1. Staff Updates Washington, D.C. Disability Policy Seminar February 14-16, 2011 SESSION I MONDAY, 11:00 AM FEBRUARY 14, 2011 EMPLOYMENT AND AFFORDABLE CARE ACT REVIEW

2. Employment Too many people with intellectual and developmental disabilities are underemployed, in segregated settings, and earn very little money  424,000 earning sub-minimum wages (GAO)  limited exposure to the workforce, reduced expectations, lack of access to jobs Workforce Investment Act and Vocational Rehabilitation agencies under-funded and under- trained Major changes are needed legislatively and administratively to turn the system around Disability Policy Seminar February 14-16, 2011 Washington, D.C.

3. Employment cont. Sen. Harkin, HELP Committee Chairman, developing legislation Recommendations:  Need recommendations to made general workforce programs accessible  Incentivize states to change Medicaid and other systems to embrace “employment first” policies  Support model transition services that ensure that youth transition to good jobs and postsecondary opportunities, not segregated settings Disability Policy Seminar February 14-16, 2011 Washington, D.C.

4. Health Care Reform: 2 Laws Patient Protection and Affordable Care Act (P.L. 111-148) Health Care and Education Affordability Reconciliation Act (P.L. 111-152) “Affordable Care Act” http://www.heathcare.gov  For health insurance information by state  Comprehensive ACA implementation 4 Washington, D.C. Disability Policy Seminar February 14-16, 2011

5. Groundbreaking Legislation Expand Coverage and Access to Care  32 million uninsured will be covered  New insurance exchange with premium sharing subsidies, and cost sharing caps  Large expansion of Medicaid eligibility Significant insurance market reforms  Completes the ADA Prevention, research, Medicare and others Long term services and supports expansions 5 Washington, D.C. Disability Policy Seminar February 14-16, 2011

6. ACA Implementation Phased in over next several years Awaiting regulations and guidance on many key issues Regulations arriving at a steady pace States working on implementing legislation Numerous threats to the ACA 6 Washington, D.C. Disability Policy Seminar February 14-16, 2011

7. Insurance Reforms In Effect Now Means for plan years beginning on or after September 23, 2010 Eliminates pre-existing condition exclusion for under age 19 Lifetime limits not allowed Phase-in of elimination of annual limits Rescissions Access to doctors Emergency room Appeals 7 Washington, D.C. Disability Policy Seminar February 14-16, 2011

8. Full repeal passed in the House –failed in the Senate Lawsuits pending Partial repeal votes expected If politically unpopular aspects repeal has cost implications Defunding implementation and specific programs Threats to ACA Washington, D.C. Disability Policy Seminar February 14-16, 2011

9. Highly politically charged debate Our organizations long term supporters of health care reform and long term services and supports expansions Not a partisan choice Rely on credible, non-partisan sources of information Political Climate Washington, D.C. Disability Policy Seminar February 14-16, 2011

10. Premiums Secretary can’t set premiums Transition period until 2014 $250 million over 5 years for states to build capacity for rate review Medical Loss Ratio  85% of premiums spent on benefits  Hotly debated Washington, D.C. Disability Policy Seminar February 14-16, 2011

11. Grandfathered Plans Grandfathered plans—plans in existence on March 23, 2010 Most health insurance through large employers (100 or more workers) will not see major changes to their coverage Routine changes allowed:  Keeping pace with medical inflation  Adding new benefits  Modest adjustments to existing benefits  Voluntarily providing new consumer protections Washington, D.C. Disability Policy Seminar February 14-16, 2011

12. Applies to Grandfathered Plans? YES Pre-existing condition exclusions (EXCEPT individuals plans) Lifetime and Annual Limits (EXCEPT individual plans) Rescissions Dependent Care extension ( EXCEPT if other employer- sponsored) NO Access to Doctors Emergency room Appeals changes Washington, D.C. Disability Policy Seminar February 14-16, 2011

