On April 1, tell people to count
all children at their address who have no permanent residence.
As the spread of the
Coronavirus has increased, the vulnerabilities within our system have become
clear. Children and families living in poverty and experiencing homelessness already
lack the financial stability to access nutritious food, stable housing,
healthcare, and all of the resources needed to support a child’s healthy
development consistently. A public health crisis – when resources are scarce
for everyone – only exacerbates these needs.
While we are all busy urging decision-makers to take action and fund resources to support children and families hit hardest by this outbreak, we must also remember that we cannot show the true needs of all of our nation’s children and families without an accurate 2020 Census count.
While this is
a good start, we know there are many households that are unlikely to
self-respond on their own or may leave children off the form when responding. In 2010, two million children were
missed in the Census
and those most at risk of being undercounted include young children in families
and unaccompanied youth living in very transient situations who are
experiencing homelessness or housing instability.
The majority of these children and youth are in “doubled-up situations” meaning they are living with others because they have nowhere else to go. These are often overcrowded, unstable and very temporary situations that put children at high risk of predation, trafficking, and abuse.
The recent Coronavirus outbreak only serves
to put more children and youth at risk of homelessness or housing instability.
As businesses close or reduce hours, and consumers
stay home, low-income household budgets are being stretched even thinner, with
less money for rent and utilities. Children
and youth already experiencing homelessness are being put into even more
perilous situations. They may be kicked out of doubled-up situations or be
stuck in overcrowded and stressful environments all day due to school and
childcare closures that make social distancing,
quarantining and remote learning nearly impossible.
Children experiencing homelessness and
housing instability have poorer
educational and health
outcomes than their stably housed peers.
This has consequences for their future success, as well as our country’s
economic future. Yet these same children and youth most in need of resources
such as healthcare and educational support are the ones at high risk of being
missed during the 2020 Census. If they are missed, they risk not being taken into
consideration when communities receive and allocate resources based on census data.
The U.S. Census Bureau guidelines are clear that if people are staying in your home on April 1, including babies and young children, and they have no permanent home elsewhere, you should count them on your Census form. This includes temporary residents — whether related or unrelated — unless you know they are being counted elsewhere. So even if a family is staying at an address and not paying rent, all members of that family, including young children, should be included on the census form for that address. Grandparents, foster parents, or legal guardians who are caring for young children or babies should include them on the census form for that address as well.
If families with children or unaccompanied youth
are not sure if they are being included on the census form at the address where
they are temporarily staying, then they should
self-report to the U.S. Census Bureau
on their own to ensure they are counted. They can use the online or phone
response system, and just use the address they are staying at on April 1.
The Count All
Kids committee, a group of national, state and
local children’s organizations dedicated to ensuring our nation’s children are
counted in the 2020 Census, has a toolkit of
materials to help with outreach to the
millions of children in families or unaccompanied youth experiencing
homelessness or housing instability. These materials use tested messaging that
stress the importance of a full count to help determine how much money
communities get for vital resources for children as well as stressing that the
Census has the strongest confidentiality guarantees in the federal
government. They also have resources saying explicitly to count everyone at
that address on April 1 with no permanent residence.
While we are all rightfully focused on
the current Coronavirus outbreak, we must also remember that an accurate 2020
Census has implications for the next 10 years – the span of a full childhood –
and can help ensure that children and youth most impacted by Coronavirus get
all of the resources they need to be healthy, safe and successful.
For more information on the undercount of children in the Census and how to take action, visit www.countallkids.org and follow Count All Kids on Twitter at @CountAllKids.
There is real momentum towards addressing the high rate of child poverty in the United States and the Coronavirus outbreak has only served to confirm that action to reduce child poverty and support family economic security is more necessary than ever. Congress has held three separate committee hearings on child poverty in the past six weeks, all which have highlighted that we know what is needed to address the problem, now there just has to be the political will to act.
In 2019, the National Academy of Sciences released A
Roadmap to Reducing Child Poverty, a non-partisan, evidence-based study
that models a set of policy and program changes, that if implemented, would cut
our child poverty rate in half within a decade. The policies in this roadmap,
such as establishing a national monthly child allowance program, increasing
SNAP benefits, housing vouchers, and other proven solutions would ensure that
families have the resources needed to support their children’s healthy
development and support their long-term success.
As the spread of the Coronavirus has grown, the
vulnerabilities within our system have become clear. Children and families
living in poverty already lack the financial stability to consistently access
nutritious food, stable housing, healthcare, and all of the resources needed to
support a child’s healthy development. A public health crisis only exacerbates
these needs when resources are scarce for everyone.
As schools close, businesses close or reduce hours, consumers
stay home, and events are canceled, low-income household budgets are being
stretched even thinner and children’s healthy development is at risk as
children miss meals and other resources usually provided in school, and parents
miss paychecks due to reduced work hours or lack of childcare.
For children, youth, and families also experiencing
are additional safety concerns. The majority of children and youth
experiencing homelessness in the United States are not in shelters but moving
between different temporary situations that include living doubled-up with
others or run-down motels. When schools close, children and youth are in these overcrowded
and stressful environments all day without many resources. This not only makes
quarantining nearly impossible, but these unstable situations also put children
and youth at increased risk of predation, trafficking, and abuse.
