[Extensions of Remarks]
[Pages E2476-E2477]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

GOVERNORS OF NEBRASKA, NORTH DAKOTA, NEVADA, AND RHODE ISLAND EXPRESS
CONCERNS WITH UNFUNDED MANDATES IN HEALTH REFORM

______

HON. MIKE ROGERS

of michigan

in the house of representatives

Wednesday, October 7, 2009

Mr. ROGERS of Michigan. Madam Speaker, I rise today to express
concerns regarding health reform proposals which would create unfunded
state mandates. Legislation currently before the House would
dramatically expand the Medicaid program and place over $35 billion in
new liabilities on state budgets over the next ten years. In addition,
these proposals would expand the federal government's role in
administering Medicaid, which would severely handcuff states' ability
to run their own programs and preempt state authority to manage
Medicaid eligibility and benefits.
Over the last several weeks, governors have expressed concerns over
these proposals. I would like to submit for the Record the following
letters from the governors of Nebraska, North Dakota, Nevada and Rhode
Island:

September 16, 2009.
Hon. Benjamin Nelson,
U.S. Senator, Hart Building, Washington, DC.
Hon. Mike Johanns,
U.S. Senator, Russell Senate Office Building, Washington, DC.
Dear Senator Nelson and Senator Johanns: I am writing to
alert you that the analysis provided by the staff to the
members of the NGA Health Care Reform Task Force indicates
that the Chairman's Mark released by Senator Baucus this
morning contains a new unfunded Medicaid mandate. Earlier
this year I wrote both of you expressing my concern that this
might occur as part of health care reform.
I greatly appreciate the fact that both of you have
repeatedly expressed concerns about the negative impact that
health care reform could have on the Federal deficit and the
State budget. As former Governors you understand the impact
that Medicaid has on state spending. This new unfunded
federal Medicaid mandate could result in higher taxes on
Nebraskans or in cutting state aid to Nebraska's school
districts as well as state appropriations to our
universities, state colleges and community colleges. This
proposal is not in Nebraska's best interests.
As we develop more specific information, I will be
providing you with our best estimates of the magnitude of the
impact on Nebraska. Thank you for your attention to this
matter.
Sincerely,
Dave Heineman,
Governor, Nebraska.
____

September 30, 2009.
Kathleen Sebelius,
Secretary of Health and Human Services, Hubert H. Humphrey
Building, Washington DC.
Dear Secretary Sebelius: As Congress and the Administration
work through the various versions of health care reform
currently moving through the legislative process, we ask that
you carefully consider the following issues.
First, having served as chief executive of a state
yourself, I am sure you are mindful of the growing concern
among the nation's governors about the risk to states of
including unfunded mandates in national healthcare
legislation. States are constitutionally mandated to balance
their budgets, which means that any shortfalls caused by
unfunded federal mandates could force increases in taxes, a
reduction in services or both. This potential is especially
troubling at a time when states are financially struggling.
We cannot be certain what form evolving legislation will
take, and what the impact of that final legislation will be
on state budgets. For that reason, we, along with the
National Governors Association, urge extreme caution in
moving forward with any plan that would commit the states,
without their express participation and consent, to
obligations that may financially bind them for decades into
the future.
Second, it is important that any healthcare reform plan
passed by Congress and signed by the President reward the
states for good Medicare and Medicaid outcomes. North Dakota
health care providers, for example, consistently provide low-
cost, high-quality healthcare, yet have the lowest
reimbursement rates in the nation. Any reform of the system
must have incentives for good performance and cost-
effectiveness.
Notwithstanding these issues, like Americans everywhere, we
too are concerned about rising healthcare costs and the need
to provide access to affordable, high-quality healthcare for
our citizens. Congress and the Administration should be
looking at a range of reforms chat can deliver meaningful and
almost immediate benefits for our healthcare system. These
include measures, among others, like tort reform for medical
liability; tax credits to help make insurance more
affordable; providing transparency in billing; ensuring
healthcare insurance portability; and limiting denials for
preexisting conditions.
Clearly, healthcare reform is needed. On that matter there
is no disagreement, but it needs to be done right. To that
end, I do hope that you will keep in mind OUR concerns and
recommendations as you consider proposals to improve
America's healthcare system.
Sincerely,
John Hoeven,
Governor, North Dakota.
____

September 11, 2009.
Hon. Harry Reid,
Senate Majority Leader, U.S. Senate, Washington, DC.
Dear Senator Reid: It has been clear from the early days of
the 111th Congress that health insurance reform will be a top
priority for lawmakers this year. Comprehensive reform should
lower health care costs while increasing insured populations,
quality of care, and point-of service accessibility for all
Nevadans.