13. Insurance Reforms in 2014 Can’t consider health status when calculating premiums Prohibit discrimination based on health status Eliminate use of annual limits for all Guaranteed issue and renewability Washington, D.C. Disability Policy Seminar February 14-16, 2011

14. Individual Responsibility Tax penalties for no coverage-administered by IRS  2014-- $95  2015--$325  2016-- $695 Percent of household income 1% in 2014, 2% in 2015 2.5% in 2016 and after Exempts individuals with incomes too low to pay taxes Washington, D.C. Disability Policy Seminar February 14-16, 2011

15. Need all people to be covered by insurance Shares the risk for insurers Helps keep premiums lower Guarantee issue requirements and other reforms cannot work without greater coverage Why is this important? Washington, D.C. Disability Policy Seminar February 14-16, 2011

16. Temporary Pre-Existing Conditions Plans  Now until 2014 Coverage for Dependents (age 26)  Effective now Medicaid Expansion  Effective 2014 but states can begin early Health Insurance Exchanges  Effective 2014 –can be state, regional or run by the federal government Expanding Coverage Washington, D.C. Disability Policy Seminar February 14-16, 2011

17. Medicaid Expansion Expands Medicaid eligibility to 133 % of Federal Poverty Line (2014) - approximately $14,600/ individual; $29,400/family of 4 (2009 FPL Guidelines) New method of disregards brings it up to 138% of Federal Poverty Level No asset test for eligibility Washington, D.C. Disability Policy Seminar February 14-16, 2011

18. Medicaid Expansion, cont. People with disabilities likely to benefit  People receiving SSDI and in the 2-year Medicare waiting period  People who do not meet Social Security disability standard and are low income  People who meet the disability standard but income or assets are too high Washington, D.C. Disability Policy Seminar February 14-16, 2011

19. Medicaid Expansion, cont. Federal Share (FMAP): 100% for 2014 – 2016 (3 years) Phases down to 90% for 2020 and subsequent years CMS guidance--States can start earlier and phase it in By 2019 CBO estimates 16 million new enrollees Maintenance of effort requirements Washington, D.C. Disability Policy Seminar February 14-16, 2011

20. Health Insurance Exchanges (2014) Provide coverage, increase competition, lower costs to small employers and individuals without access to affordable employer coverage “Marketplace”: Private insurance plans that meet minimum standards on benefits and cost-sharing set forth in regulations Multi-state Exchanges run by HHS for states that choose not to operate their own Exchange Subsidies to low income individuals Washington, D.C. Disability Policy Seminar February 14-16, 2011

21. Hospitalization, emergency services, ambulatory (i.e. outpatient) services Prescription drugs and laboratory services Rehabilitative and habilitative services and devices Mental health and substance abuse disorder services including behavioral health treatment Essential Benefits Package for Exchange Plans Preventative and wellness services and chronic disease management Pediatric services including dental and vision care Maternity and newborn care Washington, D.C. Disability Policy Seminar February 14-16, 2011

22. Essential Benefits, cont. LAW REQUIRES: Appropriate balance among the categories Cannot discriminate against individuals because of their age, disability or expected length of life Must take into account the health care needs of diverse segments of the population including women, children, persons with disabilities and other groups Washington, D.C. Disability Policy Seminar February 14-16, 2011

23. Challenges to the Essential Benefits Comprehensive benefits versus costs What do the key terms mean?  What is essential?  What is appropriate balance?  How should medical necessity be defined? What coverage limits are allowed? What is the scope of each benefit category What is covered in a typical employer plan? Washington, D.C. Disability Policy Seminar February 14-16, 2011

24. Rehabilitative and Habilitative Services and Devices Broad category -- everything from therapies to wheelchairs Medicaid definition of habilitation Importance of acquiring and maintaining skills No limitation on scope or setting Powerful opposition to the disability position Washington, D.C. Disability Policy Seminar February 14-16, 2011

