,
  • maintaining the ability of states to exempt 20 percent of their caseload, as defined by the state, from federal time limits.

Data Collection and Reporting Requirements

NCSL opposes:

  • The establishment of a national error rate for TANF and Child Care and Development Block Grant (CCDBG) programs under the Improper Payments Act.

Child Care

NCSL urges Congress to continue its support of state initiatives and creative approaches in offering high quality and safe child care.  In partnership, the state and federal governments can address the wide spectrum of needs for child care in the community offered in varied delivery settings ensuring parent choice quality and affordability.

Child Care Development Block Grant (CCDBG)

NCSL strongly supports full funding for the Child Care Development Block Grant Fund (CCDBG) program, which serves as the main source of federal funding dedicated primarily to child care subsidies for low-income working families.  As child care needs vary in the states, NCSL opposes restrictive CCDF regulations that restrain state autonomy in directing the use of funds, and proposed changes to the CCDBG that include additional mandates.

In a varied child care marketplace, state legislators are faced with the demands of directing CCDBG funding where it is most needed to ensure the availability of high quality and affordable child care:

  • enabling welfare recipients on wait lists to gain employment,
  • ensuring that former welfare recipients do not return to the welfare rolls,
  • meeting the special needs of children with disabilities,
  • providing care for infants and older children in after school care, and
  • ensuring access to care for children of parents who work off shift and non-traditional hours.

NCSL urges Congress and the U.S. Department of Health and Human Services (HHS) to maintain and support state flexibility as they examine and revise the CCDBG.  In addition, NCSL opposes earmarking CCDBG increases in funding as they would reduce state flexibility, which is crucial to state innovation.  The portion of unobligated CCDBG funds should remain consistent with congressional intent and leave the use of those funds to the discretion of the state for their CCDBG programs.  NCSL urges the federal government to not withhold funding from states that choose to operate their programs under stricter standards than the federal standards. 

NCSL supports the following program flexibility options for states:

  • Offering differential payment rates for providers of higher quality services or who serve children with special needs;
  • Permitting states discretion to govern the establishment of rules on the registration of unlicensed providers;
  • Allowing parental choice of providers within a state regulatory framework;
  • Permitting the inclusion of quality supply and system building activities as acceptable expenditures in addition to reimbursement;
  • Permitting states to make child care services accessible to all individuals’ subject to welfare-to-work programs with federal funding support; and
  • Providing states the option 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.

Funding

NCSL urges Congress to continue its commitment to support the CCDBG program at sufficient levels to complement ongoing state efforts to provide high quality child care services to welfare recipients and low and moderate income working families.  Support of the CCDBG program also strengthens state efforts to employ welfare beneficiaries under TANF work requirements, which can only be enforced if access to child care is ensured.  For these reasons NCSL believes that the preponderance of CCDBG grant funds must remain an entitlement to states. 

NCSL supports 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.

Child care is a critical component that enables states to meet increased requirements for work participation, and imposing a state match may serve as a barrier for some states in accessing badly needed child care funds.  Maintenance of effort (MOE) requirements also make it difficult for states to take advantage of federal funds when they face difficult decisions about how to fund all human services programs.

If an administrative cap is imposed, 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 required and critical to the provision of quality services and should be defined as services.  NCSL urges the federal government to provide technical assistance to states to improve the coordination and financing of child care programs.

TANF and Child Care

NCSL strongly supports child care as a legitimate use of the Federal TANF block grant and state MOE funds. NCSL supports state options to transfer up to 30 percent of their federal TANF block grant allotments to the CCDBG. We urge the administration and the Congress to eliminate the distinction between how child care is treated for working families based on funding stream.

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.

NCSL supports these families having 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.

Standards

NCSL believes that states should retain regulatory, licensure, and operational oversight of child care facilities. Any regulatory requirements imposed by the federal government should serve as a floor and not a ceiling, and not restrict state flexibility in determining how child care facilities should function in their jurisdictions. NCSL urges the federal agencies to support state efforts through guidance and technical assistance, particularly in regard to building a child care workforce, provider education, development of models for special needs populations, and the homeless.

Taxes and Benefits

NCSL supports options through use of federal and state tax incentives that can encourage creation of child care programs and help parents better afford child care services. NCSL supports:

  • Tax credits for employers that establish, operate, supply and/or support 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;

Options that enable states to create or allow the development of publix private partnerships to strengthen the child care system.

Child Welfare and Family Services

NCSL supports federal efforts to:

  1. promote the welfare and safety of all children
  2. protect against and prevent child abuse, neglect, or exploitation;
  3. establish a system of family support services;
  4. permit children to remain in their own homes or return to them whenever it is safe and appropriate, or promote kinship and guardianship placements when it is not;
  5. promote safety, permanency, and well-being for children in a range of foster care alternatives or with adoptive families;
  6. ensure educational stability for foster care children; and provide training to ensure a well-qualified child welfare workforce. 
     

NCSL believes the primary goal of child welfare services should be to support the integrity of the family unit, ensuring the safety of children, and lessening the need for long term intervention. Supportive family services are critical to reducing the number of children in the foster care system. NCSL urges the administration and Congress to continue federal support of:

  1. programs that preserve the family unit, or reunify families after child welfare service intervention is required, and
  2. state initiatives and creative approaches to develop cost-effective alternatives to foster care.
     