There is already an unacceptable
downward trend on the federal share of spending on children. In fact, our Children Budget 2019 publication shows that the share of spending on
children declined to an all-time low of just 7.21 percent. And, just last
month, the President released the FY2021 budget request that would dramatically cut spending on
critical programs benefitting children, such as Medicaid, the Children’s Health Insurance Program,
and the Temporary Assistance for Needy Families program, and eliminate or block
grant over 50 other programs including, preschool block grants, the Low Income Home
Energy Assistance Program, the Social Services Block Grant, the Community Development Block
Grant and creating block grants for 29 education programs, foster youth
programs, and Centers for Disease Control and Prevention. This signals
that we have a steep, uphill battle to reverse the downward spending trend for
children’s programs and services.
Undoubtedly, the Coronavirus outbreak requires
increased investment in many of these same, underfunded programs that benefit
low-income families, children, and vulnerable populations in order to solve it.
Congress must act swiftly to support struggling children and families
through investments that provide immediate economic relief in the form of
nutrition assistance, paid sick leave, housing assistance, education support,
child care assistance, and direct cash transfers that provide families with
some financial stability to help weather times of uncertainty. As Congress acts to address this public health emergency, it is our expectation
that our nation’s children will figure prominently in the decision-making
process before us.
We cannot make progress to reduce child poverty and
homelessness without holding ourselves accountable and making it a priority.
This is why First Focus, along with 25 other national
organizations, launched the End
Child Poverty US campaign to call for a national commitment to cut
child poverty in half within a decade.
This current crisis makes clear that anti-poverty strategies
are public health strategies. We hope you will join us to ensure that no child
or family experiences poverty or homelessness in the United States.
Yesterday, President Trump released a $4.8 trillion budget proposal that would impose massive cuts to critical programs that children and families rely on every day.
The proposal calls for $200 billion in cuts to programs that combat childhood poverty like SNAP and TANF, eliminated 29 programs from the Department of Education — including specific funding that helps homeless (McKinney-Vento Act) and low-income students (Title I), not to mention a $920 billion cut to Medicaid and CHIP which provide vital care that keep kids healthy.
“The budget is a moral document,” First Focus on Children president Bruce Lesley said in a statement yesterday. “Although we fully expect both Democrats and Republicans in Congress to reject these cuts as they have in the past, we are dismayed that the president places so little value on our nation’s children.”
The President’s budget — which Congressional leaders have already blasted as “devastating” and a “double-cross” — proposes a $1.5 trillion cut over 10 years to non-defense discretionary spending, which takes aim specifically at children. As we noted last year, 82% of all programs that benefit children fall into this category — from health to education to financial security to nutrition and others.
As Bruce Lesley noted in our annual Children’s Budget report last year, “Children are often an afterthought among federal policymakers in this process. Time and time again, children’s policy issues are ignored or neglected by Congress.” Our report found that the share of federal spending dedicated to children would have been just 6.45% if President Trump’s budget was enacted completely in FY20 — a $20 billion cut since FY 2015. And, for the first time in U.S. history, we are spending more to service the national debt than we are on the children who will inherit it.
If a budget documents our values and priorities — what does this year’s budget say about how we value children?
On February 5 and 6, 2020, the Committee on Oversight and Reform conducted an in-depth, two-day series of hearings held by four of its subcommittees to examine the negative effects of regulations proposed by the Trump Administration relating to children. This unique and extensive series of hearings assessed the detrimental impact of the Administration’s actions on child poverty, housing, hunger, and health.
First Focus Campaign for Children was proud to join a broad coalition of nonprofit and faith-based groups from across the nation in support of these hearings. We stand together in the belief that no child in the world’s wealthiest nation should go to bed hungry or be deprived of clean air or be without a safe, affordable place to call home. The proposed rules assessed at these hearings collectively rob children of the American Dream and deprive the future of healthy, happy, productive adults.
Below are a few highlights from the four hearings:
experts told members of the Government Operations Subcommittee that current
federal poverty guidelines underestimate the number of people experiencing
poverty in America and that any changes to the measure should seek to correct
“The Federal Poverty Guidelines say that I’m not poor,
but I cashed in a jar full of change the other night so that my daughter could
attend a high school dance competition,” said Amy Jo Hutchison, an organizer
with West Virginia’s Healthy Kids and Families Coalition. “Believe me, I’ve
pulled myself up by the bootstraps so many damn times that I ripped them
aimed at a Trump Administration proposal to rejigger the poverty line
calculation in a way that would shed hundreds of thousands of children and
families from benefit programs, was the first in a series of four to be held
this week by the Committee. Collectively titled “A Threat to America’s
Children,” the hearings will address Trump Administration proposals that
side-step the will and intent of Congress by rolling back bipartisan
legislation on poverty, homelessness, nutrition and environmental health.
Testimony and questions broke down along party lines. Rep. Alexandria Ocasio-Cortez(D-NY), who is sponsoring the “Recognizing Poverty Act,” sat in the witness chair and set the tone by saying even by the flawed calculations, 40 million Americans are considered to be living in poverty.