25. Autism Services Mental health and substance use disorder services, including behavioral health treatment Autism Speaks –this includes autism services  Primarily concerned about Applied Behavior Analysis (ABA)  State coverage mandates for autism are often broader and include habilitation  May be an issue in states with mandates Washington, D.C. Disability Policy Seminar February 14-16, 2011

26. Challenges to the Exchanges Grants to states to plan the exchanges Enforcement responsibilities Level insurance playing field Ensuring accessibility Qualified plans (sufficient providers etc.) Seamless interplay with Medicaid and CHIP Helpful services to employers who use it Advocates need to be involved Washington, D.C. Disability Policy Seminar February 14-16, 2011

27. Impact on Employers Designed to build on employer-sponsored insurance Impact varies by the size of the employer Pay roll tax deduction available for small employers who provide health insurance Washington, D.C. Disability Policy Seminar February 14-16, 2011

28. Summary Slide Grandfathered plans Large employers Part-time employees Penalties for unaffordable or non-coverage Credits and subsidies for very small employers Free choice vouchers Fraud provisions Washington, D.C. Disability Policy Seminar February 14-16, 2011

29. Disability and aging communities worked together Goal – Ensure two-pronged inclusion of LTSS in health reform:  National LTSS insurance program – avoid impoverishment  Improve Medicaid – eliminate institutional bias Inclusion of Long Term Services and Supports in Health Care Reform Washington, D.C. Disability Policy Seminar February 14-16, 2011

30.  Accomplished: ◦ CLASS Act ◦ Improvements to Medicaid  Community First Choice Option;  Improving existing Section 1915(i) option;  New state balancing incentives;  Spousal impoverishment protections;  Extend Money Follows the Person demonstration;  Expand Aging and Disability Resource Centers Long Term Services and Supports in Health Care Reform Washington, D.C. Disability Policy Seminar February 14-16, 2011

31.  New national LTSS insurance program  Based on voluntary payment of premiums ◦ through employer or directly ◦ Nominal premium for full-time students and people with income below poverty level  Vesting after 5 years of premium payments  Work requirement Community Living Assistance Services and Supports (CLASS) Act Plan Washington, D.C. Disability Policy Seminar February 14-16, 2011

32.  No exclusions based on pre-existing conditions  Benefits eligibility is based on functional need ◦ Need for assistance with activities of daily living or equivalent CLASS Act Plan, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

33.  Cash benefits for maximum consumer and family control ◦ No impact on federal benefits eligibility SSI and Medicaid  No “means-testing” – income is not considered ◦ No need for lifetime impoverishment ◦ Individual can continue to work  Advocacy and advice/assistance available CLASS Act Plan, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

34.  Separate CLASS Independence Trust Fund  Secretary of HHS to develop the Plan  Plan can pay for itself AND take pressure off the Medicaid program  Important for future of Medicaid program CLASS Act Plan, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

35. The need for change:  Institutional Bias within Medicaid  Nursing homes mandatory  Community-based services optional or waiver  People with disabilities and their families do not have an equal choice  Long waiting lists for community-based services and supports Improving Long Term Services and Supports in Medicaid Washington, D.C. Disability Policy Seminar February 14-16, 2011

36. Improving LTSS in Medicaid, cont. Disability Community Long Term Goal: Enact the Community Choice Act Would mandate Medicaid community-based attendant services and supports Too costly and politically impossible to enact a mandate to states Worked with White House and Congressional Sponsors on a first step in that direction – Community First Choice Option Washington, D.C. Disability Policy Seminar February 14-16, 2011

37. New state Medicaid plan option included in health reform law Comprehensive home and community based services for people eligible for an institutional level of care (nursing home, intermediate care facility (ICF), or IMD) States receive 6 percent additional federal match for CFC services Permanent provision in Medicaid program – does not “sunset” Community First Choice (CFC) Option Washington, D.C. Disability Policy Seminar February 14-16, 2011