States must be able to rely on clear federal guidance, technical assistance, and support for training to successfully and efficiently implement a comprehensive system of child welfare services. However, states should be afforded flexibility to better administer and coordinate delivery of these programs and their various support systems, including:

  1. children’s mental health services;
  2. the juvenile justice system; and
  3. other programs offering Temporary Assistance for Needy Families (TANF), housing assistance, educational services, and health care delivery.
     

NCSL also supports federal efforts to improve judicial processes in child welfare cases and to support state efforts to sustain the integrity and efficiency of these efforts through interagency training, budgeting, planning, and conflict resolution as well as integrated data systems.

NCSL opposes any efforts to earmark or restrict the use of federal funding and urges the Department of Health and Human Services (HHS) to permit states to determine the use of funding within their communities. In addition, any caps on administrative funds should not categorize the vital work done by caseworkers as an administrative cost.

Foster Care

NCSL urges the federal government to support the Foster Care program as an open-ended entitlement program under the Title IV-E of the Social Security Act. These funds support out-of-home care, administrative costs, and training for state agency staff, and foster care advocates (court appointed special advocates and guardian ad litem), and adoptive and foster care parents. NCSL opposes any proposals to cap Title IV-E expenditures. In addition, 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:

  1. Promptly pay state claims;
  2. Refrain from imposing stringent time limitations on the submission of state claims;
  3. Monitor and review state performance fairly while giving states tools for improvement;
  4. Emphasize services and other programs designed to help children at risk of foster care placement remain with their families;
  5. Define and support the separation of states’ reporting of foster care administration activities from child placement activity accounts;
  6. Entrust states to determine when and if a congregate care setting is appropriate for foster care placement;
  7. Allow states to prioritize custody and placement with family members over placement in a foster home with non-relatives, unless determined by the court that placement in the foster care system is in the best interest of the child. Federal funds should also be made available to support services for caretaker relatives. NCSL opposes federal actions that would eliminate federal reimbursement for relative foster care that is non-licensed or limits state flexibility in allowing a relative to care for these children;
  8. Support states in assisting 18- to 21-year-olds who are transitioning from foster care to self-sufficiency, and offer flexibility to expand services to different ages for foster care adoption and relative guardianship. Congress should support programs like the John H. Chafee Foster Care Independence Program that funds education and training vouchers for youth aging out of foster care;
  9. Increase the recruitment of and training for foster care and special needs adoption providers, and supportive services inclusive of respite care as appropriate;
  10. Provide the necessary coordination of services to high risk children and families under the scrutiny of the child welfare system including:

a. Health and mental health care,
b. Drug and alcohol abuse treatment and services,
c. Education and job training services, and

11. Promote policies that keep children in their own communities and schools;

12. Not restrict state authority to determine the criteria for termination of parental rights if it should be necessary to do so; and

13. Support states in addressing the challenges they face in meeting the needs of Native American children within the federal and tribal government requirements.

Child Welfare Workforce

NCSL supports federal efforts to develop the supply and quality of the child welfare workforce, including funding for training, student loan forgiveness, and funding to states to improve staff training and reduce caseloads.

Information Services

NCSL supports federal government efforts to develop a national information system to track data on families in the child welfare system and to solicit critical child welfare data, including outcomes for children and the impact of problems such as substance abuse and the effectiveness of treatment options.

Adoption Assistance and Services

Under Title IV-E of the Social Security Act, states, territories, or tribes with an approved Title IV-E plan are required to enter into an Adoption Assistance Agreement with the adoptive parents of any child who is determined by the Title IV-E agency to have special needs. Adoption incentive funds enable states to implement a range of programs including support for foster and adoptive parent, and other child welfare services. NCSL supports incentive criteria that considers the population of special needs children without defining them in terms of age alone. NCSL also supports assistance with post-legal adoptive and respite services that is critically needed for families adopting these children, many of whom may have health and mental health problems as they mature. 

A state, territory, or tribe with a Title IV-E plan approved by HHS may seek federal reimbursement for part of the cost of making payments agreed to under Title IV-E Adoption Assistance Agreements and for related program administration costs, including training. NCSL urges HHS to reimburse states for program expenditures in a timely manner for claims owed to the state for adoption assistance. NCSL requests that the administration and Congress consider potential unintended consequences resulting from changes in the funding structure that might fundamentally alter the capabilities of the program.

The Interstate Compact on Adoption and Medical Assistance, which has been adopted by 49 states and the District of Columbia and governs procedures by which Medicaid coverage and other supportive services of adopted children may be transferred between states. For adoption subsidies to be effective, adoptive parents must be assured that coverage will be provided, regardless of their state of residence. 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. NCSL urges HHS to support these efforts and work with states in providing continuity of services for adoptive families when they relocate to another state.

Flexible Funding for Children's Services

NCSL urges the federal government to provide states the flexibility they need to reform children’s services systems and to meet locally-determined community needs, and remove federal regulatory barriers that often impede state efforts. States should also be given options to use 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.