“We do not want to recognize the level of poverty in this
country,” she said, “because if we did, it would be a national scandal.”
The Administration’s proposal assumes that families living in poverty enjoy the same consumer choice and price comparison options as wealthier families, Network Lobby Executive Director Sister Simone Campbell told lawmakers. In fact, she said, their limited options mean they are already living at the very edge. Indi Dutta Gupta of Georgetown University Law School’s Center on Poverty stressed that health, nutrition and other programs that rely on poverty line calculations contribute to American economic prosperity by strengthening children. Republican witness Rob Smith, an African-American Army veteran, and rising conservative pundit, blasted assistance programs as projecting a “soft bigotry of low expectations” and proclaimed that he is “not a victim.” He advocated self-reliance and attributed his emergence from a low-income childhood in Akron, Ohio to a strong sense of self.
offered lawmakers what she said will be the most effective remedy for children
and families experiencing poverty.
“If we start
talking more to poor folks and not about them,” she said, “that’s
how we’re going to fix this problem.”
SNAP proposal is a gut shot to those least equipped to take the blow or to
fight back,” said Diane Sullivan, a mom and advocate who calls herself “an
expert in the experience of hunger.” She and her children, who live in the
high-cost state of Massachusetts, are among the millions who will lose
benefits, including school meals.
Sam Adolphsen, Vice President of Executive Affairs at
the Naples, Fla.-based
think tank the Foundation for
Government Accountability, hailed the Administration’s proposal as a “simple, common
sense rule” that would push financially struggling families toward
“self-sufficiency” and “the American Dream.” Adolphsen cast the provision in question as an
“open door to fraud and abuse,” offering the anecdote of a recipient in Maine
who owned an airplane.
am not a fraud,” Sullivan said. “I work. I do the best I can, just like
everyone in this room. I want the best for my children.”
The Administration acknowledges that the measure would increase food insecurity. According to its own analysis, the Administration estimates that 1.9 million people — 1.2 million of them children— would lose SNAP benefits.
In November 2019, the Trump administration published a proposed rule in the Federal Register, “Rules Regarding the Frequency and Notice of Continuing Disability Reviews” from the Social Security Administration (SSA). Comments, originally due on January 17th, were postponed and due today, January 31st. At this writing, there are over 120,000 comments posted on Regulations.gov, and we hope more will be posted before midnight tonight.
For someone who is not a Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) expert, this rule was complicated and convoluted. As I learned more and spoke with people who receive these benefits, along with other experts, I discovered the proposed rule was convoluted and unclear to most of us.
Essentially what is happening in the rule is: the SSA plans to increase the number of Continuing Disability Reviews (CDR) for people who receive SSI and SSDI. The added frequency of reviews will be burdensome in terms of time and cost to families, as well as the administration, and the SSA has not shown how many people will lose benefits, nor precisely why these added reviews are needed.
We know that children and their families will be harmed due to additional CDRs. Complicated administrative paperwork that takes hours and the help of medical staff to fill out means parents will have less time and money to take care of their children with disabilities and tend to their jobs and other responsibilities. We oppose this proposed rule and submitted comments today.
Below is an excerpt from the comments we submitted:
More Frequent CDRs Will Be Burdensome for Families of Children with Disabilities
The families of children with disabilities face many difficulties throughout their days. Managing medical appointments, recurring illness, filling, and managing prescriptions, getting to and from work, school, and/or childcare all take on a different meaning when it involves a child with disabilities. Parents may be in constant contact with a school or child care center related to their child’s condition and needed care or treatment. Access to prescribed medicine may be a struggle. Transportation to and from medical appointments, school, and/or childcare can may require much planning and asking others for help. If these families are also receiving lower wages and/or working at inflexible jobs with shifts, they have a harder time staying connected to work and thus their families are at higher risk of eviction, losing their utilities, and may become food insecure.
Families of kids with disabilities will have to schedule and attend more frequent doctor appointments in order to complete the CDR, creating a burden for them. Paying for copies of medical records is financially burdensome. Asking employers to complete comprehensive employment data in the Mailer could be an annoyance and create a rift between the employee and the employer. Some of the forms may be too complex for some individuals with disabilities and/or their families to fill out, prompting them to miss answers or seek out help that will cost money. Families struggling to make ends meet, care for their children with disabilities and perhaps their own health needs do not have extra time to spend on arduous administrative red tape and paperwork.
In 2015 alone, 34% of initial cessations were reversed on appeal – revealing that this system does not work as it is now and should not be made more frequent. This is not the right step to improve the system.
Childhood should be a time to grow, learn, play and feel safe. As Matthew Desmond, author of Evicted: Poverty and Profit in the American City writes:
Home is where children find safety and security, where we find our identities, where citizenship starts. It usually starts with believing you’re part of a community, and that is essential to having a stable home.
Whether by government, the larger society, and even some parents, children and their needs are often treated as an afterthought, or even worse, purposely excluded or made invisible. Whether intentionally or not, the concerns and needs of children are often ignored, dismissed, or marginalized, as some political leaders look the other way.