38. Included services and supports: – Assistance with activities of daily living (ADLs) – Assistance with instrumental activities of daily living – Assistance with health-related tasks – Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish the above – Back-up systems or mechanisms (such as beepers, electronic devices) – Voluntary training on how to select, manage, and dismiss attendants CFC Option, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

39. Manner of service provision: – Hands-on assistance – Supervision – Cueing Other permissible services – transition costs (first month’s rent and utility deposits, bedding, kitchen supplies, etc.) – needs identified in person-centered plan that would increase independence or substitute for human assistance CFC Option, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

40. Eligibility is based on functional need (not age, diagnosis, etc.) Allows people with incomes up to 300 percent of the SSI level to be eligible (depending on state rules) CFC Option, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

41. States must: – provide services in a home or community setting – provide consumer-controlled services, statewide, in the most integrated setting appropriate – create a Development and Implementation Council – majority of members must be people with disabilities, elderly individuals, and their representatives – establish a comprehensive quality assurance system using feedback from consumers, families, providers CFC Option, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

42. Available beginning October 1, 2011 Advocates should be working with states now CFC Option, cont. Washington, D.C. Disability Policy Seminar February 14-16, 2011

43. Home and Community Based Services (HCBS) State Plan Option (Section 1915(i)) Medicaid 1915(i) Option  States can provide services without a waiver  States must establish eligibility that is less strict than for institutional and HCBS waiver services – states serve people who are not eligible for the state’s HCBS waiver  Very few states took up this option to expand community- based services Washington, D.C. Disability Policy Seminar February 14-16, 2011

44. ACA improved it to: – Allow states to provide full range of services allowed in HCBS waiver –including “other services approved by the Secretary” – Remove the authority for states to cap services, limit services to certain sections of the state, and maintain waiting lists – Align income eligibility criteria with other HCBS programs – allows people with incomes up to 300 percent of the SSI level to be eligible Amendments to HCBS Option (Section 1915(i)) Washington, D.C. Disability Policy Seminar February 14-16, 2011

45. Amendments to HCBS Option (Section 1915(i)), cont. States may target certain populations in need for 5 years CMS letter to State Medicaid Directors: August 6, 2010 http://www.cms.gov/smdl/downloads/SMD10015. pdf http://www.cms.gov/smdl/downloads/SMD10015. pdf Effective Date: October1, 2010 Washington, D.C. Disability Policy Seminar February 14-16, 2011

46. Department of Health and Human Services CLASS Act Plan – Design/implementation of programs/public education Centers for Medicare and Medicaid Services (CMS) Community First Choice Option; Section 1915(i); State Rebalancing; Money Follows the Person – Guidance to states – Funding decisions Will need your input and responses to alerts on regulations, etc. Federal Implementation Washington, D.C. Disability Policy Seminar February 14-16, 2011

47. Implementation of Medicaid Long Term Services and Supports changes States have many choices – Community First Choice Option – Section 1915(i) option – Other new provisions Work with Governor, State Legislature State Implementation Washington, D.C. Disability Policy Seminar February 14-16, 2011

48. Message to Congress Full Implementation – No Repeal Support the CLASS program  Oppose repeal Support full implementation of the Communty First Choice Option and other Medicaid long term services improvements Washington, D.C. Disability Policy Seminar February 14-16, 2011

49. Q & A Washington, D.C. Disability Policy Seminar February 14-16, 2011

50. SESSION II TUESDAY, 9:00 AM FEBRUARY 15, 2011 BUDGET OVERVIEW, SOCIAL SECURITY, MEDICAID, HOUSING AND AUTISM Staff Updates Washington, D.C. Disability Policy Seminar February 14-16, 2011

51. Budget and Appropriations process In general… President’s Budget – First week of February Budget Resolution – sets overall blueprint for spending (March-April) 12 Annual Appropriations bills – May – Sept.  Discretionary vs. authorization Oct. 1 New Fiscal Year However, this year’s a little different… Washington, D.C. Disability Policy Seminar February 14-16, 2011

52. Political Climate Elections – Major Political Shift  Over 100 new Members  94 new Representatives – 85 Republican  13 new Senators – 12 Republican  House shift to Republican majority: 242 to 193  Senate – Democrats now have narrow majority: 53 to 47 New House leaders - Speaker John Boehner (OH)  Eric Cantor (VA) Majority Leader Highly partisan, difficult to pass anything Already preparing for 2012 presidential elections Need to develop Republican disability champions Disability Policy Seminar February 14-16, 2011 Washington, D.C.