NCSL opposes a reduction or limitation of funding that caps Title IV-E for these programs as a condition of children's services proposals. NCSL urges Congress to consider separating foster care eligibility from AFDC eligibility for all states and move towards reimbursement for all children in care, as the states determine.

Child Abuse and Neglect

NCSL supports early identification, intervention, and treatment of children who are victims of or at risk for child abuse, and neglect, or trafficking, and believes in the importance of efforts to reduce the incidence of neglect or physical, sexual, or emotional abuse.

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

NCSL encourages the federal government to support states in training mandatory reporters, and opposes federal preemption in defining who qualifies as a mandatory reporter.

Families with Addiction Treatment Needs

NCSL urges the federal government to support the addiction treatment needs of families who are involved in the child welfare system. State legislators are concerned that many women with substance use disorders are pregnant and current treatment programs are ill-equipped to provide services to this population.

NCSL supports:

  1. 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;
  2. Federal incentives for partnerships between substance abuse agencies and child welfare agencies to conduct cross-system training of staff, improve screening and assessment procedures, provide comprehensive treatment and prevention programs, provide after-care services, and improve data collection;
  3. Federally-funded programs that recognize that public policy utilizing criminal penalties instead of rehabilitation and collaborative efforts can be a disincentive to women seeking prenatal care, and these interventions must be properly funded and implemented to prevent substance use disorder before women become pregnant; and
  4. The use of employee assistance professionals at the worksite to help impaired employees become more productive in the workforce and in society.

 

Family Violence

NCSL supports federal efforts assist state programs to prevent family violence, provide immediate shelter and related services to victims, and offer trauma informed training and strategies training and technical assistance to state and local agencies on program administration.

Federal incentives for coordination between child welfare systems, domestic violence agencies, juvenile courts, and services to at-risk households, such as emergency crisis services, in-home services, and parent and family counseling, should be continued.

Demonstration grants to support state efforts 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 should be continued.

 

Encouraging Comprehensive Approaches to Preventing and Treating Behavioral Health Issues ( Directive)

Behavioral health describes both mental health and substance use disorders (SUD). NCSL supports efforts that examine the issues of behavioral health through the comprehensive and holistic approach of the four pillars-prevention, intervention, treatment and recovery.

NCSL supports federal legislation, funding and programing that would:

  • Provide block grants to states with flexibility to address the most pressing behavioral health issues in their states,
  • encourage federal proposals that supports states working to further integrate behavioral health and primary care services and promotes providers to work easily together in this model,
  • remove the unnecessary barriers created by 42 CFR Part 2 by allowing providers to communicate with one another. NCSL recognizes that it was originally attended in stopping discrimination, but it has become a barrier to accessing care and has further increased stigma, and
  • reduce stigma and treat behavioral health conditions in a wholistic and integrated way.

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 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: (1) Imposes improved recordkeeping requirements to implement these recommendations; (2) Prohibits the commercial importation of tobacco products, including smokeless tobacco products, into any state in violation of state or federal law; (3) Increases the penalties for noncompliance with the federal laws regulating interstate and internet sale of tobacco products; (4) Authorizes states to enforce tobacco tax collections through the Jenkins Act; (5) 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; (6) 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 (7) 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 (FDA) Administration Regulation Health Programs

The Food and Drug Administration Safety and Innovation Act

The National Conference of State Legislatures (NCSL) supports efforts to improve the safety and quality of our drug supply including the FDA Safety and Innovation Act which:

  • Enhances the safety of the drug supply chain,
  • Provides incentives to drug manufacturers to develop new effective pharmacotherapies,
  • 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.

Regulation of Internet Pharmacy – NCSL supports Congressional actions through the Ryan Haight Online Pharmacy Consumer Protection Act to:

  • Establish disclosure standards for internet pharmacies,
  • Prohibit dispensing of prescription drugs over the internet to persons who have not been seen by a physician, and
  • Authorize state attorney generals to shut down non-complying sites by using the federal court system.

 Unfortunately, NCSL believes the provisions of the Act have not been sufficient to control rogue websites and urges Congress and the Administration to increase efforts to prosecute organizations in violation of the law

Safety and Quality of the National Drug Supply

NCSL believes state drug pedigree laws should not be preempted unless, a national standard is adopted that provides at least the same level of protections as the state laws. The FDA should assign a high priority to initiatives to both identify quantities and ensure 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 acts of terrorism, and the serious consequences of either call for a vigorous and vigilant response by the federal government.

Access to Affordable Prescription Drugs

Importing Prescription Drugs - NCSL believes that it should be a national priority to expand access to affordable prescription drugs. NCSL supports efforts to explore the feasibility of importing prescription drugs from other countries to move toward goal of containing costs and improving access to safe, and effective pharmaceuticals.

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 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 to 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.

Regulation of Compounding Pharmacy

NCSL urges the FDA to work closely with state legislators, state public health officials, state boards of pharmacy and other important state and local officials, and 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, and the regulation of compounding pharmacies.