In the case of children who are homeless, some Members of Congress and bureaucrats at the Department of Housing and Urban Development (HUD) remain quite purposeful in their exclusion of children from being identified as homeless and from receiving any assistance.
For example, HUD has such a narrow and restrictive definition of homelessness that it does not count children and youth that are identified as homeless by schools, domestic violence shelters, or runaway and homeless youth programs. The result is that the vast majority of homeless children are not counted in HUD’s “point-in-time” (PIT) count. Since they are not identified as being homeless, the vast majority of children and families are diverted from or excluded from receiving critically important services or protections.
Underscoring this problem, in its 2019 Annual Homeless Assessment Report Part I (AHAR), HUD estimates that just 53,692 parents and children experienced homelessness during the agency’s January 2019 count.
HUD’s data perpetuates a fundamentally dishonest conversation about homelessness. It keeps homeless children, youth, and families invisible, and ignores their growing ranks in public schools and early childhood programs. We won’t make a dent in reducing homelessness until we acknowledge how children and youth experience it, and reform federal, state, and local policies to meet their needs.
In sharp contrast to HUD, the U.S. Department of Education rightfully recognizes that homeless children are those who “lack a fixed, regular and adequate nighttime residence,” including those:
doubled up due to loss of housing or economic hardship;
living in motels, trailer parks or campgrounds;
living in emergency or transitional shelters;
abandoned in hospitals;
awaiting foster care placement; and,
living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations.
Philadelphia’s PIT numbers under-report thousands of youth and families who experience homelessness. The School District identified 7,112 children and youth who experienced homelessness in the 2017–2018 School Year, compared to the 1,271 children under 18 years of age identified by the PIT count in FY 2018. As a result, Philadelphia devotes very few resources to addressing youth homelessness. In addition, the City “diverts” or “prevents” families away from accessing emergency housing, but does not consider that number in its PIT calculations. These experiences undermine Philadelphia’s ability to adequately address family and youth homelessness.
Therefore, without HUD’s recognition and assistance, homeless families with children are often forced into the shadows and must seek other means of shelter that can sometimes put their children at risk. While HUD creates a caste system whereby families with children are ignored or brushed aside, kids move from one temporary place to another, are more likely to stop attending school, and more often become the victims of violence, abuse, neglect, trauma, and sexual exploitation.
Despite a rapidly growing crisis on homelessness for children in Salinas, California, where the number of homeless children has grown from 2,042 in 2012–2013 to 3,566 in 2018–2019 — a 75 percent increase in just six years — HUD was reporting a 15 percent decline in homelessness.
Intentionally looking away, “invisibilizing”, undercounting, and ignoring the trauma that so many homeless children and youth are facing in our country does not solve the problem.
I’ve lived in over sixteen places in my life: six shelters, four times doubled-up with many different people, and we had our own house six times. We also had to go to emergency motel rooms many other times, in between shelters and houses… I really hate moving from place to place. It is so hard because you get to know people and then have to move. It has made my life hard… I would like people to know that it is different going through this then just hearing about it. You may not have ever experienced being homeless. It is worse than hearing about it or watching a movie about it. You are in it. There are a lot of kids going through it.
In this video of that testimony from Brooklyn along with witnesses Brandon Dunlop (Chicago, IL), Rumi Khan (Carlisle, PA), Brittany Amber Koon (Ft. Hood, TX), Destiny Raynor (Sanford, FL), and Starnica Rodgers (Chicago, IL). It is tragic that Congress and HUD still have not addressed the issue nearly eight years later.
These young people were all homeless, but throughout much of their families’ struggles, HUD and some Members of Congress pretended they were not. To HUD, these children simply do not count — both literally and figuratively — and the consequences are tragic.
Children experiencing homelessness are among the most invisible and neglected individuals in our nation. Despite their ever-growing number, homeless children have no voice and no constituency. Without a bed to call their own, they have lost safety, privacy, and the comforts of home, as well as friends, pets, possessions, reassuring routines, and community. These losses combine to create a life-altering experience that inflicts profound and lasting scars.
These youth are survivors, but not without a great deal of damage to them along the way. The statistic regarding homeless youth to increased risks of sexual assault, drug use, HIV/AIDS, prostitution, pregnancy, and incarceration, as well as lower graduation and employment rates, clearly indicate that these young people are not being given the opportunity for a bright, productive future that we hold out to young people in America.
Children making their way through life homeless, impoverished, abandoned, hungry, vulnerable, neglected, and abused deserve better from us. They deserve a childhood where they can grow, learn, play, and feel safe rather than endure a daily struggle at the margins of society.
The legislation also recognizes that children are not little adults and that the needs of families with children are often quite different from the one-size-fits-all “housing first” model used by HUD for veterans and chronically homeless adults. H.R. 2001 achieves this by allowing services and assistance to be tailored to address the unique needs of each homeless population in their community.
Children, youth, and families are unable to access appropriate and necessary housing assistance and services because current HUD definition of homelessness disqualifies them appropriate interventions and standard prioritization, not based on their vulnerability or need, but based on which couch or floor they were able to sleep on last night. We, as communities and a nation, are working to serve the most vulnerable when addressing homelessness. To truly accomplish this, we must stop excluding children and youth from the conversations and allow them to have equal access to the current housing assistance and services. The Homeless Children and Youth Act does just this.
