May 4, 2020

The Honorable Roy Blunt Washington, DC

Dear Senator Blunt;

We are deeply grateful for your work to leverage critical federal assistance for our state as Missourians face the catastrophic health and economic impacts of the COVID-19 pandemic. While the Families First Coronavirus Response Act and the CARES Act put in place important measures to help individuals, families, and states, it’s become clear that much more is needed to fully address this public health and economic crisis for Missourians.

We understand that you will soon be considering the next federal COVID-19 relief legislation, and ask for your continued advocacy on behalf of Missourians by supporting the following crucial provisions:

o Extension of key relief measures — Critical provisions in earlier relief packages should be extended until the labor market recovers, including expansions to unemployment insurance, state fiscal relief, an increased FMAP for Medicaid, and any increase in SNAP benefits. These measures will be necessary beyond the public health emergency, and their extension will ensure that they are available to families and communities.

o Targeted assistance. Additional assistance is needed by those who are experiencing the brunt of the pandemic and resulting economic downturn, including Missourians with low-incomes, communities of color who’ve been disproportionately impacted by illness and job loss, children in foster care and adoptive families, and immigrants, many of whom have been left out of relief measures so far.

Continuing relief measures until the economy recovers: The new COVID-19 legislation provides a critical opportunity to strengthen the supports that were initiated with the Families First and CARES Acts. In particular, many of the key provisions that support families and will help bolster the state’s economy are temporary and scheduled to end long before the economy fully recovers.

In particular, the CARES Act included important provisions that expanded eligibility and benefits for unemployment to help states meet the immediate needs. However, the benefit increases are set to expire on July 30th, and the eligibility expansion on December 31st, long before the economy is expected to recover. Goldman Sachs and the Congressional Budget Office have projected that unemployment will remain high through 2021. is already experiencing an unprecedented jump in unemployment, as more than 330,000 Missourians have lost their jobs just in the last month alone. Indicators suggest that the economic impact of COVID could increase unemployment further, and the struggle could be deeper than the last recession. Missourians will need access to expanded unemployment and other critical provisions, such as food assistance expansions, well beyond the dates they are set to expire.

Similarly, critical fiscal relief to bolster state services is also set to expire long before the state can recover. The enhanced federal matching rate for Medicaid (FMAP) is tied to the length of the current public health emergency, and funding through Coronavirus Relief Fund to support state and local services must be used by December 31st. It will be essential that the next federal package align these key relief provisions to economic indicators so that they remain in effect as long as unemployment is high and as long as individuals, families, states, and the economy continue to need them.

Detailed Priorities for the Next Federal COVID Package:

I. Additional state fiscal relief to help address the emerging fiscal crises: The pressures on state and local finances from the COVID-19 outbreak and the economic fallout are mounting and quickly becoming severe. State budget shortfalls could total more than $500 billion.

In our state, Missouri Budget Project estimated that if the economy experiences similar declines to what occurred during the Great Recession, state general revenue would drop by $937 million in Fiscal Years 2020-2021 combined, followed by a decrease of $1.9 billion in Fiscal Year 2022. The amount is in comparison to a $10 billion state general revenue budget. Given that the projected severity of this economic decline may exceed that of the Great Recession, Missouri could face even greater losses of state general revenue funding. Without additional federal fiscal relief, the drop in state revenue will require cuts to an array of vital public services including health, education and public safety. Such cuts would come at a time of increasing need and would further diminish the state’s economy.

Missouri needs additional federal assistance to help meet the immediate public health emergency, absorb increased program costs as more Missourians access safety net services, and avoid sharp spending cuts that would deepen and prolong a recession.

The most important way to get fiscal relief to states is through a larger and sustained increase in the Federal Medical Assistance Percentage (FMAP) for Medicaid that adjusts with economic conditions and remains in place as long as unemployment remains elevated. This would help states that are seeing sharp increases in their Medicaid enrollment and provide flexible relief by freeing up state funding that can be spent in other areas.