State Prescription Drug Monitoring Programs

NCSL supports the five-year reauthorization of the National All Schedules Prescription Electronic Reporting Act (NASPER) adopted in the Comprehensive Addiction and Recovery Act (CARA). NCSL is particularly interested in continued discussions to increase the effectiveness and interoperability of State Prescription Drug Monitoring Programs (PDMPs) and looks forward to working with federal partners to expand and improve the programs.

General Guiding Principles: Federalism and Health, Human Services (HHS), Medicaid and Chip Programs 

Guiding Principles:

The underlying goal of the Medicaid program should be to achieve mutually agreed upon goals, improved outcomes for patients, and flexibility in administration of programs and savings for states, territories and local governments. NCSL supports accountability and transparency from their federal partners and welcomes public feedback and participation in Medicaid oversight and we also understand that flexibility requires accountability and transparency on their part. We ask the federal government to consider that not all state legislative sessions are on a year-round basis, and ask them to be sensitive to state, territories and local governments’ legislative schedules and resources when making changes to Medicaid programs.

NCSL also urges Congress and the Administration to seek the counsel and expertise of state and territory legislators as new Medicaid initiatives are being developed. It is important that federal agencies take the state and territory consultation requirement seriously when drafting legislation and regulations to implement changes. Federal partners must give states a fair amount of time to review and ultimately implement any new changes. We also caution against uniform proposals and changes as they can compromise the effectiveness of programs by making it difficult for states and territories to respond to local conditions.

Medicaid Landscape:

NCSL sees the following Medicaid issues as most pertinent to states, territories and local governments:

Block Grant and Cost Shifting Proposals:

When Congress and the Administration are exploring block grant programs, flexibility needs to be a key principle. Any proposals should refrain from establishing unfunded mandates and any cost shifting requirements for implementing a block grant program in states and territories.  

Waivers:

NCSL supports Congress and the Administration in their ongoing efforts to grant waivers, where appropriate, and in permitting states and territories to develop innovative programs and service-delivery systems in health, and human services. Successful waiver programs should be brought to scale and integrated into the underlying program when appropriate and encourages federal efforts to streamline waiver applications, reviews and approvals.

Emergency Assistance and Countercyclical Assistance:

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

Medicaid Managed Care:

NCSL urges the Centers for Medicaid and Medicare Services (CMS) to work with states and territories as stakeholders to continue to provide support in the operation and upholding of quality standards for Medicaid managed care entities contracting with states and territories.

NCSL encourages federal partners to recognize and support the work of states and territories with their Medicaid managed care stakeholders in the following areas:

  • Expanding care to those with complex medical needs,
  • improving reach and support for rural health care populations,
  • improving the implementation of patient-centered care and facilities,
  • increased integration of physical and behavioral health care services,
  • continued development of value-based purchasing and payments focusing on health outcomes over number of services delivered, and
  • the role of community health centers, safety-net hospitals and academic medical services in providing primary and emergency care for Medicaid enrollees.

Children’s Health Insurance Program (CHIP):

As a partnership between the states and the federal government, CHIP is an essential program that must be authorized on time as it provides health care coverage to countless children across the country. NCSL also encourages the federal government to continue providing flexibility to carry out the program’s operation. Therefore, NCSL supports Congress’ multi-year authorization of CHIP funds moving forward.

As CHIP funding winds down from its previously increased Federal Medical Assistance Percentages (FMAP) rate to participating states and territories, we encourage federal partners to recognize states may require additional flexibilities for running the CHIP program as a result. As these FMAP rates come back down to their original rates, and the CHIP maintenance-of-effort (MOE) runs to ensure a source of health care cover for children, NCSL recommends the following for the program:

  • support for states to develop and test systems of coverage for low-income children and explore ways for states to share examples of best practices with each other,
  • eliminate any burdensome waiting periods for CHIP enrollment to ensure a reduction in gaps of coverage for children, and
  • continued efforts to streamline and facilitate the CHIP and Medicaid application process.

Principles for Federal Health Insurance Reform

States should regulate health insurance and should continue to set and 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 (ERISA), the Patient Protection and Affordable Care Act (ACA), and that would exempt any insurer or entity from state health insurance standards and laws. Federal health insurance legislation that establishes mandated benefits or uniform standards, should have inclusive state feedback prior to implementation, and work to establish standards that work for all states.

Implementations of Health Reforms at the Federal Level:

Any implementation of health reforms at the federal level should require state action to comply and must allow a reasonable amount of time for state legislatures to debate and enact any necessary legislation for their constituents. Where states already have similar legislation in place, a process for declaring "substantial compliance" should also be developed.  Federal partners should also recognize health insurance programs in the states and territories are where innovations in health insurance and healthcare delivery happen and to utilize states models of health insurance and care moving forward.  