The United States has some of the
highest maternal and infant mortality rates in the developed world and they
continue to rise.
African-American women are at especially
high risk and are three times more likely to die from maternal health issues
than their white counterparts. African-American babies are more than twice as
likely as white babies to die within their first year of life, and American
Indian and Alaskan Native babies are nearly twice as likely.
Four experts in maternal and infant mortality outlined this crisis for members of Congress and their staff during a standing-room-only briefing on November 19 on Capitol Hill. Reps. Alma S. Adams, Ph.D, (D-NC) and Lauren Underwood (D-IL), co-chairs of the Black Maternal Health Caucus, hosted the event along with First Focus on Children and the March of Dimes.
Our four expert speakers discussed the role of structural racism in the racial disparities in maternal and infant mortality rates; trends at the national and state levels; the importance of federal health care coverage policies in combating maternal and infant mortality; and steps that are being taken in states such as Illinois and Texas to improve care and outcomes for women and babies.
Child care is one of the greatest multi-taskers that exists – it simultaneously provides both early care and education for our youngest citizens, enables parents to work and attend school, provides an economic driver for business that ensures a stable workforce, and employs more than one million workers. Each of us, whether we have children or not, has a stake in the success of child care in this country. First Focus on Children is proud to be a co-signer of Principles for Child Care: A Vision for Investing in High-Quality, Affordable Child Care. Signed by more than 25 advocacy organizations, this document lays out the core principles any comprehensive child care proposal must have. Combining high-quality, access, affordability, and a well-supported workforce will improve our child care system to provide the care, education and economic stability we need for the success of our children and the national economy.
current child care system has many challenges and areas for improvement:
Most American families cannot afford
child care. For one infant, a
two-income household spends more than 10.6 percent of its income on child care.
A single-parent household spends 37 percent of its income on child care. The
cost of child care for two children exceeds mortgage costs for homeowners in 35
states and the District of Columbia. And child care fees for two children in a
child care center exceeds annual median rent payments in each and every state.
child care hurts our economy.
The annual cost of lost productivity, earnings and revenue to our economy due
to child care problems tops $57 billion.
early childhood professionals are grossly underpaid. In 2017, child care workers earned
less than two-thirds of the median wage for all occupations in their states.
Child care workers in 21 states
and Washington, D.C. would have to spend more than half of their income to pay
for center-based care for their own infants. Forty-six percent of early
childhood professionals rely on one or more public support programs annually.
youngest children’s brains are making more neural connections than at any other
time in their lives, making it a critical time for learning and development.
The settings that our children spend their days in matter for improved outcomes
in health, well-being, education, economic stability and reduced involvement in
the criminal justice system.
We must do better for our children, their families, the professionals who care
for them every day and our economy.
As outlined in these Principles for
Child Care, First Focus on Children believes that all children should
receive high-quality child care; that families should be able to access the
high-quality child care setting that best meets their needs; should get the
financial support they need to afford high-quality child care; and that early
childhood professionals in all settings should receive the support, resource,
and compensation they need to provide high-quality care and to support their
This is an investment that is worth
making and that we must make.
When it comes to making
public policy related to children, the vast majority of Americans support the
notion that public policy and government should act in the “best interest of
the child” or, at the very least, “do no harm” to children.
Unfortunately, far too
often, children are either an afterthought or worse. In the case of Tennessee
Gov. Bill Lee’s proposal to convert Medicaid into a block grant or per capita
capped program, it is disturbing — but sadly not surprising — that children are
actually targeted and disproportionately placed in harm’s way.
A Medicaid block grant or per capita cap is simply an arbitrary financial limit that a state would receive from the federal government to provide health care. According to a recent analysis of the potential impact of recent proposals to cap Medicaid, Avalere Health estimates for a potential loss of federal funding to states, specifically for children, of $93 to $163 billion for FY 2020–2029 nationally. As Avalere explains:
A reduction in federal Medicaid funding would require states to reduce spending in Medicaid or in other areas of their budget. In particular, states may reduce eligibility for coverage, limit access to covered benefits or services, increase beneficiary cost sharing or decrease payment for care. . .
The Tennessee concept paper to radically, and
likely illegally, (more on that later) transform the Medicaid program by Gov.