In addition to fiscal relief provided through FMAP, the next federal package should also increase and extend the Coronavirus Relief Fund, which was established in the CARES Act for aid to states. For this to be effective, states should be free to use the funds as broadly as possible – in particular to cover the rising costs in a wide range of programs and to counteract sharply declining tax revenues, so as to forestall cuts throughout their budgets. This fund could also provide additional fiscal support for local governments, but doing so should not come at the expense of providing adequate aid to states.

The next federal COVID-19 legislation must also preserve the “maintenance of effort” (MOE) provision in the Families First Act, so that states can’t impose new Medicaid eligibility restrictions or take away people’s coverage while they receive additional Medicaid funds. We encourage lawmakers to add similar maintenance of effort provisions to the broader fiscal relief, so that the states who receive the aid are required to maintain payment rates for critical social service providers.

II. Additional Direct Assistance for Missourians Most Impacted by the Crisis In addition to extending the unemployment provisions discussed previously, the following policies would strengthen the supports for Missourians who are most likely to be adversely impacted by the health and economic impacts of the pandemic, and who are most vulnerable to exposure to COVID-19.

 Improve the “recovery rebate” stimulus payments The stimulus payments are large and have broad eligibility, but they exclude certain dependents and certain immigrant households, and may not reach all who qualify. The next federal COVID- 19 legislation should ensure that all households, including those that include a tax filer or spouse without a Social Security Number who files using an ITIN, should receive stimulus payments. Dependents who are not children under 17, such as older children with disabilities and seniors who need assistance and live with family members, should qualify for the $500 additional payment now provided to children under 17. The CARES Act should also be clarified to mandate that the Department of Treasury provide payments automatically not only to Social Security retirement and disability beneficiaries and recipients of Supplemental Security Income, but also to recipients of veterans’ pension and disability benefits.

Additional clarification is requested to allow for unaccompanied homeless youth to receive the recovery payments, whether or not they were claimed as dependents in 2018 or 2019. Unaccompanied homeless youth should be defined to include students enrolled in higher education institutions who meet the definition of “independent” under 20 U.S.C. §1087vv(d)(1), and any unaccompanied homeless youth as defined in 42 U.S.C. §11434a(6).

 Temporarily increase the SNAP maximum allotment level by 15% Increasing SNAP benefits during the last recession boosted consumer spending, which the economy and local businesses need. A 15 percent increase in the SNAP maximum allotment level would amount to an increase of approximately $25 per person per month, or just under $100 per month in food assistance for a family of four. Increasing SNAP will help avert food insecurity among families who face a sudden drop in their earnings or whose temporary period of unemployment will drag on – a situation thousands of Missourians are likely to face, with substantial parts of the economy now shutting down.

 Expand health coverage options, especially for the uninsured, without weakening the existing “maintenance of effort” provision prohibiting states from reducing Medicaid benefits and eligibility. o Unless Congress includes policies to strengthen health coverage in the next COVID-19 response bill, we are likely to see a sharp increase in the uninsured rate in the midst of a pandemic. Strengthening health coverage programs is a crucial part of responding to the COVID-19 public health crisis and the severe economic downturn that is underway.

o As discussed previously, increases in the Federal Medical Assistance Percentage (FMAP) for Medicaid would help avert large coverage losses. Increases in the FMAP should continue until the economy fully recovers, scale with the depth of the recession, include strong protections to help prevent states from reductions in coverage, and apply to people covered through Medicaid expansion.

 Strengthen funding for Community Health Centers o Community Health Centers are serving a tremendous role during the pandemic: diverting demand for health services at overburdened hospitals, screening patients for COVID-19, providing telehealth services to help patients manage chronic conditions during stay-at-home orders, and providing that frontline care regardless of the ability to pay. o But, most health centers are facing steep revenue losses - as high as 80% - as a direct result of the pandemic, which has caused lay-offs, furloughs and greatly reduced hours of operation. In fact, Missouri’s federally qualified health centers are losing $25 million per month in revenue due to the pandemic. o These critical care providers across need $77.3 billion total in immediate and long-term support from Congress to remain operational. The amount includes $7.6 billion over the next 6 months to help the health centers effectively respond to the COVID-19 emergency, followed by $69.7 billion over the next five years to stabilize and expand care, expand the health care workforce and invest in infrastructure improvements.