53. New Republican Agenda Smaller, more accountable government Lower taxes Repeal and Replace “job-killing health care” law Fiscal responsibility Protecting life, American values, and the Constitution Providing for a robust national defense Disability Policy Seminar February 14-16, 2011 Washington, D.C.

54. Debt, deficit, global recession, high unemployment, uninsured Highly partisan e.g. Sens. Coburn (R-OK) and DeMint (R- SC) vow to block all future bills that aren’t “paid for” Commission on Fiscal Responsibility & Reform: “Moment of Truth” Republican Study Committee recommendations Paul Ryan (R-WI), new Budget Chairman- Roadmap New Appropriations Chairman Harold Rogers (R-KY) “biggest cuts in our history” Disability Policy Seminar February 14-16, 2011 Washington, D.C. Budget and Appropriations Context

55. Fiscal Commission: Moment of Truth Chairmen Erskine Bowles and former Senator Alan Simpson (11 to 7 vote) $200 billion in discretionary cuts Place dual eligibles in Medicaid managed care. This would save $1 billion by 2015 $260 million cuts in Medicaid administrative costs Place a global cap on all health care spending, which could include Medicaid block grants Reform or eliminate CLASS Act Reduce the Cost of Living Adjustment (COLA) in Social Security and other cuts Washington, D.C. Disability Policy Seminar February 14-16, 2011

56. Current Year Appropriations FY 2011 appropriations not completed. CR until March 4 at level funding. New overall House cap for HHS released Sets non-security discretionary spending level at $420 billion, $43 billion less than the current level. Appropriations subcommittees received new allocations Expecting $7B cuts to Labor, HHS, ED funding bill Specific cuts to be made public the week of Feb. 14 Disability Policy Seminar February 14-16, 2011 Washington, D.C.

57. FY 2012 Appropriations President sends budget request to Congress week of Feb. 14 House Budget Committee plans to cut back to pre- Recovery Act, FY 06 or 08 levels for the next decade New House budget rules such as Cut-As-You-Go, Budget Chairman alone sets overall budget caps Attacks on entitlement programs Washington, D.C. Disability Policy Seminar February 14-16, 2011

58. Democrats Republicans Harkin (IA), Chair Inouye (HI) Kohl (WI) Murray (WA) Landrieu (LA) Durbin (IL) Reed (RI) Pryor (AR) Mikulski (MD Brown (OH) Shelby (AL), Ranking Cochran Hutchison (TX) Alexander (TN) Johnson (WI) Kirk (IL) Graham (SC) Moran (KS) Senate Appropriations L-HHS-ED Subcommittee Washington, D.C. Disability Policy Seminar February 14-16, 2011

59. Republicans Democrats Rehberg (MT), Chair Lewis (CA) Alexander (LA) Kingston (GA) Granger (TX) Simpson (ID) Flake (AZ) Lummis (WY) DeLauro (CT), Ranking Lowey (NY) Jackson (IL) Roybal-Allard (CA) Lee (CA) House Appropriations L-HHS-ED Subcommittee Washington, D.C. Disability Policy Seminar February 14-16, 2011

60. What to say on the Hill Must put these cuts in Human terms! These cuts will do more harm than good! What will happen if: IDEA, early intervention, or Head start funds are cut by 20-40 percent or more? Title V Block Grant eliminated? Medicaid block-granted and capped? Health Care reform with Prevention Trust Funds, Community First Choice, Money Follows the Person, CLASS Act – REPEALED? OR DEFUNDED? Disability Policy Seminar February 14-16, 2011 Washington, D.C.