Lee’s administration would likely seek a waiver from the Medicaid law from the
U.S. Department of Health and Human Services (HHS) later this fall after three
public hearings between October 1–3 in Nashville, Knoxville and Jackson,
Arbitrarily capping the
Medicaid program, whether block grants or per capita caps, has been shown to
create enormous shortfalls in funding to provide health coverage to low-income
senior citizens, people with disabilities, children and adults that receive
health coverage. In a review of legislative proposals to impose Medicaid per
capita caps in Congress and to address likely significant shortfalls in
funding, the Congressional Budget Office (CBO) wrote:
. . .enrollees could face more significant effects if a state reduced providers’ payment rates or payments to managed care plans, cut covered services, or curtailed eligibility — either in keeping with current law or to a greater extent, if given the flexibility. If states reduced payment rates, fewer providers might be willing to accept Medicaid patients, especially given that, in many cases, Medicaid’s rates are already significantly below those of Medicare or private insurance for some of the same services. If states reduced payments to Medicaid managed care plans, some plans might shrink their provider networks, curtail quality assurance, or drop out of the program altogether. If states reduced covered services, some enrollees might decide either to pay out of pocket or to forgo those services entirely. And if states narrowed their categories of eligibility (including the optional expansion under the ACA), some of those enrollees would lose access to Medicaid coverage. . . .
proposal comes at a time when the nation’s uninsured rate is heading in the
wrong direction. According to the U.S. Census Bureau, the uninsured rate across
the country increased from 25.6 million to 27.5 million between 2017 to 2018 or
from 7.9 to 8.5 percent.
For children, the Census Bureau finds that the uninsured
rate rose from 5.0 to 5.5 percent from 2017 to 2018, which represents an 11
percent increase, and that the overall number of uninsured children rose by
425,000 to 4.3 million.
We should not be heading
backward. Every person in this country should have access to high-quality
health insurance coverage. Instead of setting arbitrary caps and putting in
place the bureaucracy to enforce cuts and limits to care, we should be looking
for ways to increase the number of insured Americans, including children, and
improving access to health care.
Even worse, Tennessee is proposing to disproportionately threaten the health of children. As Figure 2 in the concept paper shows, children would represent a vast majority of those placed in harm’s way by Gov. Lee’s unique hybrid of a Medicaid block grant and per capita cap (i.e., the 62 percent of children in this chart and another percentage share of people with disabilities subjected to the caps).
Arbitrary Medicaid caps or
limits are particularly threatening for children with special health care
needs, including infants, kids with cancer, asthma,
heart conditions, and children in foster care, because the cost of their
care and coverage would, by definition, exceed the average per capita limit
included in the proposal for the federal share.
To meet the arbitrary caps,
Tennessee and its Medicaid managed care plans would have an incentive to impose
bureaucratic barriers to care, paperwork denials, limits and other forms of
rationing for Tennessee’s vulnerable and fragile children.
This is particularly
disturbing because Tennessee has already demonstrated a desire and ability to
use such mechanisms to limit care and services to children. Just a few months
ago, a study by the Tennessean found
that the state had used a number of mechanisms to limit and ration coverage for
its children over the past few years. The investigative report explains:
least 220,000 Tennessee children were cut, or were slated to be cut, from state
health insurance in recent years in an unwieldy TennCare system that was
dependent on hard-copy forms and postal mail. . . The majority of these kids
likely lost their coverage because of late, incomplete or unreturned
In an analysis titled The
Return of Churn: State Paperwork Barriers Caused More than 1.5 Million People
to Lose Their Medicaid Coverage in 2018, Families USA’sEliot
Fishman and Emmet Ruff found:
2016, [Tennessee] began making manual eligibility redeterminations after still
not having an online system to do so. Because redeterminations could not be
processed online, the state mailed a 98-page
renewal packet to
beneficiaries to renew their eligibility. The Tennessee Justice Center, an
advocacy organization that has helped Tennesseans and their families to renew
their TennCare eligibility, reports that in many cases the state mailed renewal
packets to the wrong addresses, and as a result, beneficiaries lost coverage
for failing to return renewal packets that they never received. In other cases,
the state never processed beneficiaries’ renewal packets despite receiving them
(as documented by beneficiaries’ proof of receipt).
contrary to federal law, the state failed to screen children for eligibility
under other Medicaid categories before disenrolling them, resulting in children
losing coverage despite qualifying under another category. Additionally,
because the state did not apply the same eligibility information to all members
of the same family, parents and caregivers were required to submit separate
packets for each of their children, and the state made separate eligibility
determinations for each member of a family.
None of this is about
striving to improve the health of children and families. At a budget hearing
earlier this year, Tennessee State Sen. Jeff Yarbro pushed agency officials
about how Tennessee had the highest decline in covered children across the
country in 2018. Sen. Yarbro said:
is utterly broken to the point of where it appears to be more by design than
accident. You have to conclude that this is a management decision to trim the
rolls or at least let them shrink by relying on people either not receiving, or
not completing, the gargantuan applications.
Tennessee was rationing
care to children through bureaucratic red tape.
Arbitrary Medicaid Cap Targets Kids
Although Tennessee has
finally revamped its eligibility process this year, it is disturbing that the
state is creating new barriers to the health of children by proposing the vast
majority of those that would be subjected to the newly proposed Medicaid caps
would be kids [MK1] (Figure 2 above).
Under current law, the
federal government and states have a shared partnership (65.21 percent
federal and 34.79 percent state)to cover any increase in
Medicaid’s costs due to either enrollment or inflation.