 Provide significant funding to bolster child welfare o Research is clear that increased family stress heightens the risk of child abuse. The risk of child abuse is greater during the COVID response because many children and families are sequestered at home and experiencing extraordinary levels of uncertainty, economic stress, and health concerns. At the same time, child welfare systems have been disrupted by the pandemic, foster families are experiencing significant changes to their economic stability, and caseworkers are operating in unsafe conditions that threaten their health, as well as the health of the families and communities they serve. o Significant funding increases of at least $3 billion combined are needed to support Community-Based Child Abuse Prevention grants, Kinship Navigator programs, Title IV-B Part 2, CAPTA Title I, and CHAFEE grants in order to assist child welfare agencies in meeting the increased needs caused by the pandemic. Increased funding will help these critical providers stabilize families, prevent child abuse and bolster foster care. o Further, the enhanced FMAP should be extended to the Title IV-E Prevention Program to help avoid unnecessary disruptions of families.

 Invest $50 billion in Child Care: Our child care providers are essential workers on the front-lines of this crisis. By taking care of them, we’re also ensuring that other essential personnel can go to work without having to worry about who is taking care of their children.

 Create an emergency fund, similar to the TANF Emergency Fund created during the last recession that could quickly provide both families with children and others with cash assistance to meet their basic needs and other forms of crisis assistance.

 Further boost funding for housing and homelessness programs to prevent increased evictions and homelessness. o While the CARES Act took some important steps, additional expansions of housing and homelessness prevention and service programs will be needed to avoid increased evictions and homelessness. Congress should provide substantial additional funding for the Emergency Solutions Grant program, which states and localities can use to prevent or address homelessness; expand the Housing Choice Voucher program to provide rental assistance for more low-income families at risk of losing their housing; provide additional funding for public housing and rental assistance programs to offset reductions in rent that households will pay as their incomes fall; and provide additional grant funding for housing assistance for special populations, such as those with substance use disorders and those being released from jails and prisons.

Please contact Amy Blouin, President and CEO, Missouri Budget Project at 314-518-8867 or [email protected] with any questions.

With deepest regards on behalf of the following organizations;

Maureen Cunningham Whitney Lanning, M.S. Executive Director Executive Director Brain Injury Association of Missouri Community Action Partnership of St. Louis, MO Headquarters Greater St. Joseph St. Joseph, MO Rev. Emily Bowen-Marler Associate Minister Dr. Christopher A. Small Brentwood Christian Church Executive Director Springfield, MO Community Action Partnership of North Central Missouri Theresa Ruzicka, President Trenton, MO Catholic Charities of St. Louis St. Louis, MO Headquarters Janet Dankert President and CEO Robin Phillips, CEO Community Partnership of the Child Care Aware of Missouri Springfield, MO St. Louis, MO Headquarters Denise Cross Vickie Dudley, Executive Director President and CEO Children’s Center of Southwest Missouri Cornerstones of Care Joplin, MO Kansas City, MO Headquarters

Emily van Schenkhof Lana Dominguez Executive Director Food Access Program Manager Children’s Trust Fund Cultivate Kansas City Jefferson City, MO Kansas City, MO

Terry Weiss, M.D. Jan K Huneke Executive Director Executive Director Civic Arts Company Delta Gamma Center St. Louis, MO Maxine Clark, CEO Bob Fox, Chair Douglas A. Freeman, Owner Clark-Fox Family Foundation Douglas A. Freeman Consulting Chesterfield, MO