61. Combating Autism Act (PL 109-416) Expanded research and coordination at the National Institutes of Health (NIH) Increased awareness and surveillance at the Centers for Disease Control (CDC), and Expanded the interdisciplinary training of health professionals to identify and support children with ASD and their families Disability Policy Seminar February 14-16, 2011 Washington, D.C.

62. Combating Autism Act Successes “These collaborative and coordinated efforts have served well to identify promising ASD research areas as well as to pinpoint both best-practices and gaps in ASD research and supports.” “Recent highlights in ASD research include the development of new diagnostic tools, identification of novel genetic and environmental risk factors, clinical trials of interventions, and measures of the efficacy and cost-effectiveness of evidence- based services for people with ASD.” Source: Office of Autism Research Coordination, National Institute of Health, Report to Congress on Activities Related to Autism Spectrum Disorders and Other Developmental Disabilities Under the Combating Autism Act of 2006 (FY 2006 – FY2009), December 2010 Disability Policy Seminar February 14-16, 2011 Washington, D.C.

63. Combating Autism Act Successes But, significant gaps remain in access to evidence-based interventions, education, supported employment, family supports, and transition services across the lifespan Progress made under CAA in increasing the capacity of professionals and service systems to address these gaps must be sustained and expanded Disability Policy Seminar February 14-16, 2011 Washington, D.C.

64. Reauthorization of CAA This law must be reauthorized or it will expire Sept 2011 because of sunset provisions Former Sen. Dodd (D-CT) introduced a reauthorization bill before he retired Repeals sunset, demos for services, expands P&A services, and training and technical assistance using the UCEDD network, new NIH Institute Sen. Menendez (D-NJ) interested in championing Reps. Doyle (D-PA) and Smith (R-NJ), Co-chairs of Autism Caucus Political climate is challenging for anything new Disability Policy Seminar February 14-16, 2011 Washington, D.C.

65. Social Security Is More Than Just a Retirement Program Social Security - Old Age, Survivors, and Disability Insurance (OASDI) programs established in Title II of the Social Security Act. Insurance programs – protecting against poverty –  in retirement years;  when disability may limit the ability to work; and  for dependent survivors. People with disabilities and their families receiving Social Security include: Disabled workers and their dependents, Retirees with disabilities, Disabled dependents of retirees, Disabled survivors, and Disabled adult children and disabled widow(er)s. Washington, D.C. Disability Policy Seminar February 14-16, 2011

66. Social Security Funding Two Trust Funds  Old Age and Survivors Trust Fund  Disability Trust Fund Usually treated as one Trust Fund Trust Funds are financed through payroll taxes – FICA taxes Trust Funds are currently running a planned $2.6 trillion surplus, rising to $4.2 trillion by end of 2024 Washington, D.C. Disability Policy Seminar February 14-16, 2011

67. Long Term Solvency Goal - Trust Fund solvency over the next 75 years Projected shortfall of less than 1 percent of gross domestic product (GDP) As a result of the current recession, Social Security’s FICA tax income is down – that is seen as temporary. After surplus is spent, full scheduled benefits until 2039; 80 percent in 2040; and 76 percent in 2084. Washington, D.C. Disability Policy Seminar February 14-16, 2011

68. Modest Changes Are Needed Modest changes now can impact the shortfall. There is no need for major cuts in benefits or changes in the structure of the program. National Commission on Fiscal Responsibility and Reform, private commissions, and Members of Congress are calling for major changes in Social Security. Major cuts will harm people with disabilities and their families and are not needed. Washington, D.C. Disability Policy Seminar February 14-16, 2011