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:

  • Increase access to health care services to the uninsured or underinsured,
  • improve the quality and cost-effectiveness of our health care system and the flexibility to test new models that do so,
  • increase access to the broad range of long-term care services including home and community-based services (HCBS) that will enable constituents to live in their own homes or communities that provide personalized and a high-quality care,
  • support for health insurance plans that work to integrate physical, behavioral and social determinants of health with the aim of reducing costs and improving overall health outcomes for individuals, and
  • explore a broad range of approaches and financing mechanisms to improve our health care system including reinsurance programs.
  • Allow states to continue their work on addressing issues which include but are not limited to surprise medical billing, out-of-network and in-network billing practices and transparency for health care prices and health insurance plans and/or Certificate of Need regulated by states. This includes programs providing patients with the information they need to be an active consumer in healthcare pricing across providers and services. We also encourage federal partners as they pursue any changes to medical billing practices to not supersede states ongoing work or authority in state regulated health plans, and to involve states in a timely way when drafting any potential changes to medical billing practices and transparency along with adequate time to states to implement any changes.

Expires August 2020

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 a secure 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 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; (3) employers support the system and believe that it is cost-efficient and improves quality of care, and (4) states work collaboratively to address jurisdictional issues.

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 those standards under federal law. 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.

NCSL Recognizes the Impact of "Benefit Cliffs"

NCSL supports efforts to minimize “benefits cliffs” or “the cliff effect,” which refers to the sudden decrease in or elimination of public benefits that can occur with a small increase in personal earnings. When income increases families sometimes lose some or all economic supports, including Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Medicaid and health care, child care assistance, housing and school breakfast and lunch programs.

NCSL strongly encourages federal partners to work with states to find a timely solution that would remove barriers for individuals to enter or remain in the workforce and increase their household income. NCSL supports federal efforts, in conjunction with states, that would explore how to better align TANF, SNAP, Child Care and Medicaid as work supports, from eligibility and enrollment to recertification, training and employment – and how to better align these work supports to mitigate benefit cliffs and increase family financial security.

Expires August 2020

NCSL Supports National Health IT Week 2018 (Memorial Resolution)

National Health IT Week will take place September 23-27, 2019. 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. 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 Tenth 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 participate in "National Health IT Week 2019" 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.

Nutritional Programs and Assistance

The National Conference of State Legislatures (NCSL) supports the state-federal partnership to provide nutrition assistance to those in need. State legislators are concerned about the vast numbers of hungry individuals, and particularly the severity of hunger among childhood and aging populations. The Supplemental Nutrition Assistance Program (SNAP) Emergency Food Assistance, the Special Supplemental Nutrition Program for Women, Infants, and Children (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

NCSL urges continued federal funding of the SNAP program at levels sufficient to provide assistance to all that are eligible or in need due to the rising cost of food. NCSL also urges the administration and Congress to continue to make SNAP and Temporary Assistance to Needy Families (TANF) block grants more compatible. In times of economic hardship, SNAP, 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 un-funded mandates on state governments, or remove state flexibility that is critical to cost-effective administration of SNAP.

NCSL supports U.S. Department of Agriculture (USDA) initiatives to provide administrative flexibility through the waiver process by allowing states to implement administrative efficiencies such as telephone interviews, utilize Combined Application projects, and develop partnerships with community stakeholder organizations to improve quality, efficiencies, and overall nutrition access.

SNAP Benefits and Program Design

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

  1. Elimination of the annually indexed caps on excess shelter deductions to allow families to deduct high shelter costs;
  2. Adoption of the formula that each October sets the benefits for food price inflation to reflect the Thrifty Food Plan for the previous June;
  3. Exclusion of the first $150 a month by a non-custodial parent paid as child support from consideration as income in determining the SNAP allotment;
  4. Reevaluation of the rules concerning the value of a vehicle that a recipient may own and still receive SNAP benefits;
  5. Federal support and technical assistance for state outreach;
  6. Enhancement and simplification of application and eligibility determination procedures through supporting Web-based screening tools, permitting seniors and the disabled to apply at Social Security offices, and allowing use of joint applications;
  7. Continuation of state options regarding child support cooperation as a condition of eligibility for SNAP. NCSL supports the elimination of the fee for SNAP recipients’ child support collection efforts as a further incentive toward child support enforcement participation.
  8. Continuation of state options to disqualify for SNAP eligible individuals who fail to cooperate with child support enforcement authorities or who are in arrears on child support obligation. NCSL supports this option and opposes changes that would mandate these actions permit the promotion and acceptance of SNAP at farmers’ markets and other non-grocery store, produce-oriented venues, for example: from a small farmer; and
  9. Continue to support current state options regarding categorical eligibility and "heat and eat.”
     

SNAP and Legal Immigrants

NCSL supports SNAP eligibility for legal immigrant children and families. NCSL commends USDA's outreach efforts to assist eligible legal immigrants, including their work to translate materials into more than 34 languages. NCSL continues to support restoring eligibility to the small number of legal immigrants who were not covered under previous restoration. NCSL urges the administration and Congress to include state lawmakers in making decisions that would alter the eligibility status for any category of immigrants legally present in the United States.

SNAP Employment and Training Program (SNAP E&T)

NCSL supports the objectives of self-sufficiency promoted by the SNAP Employment and Training program (SNAP E&T), and will work with the federal government toward that goal. NCSL urges the administration and Congress to allow states flexibility to create, fund, and integrate SNAP E&T programs with similar state programs, particularly TANF and the Workforce Innovation and Opportunity Act (WIOA). NCSL also supports program simplification and coordination between TANF and the SNAP

In addition, NCSL appreciates the USDA's willingness to grant states waivers of the three-month rule in areas impacted by high unemployment and USDA's technical assistance to states.