Keri McCrorey Brian Schmidt Executive Director Executive Director East Missouri Action Agency, Inc. Kids Win Missouri Park Hills, MO St. Louis, MO Headquarters

Jeanette Mott Oxford LouHealth: Washington University Medical Executive Director Students for Health Equity Empower Missouri Jefferson City, MO Headquarters Ann C. McGruder Executive Director Lori Ross ma4, Missouri Association of CEO & President Area Agencies on Aging FosterAdopt Connect Jefferson City, MO Headquarters Independence, MO Headquarters Joseph Bestgen Kendra Copanas Chief Executive Officer Executive Director Marygrove Generate Health Florissant, MO St. Louis, MO Holly Bell Michael P. Meehan, Ph.D. President Executive Director Missouri Association for Infant and Early Good Shepherd Children Childhood Mental Health (MOAIMH-EC) & Family Services St. Louis, MO Amy Blouin President and CEO Carmen Schulze Missouri Budget Project Vice President St. Louis, MO Headquarters Great Circle St. Louis, MO Headquarters Dave Damico President Toniann Richard CEO Missouri Coalition for Quality Care Health Care Collaborative of Rural Missouri Dawna Fogarty Lexington, MO Headquarters Executive Director Missouri Community Action Network Qiana Thomason Jefferson City, MO Headquarters President and CEO Health Forward Foundation Michelle Trupiano Kansas City, MO Executive Director Missouri Family Health Council, Inc. Jill Quaid CEO Jefferson City, MO Headquarters Jefferson Franklin Community Action Corporation Jessica Seitz Hillsboro, MO Director of Public Policy Missouri KidsFirst Jefferson City, MO Headquarters

DeeAnn Aull Ed Weisbart MD, CPE Executive Director FAAFP Chair Missouri NEA Physicians for a National Health Program- Jefferson City, MO Headquarters Missouri Chapter

Heidi Lucas Brenda Sharpe State Director President and CEO Missouri Nurses Association REACH Healthcare Foundation Jefferson City, MO Headquarters Cass, Lafayette and Jackson Counties, Missouri Rev. Jenn Simmons Lead Pastor Nancy Cross National Avenue Christian Church Missouri Director Springfield, MO SEIU MO/KS State Council

Dianna Fine Molly Ticknor State Policy Advocacy Co-Chair Executive Director National Council of Jewish Women Show-Me School-Based Health Alliance of St. Louis, MO Missouri

Corbin McGhee Sr. Rosemary Russell Senior Manager of Advocacy Chairperson National Multiple Sclerosis Society Immigrant and Refugee Committee Sisters of the Most Precious Blood Donald D. Patrick O’Fallon, MO President & CEO North East Community Action Corporation Dede Coughlin Bowling Green, MO St. Cronan Church St. Louis, MO Scott Hummel Executive Director Karen Wallensak Our Little Haven Executive Director St. Louis, MO St. Francis Community Services St. Louis, MO Kim Lackey Senior Director-Public Policy and Independent The Honorable Lisa Clancy, Chairwoman Living St. Louis County Council Paraquad Maplewood, MO St. Louis, MO Angela Brown, CEO Mark Sanford St. Louis Regional Health Commission Executive Director St. Louis, MO People’s Community Action Corporation St. Louis, MO Jessica Woolbright Executive Director St. Martha’s Hall St. Louis, MO

Students for a National Health Program: Washington University School of Medicine Washington University School of Medicine Health Economics & Policy Interest Group Chapter Linda Zazove and Ruth Ehresman Robin Winner Co-Presidents Co-Executive Director Women's Voices Raised for Social Justice Synergy Services, Inc. St. Louis, MO Kansas City, MO Teesha Miller Jim MacDonald Executive Director Chief Community Impact Officer Youth Ambassadors United Way of Greater Kansas City Kansas City, MO Kansas City, MO Pat Holterman-Hommes Kate Kasper Chief Executive Officer PACT-STL Project Director Youth in Need Vision for Children at Risk St. Charles, MO St. Louis, MO