69. Some Elements of Reform Proposals Change formula to reduce benefits Reduce Cost of Living Adjustments (COLAs) Raise the full retirement age Rasie the FICA tax rate Raise the earnings cap on FICA taxes Extend coverage to all government workers Create private accounts Washington, D.C. Disability Policy Seminar February 14-16, 2011

70. Social Security Solvency Message: Congress should -  Ensure solvency through limited or modest changes which spread the costs widely  Prevent depletion of, or privatization of, Trust Funds  Request a beneficiary impact statement on all proposals Washington, D.C. Disability Policy Seminar February 14-16, 2011

71. Improvements to SSI and Social Security Disability Programs Many areas of Supplemental Security Income (SSI) and Social Security disability programs need improvement, including: Increase the substantial gainful activity (SGA) level Increase the SSI asset limits and income exclusions Eliminate marriage penalties Eliminate 2-year waiting period for Medicare Message: Congress needs to make improvements to these critical programs Washington, D.C. Disability Policy Seminar February 14-16, 2011

72. Medicaid Maintenance of Effort on Eligibility in ACA  Adults - 1/2014  Children - 9/30/2019  Intended to prevent states from scaling back  Cannot impose new paperwork requirements  Cannot drop lawfully residing immigrants Disability Policy Seminar February 14-16, 2011 Washington, D.C.

73. Medicaid MOE EXCEPTION: states that already cover adults above 133% of poverty can change if state deficits are high Cannot scale back for people with disabilities or pregnant women CMS can withhold federal share if states violate Has worked as intended Governors want relief from requirement Arizona has requested a waiver Disability Policy Seminar February 14-16, 2011 Washington, D.C.

74. FMAP Increased federal match phased out Ends June 30, 2011 Vital to preventing deeper cuts Should continue until ACA is fully implemented Politically difficult Disability Policy Seminar February 14-16, 2011 Washington, D.C.

75. Deficit Reduction Threats President’s National Commission on Fiscal Responsibility and Reform Basis for many deficit reduction negotiations Proposals for Medicaid  Provider tax  Duals in managed care  Reduced administrative funding  More waivers Disability Policy Seminar February 14-16, 2011 Washington, D.C.

76. Deficit Reduction Threats Continued Key Medicare Proposals  Raise deductible to $550 for Part A and B combined  20% coinsurance across the board  Restrict supplemental policies from covering the first $500 in co-insurance  No specific mention of changes to low income subsidy programs Disability Policy Seminar February 14-16, 2011 Washington, D.C.

77. Deficit Reduction Threats Continued Global budget for total health care spending Establish a process to review and limit spending If spending grows faster than the economy President and Congress required to take action Aging population and higher health costs will continue to increase spending Tremendous pressure to reduce spending Disability Policy Seminar February 14-16, 2011 Washington, D.C.

78. Global Health Care Spending Cap Major structural changes would likely result Medicaid block grants Medicare premium vouchers End to entitlement Disability Policy Seminar February 14-16, 2011 Washington, D.C.

79. Other Deficit Proposals “The Commitment to American Prosperity Act” (CAP Act) Introduced by Senator Bob Corker (R-TN) and Claire McCaskill (D-MO) Sets a cap on all entitlement and discretionary spending If exceed cap, triggers automatic spending cuts across all programs Includes Social Security spending Disability Policy Seminar February 14-16, 2011 Washington, D.C.

80. Other Deficit Proposals Continued If cap is exceeded biggest cuts come from Medicaid, Medicare and Social Security Unlike previous deficit reduction laws no protections for these and other low income programs Expect increased attention to federal balanced budget proposals Imbalance in savings from revenue and spending cuts Disability Policy Seminar February 14-16, 2011 Washington, D.C.

81. Summary Expect there will be legislation introduced to block grant Medicaid and create vouchers for Medicare Congress needs to understand the importance of these programs to the lives of people with disabilities Already disparities in access to health care for people with disabilities Deep cuts put the health of people with disabilities at risk and jeopardize our community services and supports Disability Policy Seminar February 14-16, 2011 Washington, D.C.