SNAP Program Quality Control (QC)/Judicial Waiver

NCSL supports the original intent of quality control, which is 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 strongly supports the move away from a system based on error rates to one that awards bonuses for accuracy. NCSL urges the federal government to improve systems related to appeals of waiver decisions and reinvestment of claims, including outcome measures of program goals.

NCSL supports efforts to focus on program measurement and evaluation through positive incentives and urges Congress to reexamine funding levels. State legislators urge the USDA to continue to settle QC claims through state reinvestment in program improvement.

Electronic Benefit Transfer and Automated Systems (EBT)

NCSL supports the regulation establishing 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 allowing cards to be used for multiple programs.

NCSL believes that states should be allowed to negotiate the terms of EBT with food marketers, farmers’ markets, and financial institutions. NCSL opposes preemption of state laws that govern financial institutions pertaining to 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.

NCSL is 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 through fraud reduction. NCSL discourages the federal government from over-promising savings to the states, especially those from fraud reduction, and urges further study of the impact of EBT on states. 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. NCSL also encourages the administration and Congress to continue initiatives around summer feeding and EBT to secure a permanent summer EBT program, including adding monthly funding to family’s EBT cards and including funding for state startup costs. 

SNAP Program Flexibility and Waivers

NCSL believes that the federal waiver process should recognize state participation and need. States need flexibility for further innovation and state legislators 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 a waiver being granted. Plan approval and the results of demonstration grants should be shared with state legislators.

Emergency Food Assistance and Commodity Distribution

NCSL urges Congress to fully fund The Emergency Food Assistance Program (TEFAP) at its authorized level. NCSL believes that Congress should provide adequate administrative funds to facilitate the efficient distribution of food, and should include sufficient safeguards to prevent program abuse. NCSL urges the USDA to make additional surplus commodities available to states, upon request, when additional surplus food becomes available. We also urge the USDA to provide administrative funding support for sorting, packaging, processing, and transporting donated food. NCSL supports federal programs that deliver commodities through farmers’ markets and the child nutrition commodity programs. 

Child Nutrition

NCSL urges Congress to reauthorize legislation to continue and fully fund child nutrition programs. NCSL urges the USDA to emphasize the importance of nutritionally-appropriate foods, and avoiding those high in sugar, fat, and sodium.                                                                                                                                                             

Accurate eligibility determination is important in any federal program, but efforts to ensure that only eligible children are served must not be a deterrent to program participation. NCSL supports the USDA’s proposal to create a pilot program for school districts to provide more nutritious alternatives that would allow experimentation without risk of financial loss to those schools.

WIC

NCSL supports the objectives of the WIC program to educate and inform participants with the best sources of nutrition to reduce the incidence of low birth weight, improve infant nutrition in the first year of life, and to improve the health of participants. NCSL encourages the administration and Congress to ensure time processing and approving applications for WIC applicants to be flexible and ensure continued financial support to maximize WIC coverage for women, infants, and children in need.

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 Program (NSLP) and the School Breakfast Programs (SBP) as critically important to the well-being, education, and self-sufficiency of young children. State legislators oppose the elimination of cash subsidies to schools for moderate- and high-income children under the provisions of the school lunch and school breakfast programs. Additionally, NCSL encourages more flexibility for community eligibility provisions (CEP), which help reduce paperwork for parents and schools with a high percentage of eligible students.

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. NCSL recommends that a study be conducted that would consider alternative financing scenarios that would retain program consistency. NCSL urges the USDA to emphasize nutritionally-appropriate foods.

Summer Food Service Program for Children (SFSPC)

NCSL supports SFSPC and the restoration of meal reimbursement rates that allow 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 Program (CACFP)

NCSL supports flexibility to allow seniors to transport uneaten food they receive while participating in the Child and Adult Care Food Program (CACFP). 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 CACFP to older children in after-school programs, and to ensure that the program is available in more neighborhoods and rural areas. Additionally, NCSL supports state options to expand this critical program to suppers in after-school programs.

Combating Childhood and Adult Obesity

NCSL supports federal efforts to find solutions for childhood and adult obesity without imposing mandates. NCSL urges Congress to fully fund these programs and 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.

NCSL encourages Congress to establish a taskforce to study obesity and co-morbidities of SNAP recipients in high-risk, high-disparity populations. The taskforce should make recommendations that reduce the incidence of disease triggered by malnutrition, including policy reforms to SNAP that incentivize recipients to select foods with high nutritional value.

Nutritional Quality Measures for Older Adults

NCSL supports the quality measures used by the Centers for Medicare and Medicaid Services (CMS) to quantify health care processes, outcomes, patient perceptions, and systems that are associated with the ability to provide quality health care and/or that relate to “quality goals” for health care. These Medicare clinical quality measures are used to improve facilities’ treatment of patients, yet currently no quality measures have been adopted to address malnutrition.

NCSL also supports establishing malnutrition care as a measure of quality health care. NCSL urges the administration and Congress to support state efforts to reduce malnutrition in the elderly and heighten awareness of nutrition in elderly communities.