[[Page E2477]]

One common thread appears throughout recent legislative
proposals: the expansion of Medicaid as a central ``reform''
component. Simply put, the expansion of existing healthcare
programs is not authentic reform and further, places the cost
burden to the states at a time when states can ill afford it.
It is essential that Congress take the time to examine all
possible options for health insurance reform in order to find
sustainable long-term solutions. Lowering healthcare costs
and reforming the healthcare system is possible without
unfunded mandates or Medicaid expansions forced on the
states. While certain changes to the current Medicaid program
could advance the overall function of health insurance
reform, expansion of the program without a permanent funding
mechanism is not something that any state can support, nor is
it a viable solution.
As you know, unlike the United States Constitution, most
state constitutions require a balanced budget, including
Nevada. In Nevada, we will spend nearly $907,000,000 for
Medicaid programs in Fiscal Years 2010 and 2011. This
accounts for 13.8 percent of our General Fund budget. Any
further expansion of this program would be another great
example of Washington playing budget games by passing on
costs to the state--this is unrealistic in the current
economy and as a long term resolution.
Additional expansions of the Medicaid program will force
Nevada into deep cuts in other programs and services which
are not federally mandated in order to balance our General
Fund. In the current fiscal year gaming revenues are down
12.5 percent, and sales tax revenues are down 20 percent. By
overriding my veto, the 2009 Nevada Legislature passed
substantial tax increases to burden our already beleaguered
citizens.
Many current proposals also include significant cuts to the
Medicare program. Nevada's growing senior population is
frightened by the proposed $162,200,000 reductions which will
impact an estimated 11,000,000 seniors. Harmful and arbitrary
cuts to Medicare Advantage may result in plans dropping out
of the program, limiting beneficiary choice, and causing
millions of seniors to lose their current coverage. These
proposals must be stopped.
Nevadans cannot afford more taxes. Now is not the time to
place unfunded Medicaid or other mandates on the states. By
expanding Medicaid programs, the United States Congress will
be forcing the State of Nevada into deep budget cuts in other
state programs. I do not believe that any child's education
should be placed on the chopping block to fund these new
programs, but we will face that dilemma if these proposals of
the Democratic Congress are enacted.
Health insurance reform should be addressed in a
cooperative manner by both the federal and state governments.
If states are treated as partners--not pawns--we can work to
enact important reforms in concert with federal efforts.
State-enacted caps on medical malpractice lawsuits, for
example, would have a transformative impact on the health
care and health insurance industry in each state, cutting
costs for consumers without negatively affecting the
stability of our current health care industry.
I am ready to work with my fellow Governors and the U.S.
Congress in order to support sensible, accountable, and
workable health insurance reform that helps, not hurts,
Nevadans.
Sincerely,
Jim Gibbons,
Governor, Nevada.
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September 25, 2009.
Hon. Jack Reed,
Senator, U.S. Senate, Hart Building, Washington, DC.
Dear Senator Reed: I appreciate your work and that of your
colleagues in the Congress to craft legislation to reform the
health care system in America. As you know, Rhode Island took
on reform last year, albeit on a smaller scale, as we
developed and pursued approval of our groundbreaking Global
Consumer Choice Waiver.
One of the primary reasons the State pursued the Global
Waiver is that federal Medicaid rules often limit the ability
of the states to adapt to fiscal realities and the complex
and changing needs of beneficiaries. It is difficult to
deliver vital services to the beneficiaries and be fair to
all taxpayers when the federal government denies us the
flexibility to effectively structure and manage a program
representing such a significant financial investment.
I am extremely concerned that several of the health reform
initiatives recently introduced in Congress will prevent
Rhode Island from fulfilling the Global Waiver's promise.
Such initiatives will further strain the state's budget at a
time of great fiscal uncertainty and impose even more debt on
our children, grandchildren and great grandchildren.
Therefore, I ask for your support and that of all members
of the Rhode Island Congressional Delegation, to preserve the
innovative health care initiatives now under way in Rhode
Island and in many other states. I ask that you reject any
reform proposals that impose additional financial burdens on
the states and the people and communities we serve or that
otherwise limit our capacity to meet our constituents' needs.
As originally proposed, the Senate Finance bill required a
significant portion of the costs for covering the uninsured
through Medicaid to be paid by lower and middle income
taxpayers and the states. I am aware that changes in the
proposed legislation provide, at least temporarily,
additional funding for the required Medicaid expansions to
``high need'' states like Rhode Island. However, full federal
funding will only be available for a limited period and would
cease at the very time population projections estimate we
will begin to see a surge in Medicaid eligibility for elders.
It is unclear how the state or federal government will be
able to sustain these Medicaid expansions in light of these
projections and at a time of decreasing revenues and sky-
rocketing deficits. The House legislation imposes burdens on
state budgets and working Americans that are unacceptable.
Likewise, there still remain Medicaid eligibility and
coverage mandates that will limit the flexibility of the
states to operate financially sound, sustainable programs.
Moreover, ongoing health reform efforts, such as those now
under way in Rhode Island, may be hampered as limited
administrative resources are diverted to finance the mandated
expansions. Federal oversight of the Medicaid program should
be streamlined, and allow for far greater innovation at the
state level.
As a Governor, I am particularly concerned about the
prospect of additional ``short-term funded'' federal Medicaid
mandates. The Medicaid program itself is expensive, provider-
centered, inefficient, slow to innovate and, as such,
ultimately unsustainable. For these reasons, the Medicaid
program is hardly the best and by no means the most
appropriate platform for expanding health coverage to tens-
of-thousands of additional Rhode Islanders and millions of
other Americans.
I hope you will ensure that any legislation enacted by
Congress does not include additional mandates on states, or
at the very least compensates states fully for those it does
impose, including the administrative costs associated with
expansion. Additionally, providing states with the
flexibility they need to implement the relevant provisions of
reform should be a top priority today and in the future.
There are better ways to reform America's health care
system, and I hope that President Obama and Congress will
work with Governors, providers, consumers and others to bring
about sensible reforms that increase quality, contain costs
and ensure portability of health care.
Sincerely,
Donald L. Carcieri,
Governor, Rhode Island.

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