82. HOUSING AFFORDABILITY GAP The affordability gap for housing for people with disabilities has exponentially worsened in recent years. According to Priced Out in 2008, a report by the Technical Assistance Collaborative, on a national average, over 4 million Americans with disabilities who rely on federal Supplemental Security Income (SSI) of $674 per month would have to pay 112% of their income to rent a modest one-bedroom unit or 99.3% for a smaller efficiency. Disability Policy Seminar February 14-16, 2011 Washington, D.C.

83. MELVILLE ACT IS A HUGE VICTORY After many years of effort by the disability community, the Frank Melville Supportive Housing Investment Act was passed by Congress last year and signed by President Obama on January 4 th 2011. The Melville Act is designed to streamline the Section 811 program of the Department of Housing and Urban Development (HUD) to increase the supply of integrated supportive housing for people with disabilities. Disability Policy Seminar February 14-16, 2011 Washington, D.C.

84. MELVILLE ACT IS A HUGE VICTORY cont. A great deal of credit goes to many people, including Republican and Democratic sponsors of the Melville Act : Congresswoman Judy Biggert (R-IL) & Congressman Christopher Murphy (D-CT) Senator Mike Johanns (R-NE) & Senator Bob Menendez (D- NJ) Banking Committee in the last Congress. Disability Policy Seminar February 14-16, 2011 Washington, D.C.

85. MELVILLE ACT IS HUGE VICTORY contd. Key Committee leaders: Congressmen Barney Frank (D-MA) & Spencer Bachhus (R-AL), Chair and Ranking Member of the House Financial Services Committee, and Senators Chris Dodd (D-CT) & Richard Shelby (R- AL), Chair and Ranking Member of the Senate Disability Policy Seminar February 14-16, 2011 Washington, D.C.

86. How the Melville Act Helps It reforms Section 811 to enable creation of thousands more units of integrated, permanent supportive housing every year. Section 811 is a Department of Housing and Urban Development (HUD) program that assists the lowest income people with the most significant and long-term disabilities to live in the community by providing affordable housing linked with in-home or community-based services and supports. Streamlines administrative processes for non-profit housing developers. Creates incentives for integrated Section 811 units in non-profit owned multi-family rental developments funded by federal Low- Income Housing Tax Credits, HUD HOME funds and bond financing. Disability Policy Seminar February 14-16, 2011 Washington, D.C.

87. How the Melville Act Helps cont. Creates a new “Project Based Rental Assistance” (PRAC) on a stand-alone basis to enable state and local governments to integrate supportive housing into larger rental housing developments units. PRAC is essential because it covers operating costs (e.g. insurance, maintenance, etc.) that are not covered by tenant rents. No more than 25% of the units in any one project can be set aside for people with disabilities Disability Policy Seminar February 14-16, 2011 Washington, D.C.

88. SUPPORT HOUSING PROGRAMS Congress should provide: $1 billion for the National Affordable Housing Trust Fund, which would be the first appropriation for this 2008 law – designed to develop 1.5 million new units of rental housing affordable to very low-income and extremely low- income households. At least level funding of $300 million for the FY 2011 Section 811 program –to create as many as 3,000 new supportive housing units – which are badly needed by many people with disabilities with very low incomes. Disability Policy Seminar February 14-16, 2011 Washington, D.C.

89. Support Section 8 Funding At a minimum, Congress should ensure full renewal funding for existing Section 8 Housing Choice Vouchers and renew all existing Section 8 Project-Based Contracts in FY 2012 to ensure that all vouchers are renewed and that no tenants are displaced and to protect and preserve this valuable subsidized housing for the lowest income households. Congress should provide$30 million in new funding for new Housing Choice Vouchers targeted to non-elderly people with disabilities who are institutionalized or at risk of institutionalization. Disability Policy Seminar February 14-16, 2011 Washington, D.C.

90. Q & A Washington, D.C. Disability Policy Seminar February 14-16, 2011