In 2016, CMS introduced four electronic clinical quality measures that would cover screening for malnutrition, assessment of those screened as at-risk for malnutrition, diagnosis of malnutrition, and creation of a nutrition care plan. NCSL urges CMS to adopt quality measures on malnutrition to heighten the importance of identification, evaluation, and treatment of malnutrition in the elderly.

Nurturing 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.

Arrearages

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.

Federalization

 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.

Automation

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 (ERISA) and the Patient Protection and Affordable Care Act (ACA). 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 federal 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 any necessary state 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 (CDC) and the National Institutes of Health (NIH), plays an important role in supporting state and local public health infrastructure. HHS provides national surveillance of infectious disease, applied research to develop new or improved diagnoses, disease prevention and control strategies, and helps strengthen states’ 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 the administration and Congress to continue to support: (1) grants and cooperative agreements to state and local governments for a broad range of public health activities; and (2) research and technical assistance, which assists states in the development and implementation of effective programs. In addition, NCSL supports efforts to foster the development of public and private sector partnerships to increase community accessibility to public health information and public health programs.

Health Disparities

The U.S. Department of Health and Human Services and its offices, institutes, and centers, including the Office of Minority Health (OMH), the CDC, National Institute of Mental Health, and the Substance Abuse and Mental Health Services Administration (SAMHSA) should work with NCSL and state policymakers to reduce and eliminate health disparities by: (1) identifying social determinants which lead to health disparities; (2) adopting the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards); and (3) developing standards for the collection and reporting of data on:

  1. race, ethnicity, sex, primary language, disability status;
  2. those living in rural and frontier areas; and
  3. other characteristics identified by the Secretary of Health and Human Services by federally-funded health and health care programs in order to analyze and monitor health disparity trends and develop promising practices and programs to eliminate disparities, based on the data collected.

 

Reporting Requirements - 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: (1) analyze trends; (2) improve patient outcomes; (3) improve programs; and (4) eliminate health disparities. In addition, efforts must be made to impose data collection and reporting requirements in the least burdensome way possible.

Funding - NCSL urges the President and Congress to maintain funding to HHS, including the CDC, OMH, and NIH, to:

  1. implement the HHS Office of Minority Health’s National Partnership for Action to End Health Disparities (NPA)’s efforts to mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities, and;
  2. expand support for the Regional Blueprints for Action, which aligns 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;
  4. provide quality and efficient care;
  5. improve health outcomes;
  6. increase cost-effectiveness;
  7. meet legislative, organizational, and accreditation standards; and
  8. develop additional evidence-based prevention and interventions targeting ethnic and racial minorities.
     

Clinical Trials and Research - 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 and to eliminate disparities.

Health Promotion and Disease Prevention

NCSL urges the administration and Congress to continue to support public health education initiatives that are culturally sensitive, language accessible, age appropriate, and written at the appropriate educational level for the audience. It is imperative that these public health education initiatives integrate (1) healthy lifestyle choices and (2) disease prevention messages and (3) strategies targeted for children, young adults, men, women, and 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 and reduce high-risk behaviors through education, counseling and, treatment. NCSL urges the federal government to provide adequate funding for these programs.

Preventive Health and Health Services Block Grant - NCSL urges Congress to continue to support this program. 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, including cholesterol, hypertension, and cancer screenings. Under this program, states are given maximum flexibility to design and implement programs that meet the needs of their citizens.

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.  NCSL also supports efforts to ensure that children receive age-appropriate check-ups and screenings that include recommended childhood immunizations, comprehensive 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. NCSL is supportive of initiatives that provide case management services to children with one or more chronic conditions.

Oral Health - NCSL supports federal initiatives that 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 care to overall good health. NCSL supports efforts to increase access to quality, affordable dental care, including initiatives to improve public and private sector coverage of dental services, and improve oral health literacy within the public. NCSL also urges HHS to provide states flexibility to develop innovative Medicaid dental programs to increase access to and the utilization of oral health care services.

Health Education for Health Care Professionals - 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 information.

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 based on evidence-based evaluation to be beneficial for the population served.

Technical Assistance to States to Improve the Quality, Capacity, and Access of Mental Health Services - NCSL urges HHS to provide technical assistance to states to monitor and improve the provision of mental health services to adults and children.

NCSL also urges HHS to work with the medical community to develop guidance regarding behavior therapies that may replace or be used in concert with medications to reduce the dependence of on psychotropic medications as the primary or sole treatment.

Mental Health Treatment of Children

 receive treatment on medical evidence NCSL urges the federal government to support efforts to:

  1. develop treatment protocols to be used before advancing to pharmacotherapies;
  2. offer guidance to the primary care community on the alternatives to pharmacotherapies for mental illness in children; and
  3. increase the pediatric mental health workforce.

 

Vaccines and Immunizations

Childhood Immunizations - NCSL supports efforts designed to increase the overall number of children immunized. NCSL supports the use of 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 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 ensure every child receives the recommended childhood immunizations and to improve immunization delivery and education 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 Congress to continue efforts to increase the number of adults who receive recommended immunizations. NCSL supports and encourages continued special efforts to ensure high-risk adults, young adults, and older adults receive all recommended immunizations.