. .the financing of Tennessee’s Medicaid program will no longer operate under
the traditional Medicaid financing model. Instead of drawing down federal
dollars based on a fixed percentage, the federal government will provide a
block grant of federal funds to the state for the operation of its Medicaid
In short, federal funding
would no longer be guaranteed to cover its full share of costs under the
Recognizing the potential
for significant harm, the Governor specifically exempts most senior citizens
(“expenditures on behalf of individuals who are enrolled in Medicare”),
outpatient prescription drugs, and Tennessee’s own administrative expenses from
the caps in his proposal. In other words, the health of children would be put
at grave risk but not administrative costs and bureaucracy.
Consequently, under the
draft proposal, federal funding would be allocated to the state in the first
year in the form of a block grant and future federal contributions would be
limited in the form of per capita payments above a base block grant amount.
calculated, the block grant amount will be trended forward from 2018 to the
first year of the demonstration using an inflation factor based on CBO
projections for growth in Medicaid spending.
First, CBO is often way off
in its projections and inflation rates often vary wildly from year-to-year,
depending on a number of factors. For example, in the case of natural disasters
or some public health crises, Tennessee’s Medicaid would find itself
shortchanged at the very moment when it is in need of additional federal
Much like the Tennessee
proposal, U.S. Sens. Lindsey Graham of South Carolina and Bill Cassidy of
Louisiana proposed a Medicaid cap that was supported by President Donald Trump
in his FY 2020 budget submission to do much the same but at an inflation rate
that would be below the expected medical inflation rate. According to an analysis by Avalere Health,
the Graham-Cassidy language would have cut Medicaid payments to children by an
astounding 31 percent over a 10-year period.
Tennessee Proposes to End
Its Future Commitment to Its Citizens
Even worse than the federal
caps, Gov. Lee’s radical proposal also would end Tennessee’s commitment to its
share of health costs of citizens covered by Medicaid to what it spends in
fiscal year (FY) 2019. According to the concept paper:
. .the state commits to maintenance of effort with regard to the non-federal
share of TennCare funding based on state expenditures on TennCare during state
Fiscal Year 2019, trended forward each year the block grant is in effect.
Limiting the state Medicaid
contribution to just what was spent in FY 2019 would create significant
shortfalls over time. This is particularly true in cases where enrollment and
costs increase due to demographic changes, economic downturns, natural
disasters, a public health crisis, the discovery of a medical breakthrough or
cure, or medical inflation.
The state’s proposal to no
longer pay its share of the costs of its citizens in the future is the most
disturbing aspect of the proposed Medicaid waiver. Although it is bad enough
that the federal government’s commitment or share to the health care
costs of those in Medicaid would be arbitrary capped, even worse, Tennessee
would no longer cover a dime of any additional future expenses.
This quickly becomes a
significant problem since Tennessee currently pays for more than one-third
(34.79 percent in FY 2020) of the costs of Medicaid coverage. Under Gov. Lee’s
proposal, it is difficult to see how Medicaid would cover newly enrolled
infants, foster children, children with cancer, people with disabilities, or
people who would need Medicaid coverage in the wake of an economic downturn or
To address the subsequent
shortfall, Tennessee assumes federal officials would be willing to give the
state “flexibility” to use their “block grant” to:
certain medical benefits, such as mental health, dental coverage, or new
treatments (Tennessee is asking to waive amount, scope, and duration benefit
requirements and to limit access to Food and Drug Administration approved
prescription drugs under current Medicaid law);
payment rates to hospitals, clinics, doctors, dentists, and pharmacies; and,
children, pregnant women, people with disabilities, or low-income senior
citizens off of coverage.
Despite the strange allure
to some state officials of the word “flexibility,” block grants and per capita
caps do not come with some sort of magic wand. “Flexibility” does not
make children, senior citizens and people with disabilities mysteriously less
expensive to cover without significant cuts to benefits, services or provider
Tennessee’s proposal to cap
both the federal and state payments in Medicaid would likely be found to be
illegal if challenged in the courts. According to a Health Affairsanalysis by Rachel Sachs and
Nicole Huberfeld entitled “The Problematic Law and Policy of Medicaid Block
Grants,” Medicaid law allows Section 1115 demonstration waivers “to allow
states to experiment with certain aspects of the Medicaid program to improve
beneficiary coverage or care.”
However, Tennessee’s waiver
proposal does nothing to improve beneficiary coverage or care and it does nothing
to further the intent and objectives of Medicaid law.
Moreover, as Sachs and
spells out federal payment within Section 1903, which states that the HHS
secretary “shall pay to each State…the [federal match] of the total amount
expended…as medical assistance under the State plan….” This language is not
waivable under Section 1115, which explicitly permits waivers of Section 1902
but not Section 1903. (HHS can approve more spending than Section 1903
contemplates to match a state’s expansion of Medicaid coverage, but it cannot
1903.) As a result, HHS cannot cap the Medicaid funds it disburses to states,
either per person or programmatically, because it must pay the federal match
for the “total amount” of a state’s spending.
Nicholas Bagley confirms this point in a blog titled
“Tennessee wants to block grant Medicaid. Is that legal?” for The
Incidental Economist. He writes:
can’t use section 1115 to waive section 1903. To the contrary, section 1903 is
pointedly omitted from the list of
statutory provisions that HHS is empowered to waive.
you can’t use Medicaid waivers to change Medicaid’s financing structure. And
that’s exactly what Tennessee is proposing to do.