Vaccine Supply - NCSL urges the administration and Congress to provide or appropriate sufficient funds to maintain a reasonable stockpile of pediatric immunizations and 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 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 CDC to continue to permit state and local health officials to 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.

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 the ability of their states to prepare for and respond to these events. A strong partnership between states, the federal government, and other public and private non-profit entities is the best way to accomplish this goal. NCSL urges to the administration and Congress

  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 ongoing 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 and utilize federal funds in the most efficient and effective way;
  3. require grantees to collaborate with their respective states and coordinate all of their activities with the state plan;
  4. provide 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. and the environment NCSL urges the federal government to continue to assist state and local health officials in addressing this serious health care problem.

Vector-Borne Illness - NCSL supports the efforts of the CDC to abate vector-borne illness, including-Chikungunya, Eastern equine encephalitis virus (EEEV), Lyme-Disease, Malaria, Rocky Mountain spotted fever, and West Nile Virus, and Zika virus–by:

  1. providing training and assistance to front-line disease surveillance and    response staff;
  2. offering clinical education programs;
  3. collaborating with state and local health departments; and
  4. providing funding to states to support epidemiology and response activities addressing vector-borne disease.
     

Maternal and Child Health

  • Maternal and Child Health (MCH) Block Grant - The MCH block grant allows 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) helps states identify and address unique 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.

The Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) – The MIECHV program facilitates collaboration and partnership at the federal, state, and community levels to improve the health of at-risk children through evidenced-based home visiting programs. NCSL supports community-based, state-federal partnerships and initiatives that working with parents and caregivers provides a supportive environment to:

  1. improve maternal and child health;
  2. promote healthy child development and school readiness;
  3. improve parenting skills; and
  4. prevent child abuse and neglect.
  • NCSL urges Congress to continue financial support for the MIECHV program and to provide state flexibility in the administration of the program based on needs assessments that identify community and family vulnerabilities.
  • 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.
  • Teen Pregnancy Prevention - The federal government offers a range of programs and supports to state governments to help reduce teen pregnancies recognizing that state, tribal, and local governments are best situated to determine the best programs for their constituents. NCSL supports the full range of programs available to state, tribal, and local governments and researchers to help prevent unplanned teen pregnancies. NCSL supports continued funding for these critically important programs.
     

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; and (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 Medicare coverage, but coverage gaps are likely to continue for many.  NCSL recommends that the Congress consider waiving the waiting period in some cases.

Social Services and Supports For Families and Individuals

Social Services Block Grant (SSBG)

The federal Social Services Block Grant (SSBG) 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 the states.

NCSL urges the federal government to:

  1. 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; and
  2. avoid imposing federal earmarks or set-asides within the SSBG.


Finally, if Congressional proposals to substantially reduce or eliminate funding for SSBG are enacted, state maintenance of effort requirements related to expected expenditures from SSBG, must be removed or modified.

Community Services Block Grant

The National Conference of State Legislatures supports full funding and reauthorization of the Community Services Block Grant Act. NCSL also supports efforts to improve program effectiveness and to measure program performance and effectiveness.

Low Income Home Energy Assistance Program

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. This program helps foster coordination and cooperation on the part of all levels of government and the private sector to assist low-income individuals and families meet critical heating and cooling needs.

The federal energy assistance program should have two major components:

(1) a cash assistance program to help low income households meet their immediate financial obligations to their energy supplier; and
(2) a weatherization assistance and conservation education program to help low income households to lower energy consumption and costs.

NCSL also supports the use of interest subsidized loans to assist households to weatherize their homes.

It is critically important that the Low Income Home Energy Assistance Program (LIHEAP):  

(1) includes all states in the funding allocation formula;
(2) affords 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) targets assistance to households with the lowest incomes and to households with infant, elderly, and/or disabled members;
(4) authorizes states to draw down program funds on an as needed basis; and
(5) prohibits counting energy assistance payments as income for the purpose of determining eligibility and/or benefit levels in other public assistance programs.

NCSL supports funding at the highest authorized level for this program. 

Support for Seniors and People with Disabilities

The development of a comprehensive approach to provide support services for elderly persons and persons with disabilities is critical. Without the development of such a system, long-term care expenditures will continue to overwhelm state and federal health care budgets, limiting necessary 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 for 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 persons with disabilities today is 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. 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 and integrate 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 persons and persons with disabilities 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. NCSL also urges the Administration and Congress 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

NCSL applauds the reorganizational effort within the U.S. Department of Health and Human Services (HHS) that provides supportive services to seniors and persons with disabilities into the Administration for Community Living. NCSL looks forward to continuing to work with HHS to improve community living services and supports for all who need them.
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 persons 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  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.

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.

National Plan to Address Alzheimer's Disease- The Plan proposes to: (1) prevent and effectively treat Alzheimer’s Disease by 2025; (2) optimize care quality and efficiency; (3) expand supports for persons 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.       

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:

  • increase access to health care services to veterans and their families;
  • improve and expand mental health services;
  • 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;
  • 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;
  • 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 benefit.


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