Tennessee was once
considered a national leader in health care policy. In 1994, Tennessee launched
TennCare by using savings from the use of Medicaid managed care to expand
health care coverage to the uninsured. Mandy Pelligrin of the nonpartisan
Sycamore Institute explains, “This was considered the
most expansive Medicaid eligibility in the country at the time.”
Unfortunately, rather than
seeking innovative ways to expand and improve health coverage of its citizens,
now Gov. Bill Lee and the Tennessee legislature are moving in the opposite
direction and proposing an arbitrary cap on both the federal and state shares
of Medicaid. This would lead to limits and the rationing of health care
services for low-income children, some senior citizens, people with
disabilities and adults.
Our elected officials
should protect children rather than putting them in harm’s way. When it comes
to policies that impact children, the “best interest of the child” should be
arbitrary fiscal limits on the health of kids does nothing to improve their
care. In fact, it threatens their health and well-being, and for that reason,
should be soundly rejected.
The U.S. Census Bureau released annual data on
child poverty in the United States on September 10 that shows benefit programs
are particularly effective at reducing poverty for children.
The U.S. Census
Bureau calculates the Supplemental Poverty Measure (SPM) as an alternate measure to the Official Poverty Measure. Unlike the Official Poverty Measure, which uses
an income threshold solely based on the cost of food, the SPM incorporates the
cost of food, clothing, shelter and utilities. It also adjusts for family size
and geographic differences in housing costs. The SPM further considers cash
income (including child support) and non-cash benefits, subtracts taxes (or adds
tax credits), work expenses, out-of-pocket medical expenses, and child support
paid to another household.
When taking all of these factors into account, the SPM rate for children in 2018 was 13.7 percent, compared to 16.2 percent when using the Official Poverty Measure. The nearly two-point drop in poverty illustrates that benefit programs are particularly effective for children and must not only be protected, but strengthened so they can reach many more children still living in poverty.
This year’s data shows that tax credits continue to be the strongest anti-poverty tool we have. Together, the Earned Income Tax Credit and the Child Tax Credit lifted 4.7 million children out of poverty in 2018.
The Supplemental Nutrition Assistance Program (SNAP) continued to be another powerful anti-poverty program for children in 2018. SNAP provides low-income households with monthly funds intended for grocery purchases, and while benefits under the program are modest (corresponding to roughly $1.40 per person per meal), they play a critical role in freeing up household resources and helping struggling families place food on the table. Given that more than 18 million children participate in SNAP—representing 44 percent of its beneficiaries—it is unsurprising that it kept almost 1.4 million children from falling into poverty last year. This data further underscores the importance of protecting children from proposed cuts to SNAP.
These Programs Lift Children Out of Poverty?
A recent landmark
study from the National Academy of Sciences, A Roadmap to Reducing Child Poverty, confirms that the negative outcomes associated
with child poverty directly result from a lack of income.
Studies show that
when parents and guardians receive cash assistance, they use it to provide
resources for their children such as nutritious food, stable housing and
educational supports that improve children’s healthy development. Increased
income also relieves parental stress, giving them increased time and mental
energy for their children.
More resources in a
household in the short-term also improves children’s outcomes for the
long-term. Studies show that children in households that received an increase
in income through programs such as EITC or SNAP were healthier and
earned more as adults, thereby helping to break the cycle of generational
A Roadmap to Reducing Child Poverty puts
forward a set of policy and program options that, if implemented together,
could cut our national child poverty rate in half within a decade. Within these options, they find that establishing
a $3,000 annual child allowance would have the biggest impact of any single
policy in reducing child poverty, and by itself could cut deep child poverty (children
in households with incomes below half of the poverty line) in half within a
decade. It would also address racial and ethnic disparities by having the biggest
impact in reducing poverty for Black and Hispanic children.
The bottom line is that money matters
to reducing child poverty. We could do more to reduce child poverty by:
a national child poverty target. Child poverty is a solvable problem
if there is the political will to take action. Establishing a national child
poverty target – similar to ones in the United Kingdom, Canada and New Zealand as well
as here in the United States – would be the
first step toward holding lawmakers accountable to making child poverty a
priority and implementing solutions. Bicameral legislation introduced in past sessions of Congress
established a target and we hope to see this legislation reintroduced soon.
family tax credits. Currently 26 million children are unable to benefit from
the full Child Tax Credit, and the 2017 tax law also widened income and racial
disparities and neglected to expand the EITC and the Child and Dependent Care
Tax Credit (CDCTC). Congress should alter that course and ensure that any
legislation to extend tax breaks for businesses also include improvements for
low-wage families with children.
a national child allowance – The American Family Act (S.690/H.R. 1560), the Working
Families Tax Relief Act (S.1138/H.R. 3157), and the Economic Mobility Act (H.R,
3300) would establish child allowance programs.
If signed into law, these proposals would implement one of the most
effective policy changes to reduce child poverty identified in the NASEM study
and currently adopted by numerous industrialized nations, such as Canada,
Australia and nearly every European country
— already proving the success of cash-transfer programs to struggling
families and children.