February 28, 2020

Administrator Seema Verma Centers of Medicare and Medicaid Department of Health and Human Services Washington, DC 20201

Dear Administrator Verma:

As leading national, state, and local organizations, representing health care consumers and patients, providers, and other stakeholders, we are writing in strong opposition to recent guidance from CMS, Healthy Adult Opportunity, which allows states to fundamentally change the nature of their Medicaid programs. We urge the Administration to rescind this guidance, which could hurt millions of families that rely on Medicaid.

Medicaid is an essential source of coverage for over 70 million people. Medicaid’s current state-federal partnership helps states provide quality health insurance to their residents – it ensures that children are able to get a healthy start in life, provides long-term care to seniors and people with disabilities, and vital health care for many adults including pregnant women. The current state-federal funding structure provides states and taxpayers a level of financial security, ensuring that as Medicaid spending fluctuates from year to year, the state and its taxpayers are not made solely responsible for covering any increased costs. Efforts to restructure or cut Medicaid would shift health care costs to the states, hurt local economies, and threaten care and coverage for millions.

The Administration’s long-anticipated State Medicaid Director Letter, which was published on January 30, encourages states to adopt caps on their federal Medicaid funds voluntarily under a Medicaid section 1115 demonstration waiver. This arrangement involves major fiscal risk for states; the “flexibility” states will have is to cut services or take away coverage if and when they hit their new federal funding cap. Capping and restructuring Medicaid would create an awful choice for states in the event of increasing health care costs. Once that happens, the state will start rolling back coverage for kids, people with disabilities, and seniors and cost- effective optional benefits like dental care, without oversight.

Further, the Administration does not have jurisdiction to waive Medicaid’s financing structure through the 1115 waiver process. Such a fundamental change to Medicaid’s structure requires a change in statute and therefore an act of Congress. In 2017, when Congress considered federal funding caps, millions of people from around the country raised their voices in opposition, and lawmakers rejected the proposal on a bipartisan basis.

We urge the Administration to rescind this guidance that promises flexibility, but will surely lead to catastrophic implications for state budgets, and state Medicaid programs and the communities they serve. We implore you to reconsider this proposal, and protect the children, seniors, people with disabilities, women, parents, people of color, and working families that rely on Medicaid for health care.

Sincerely,

National Organizations Families USA ACCESS 1,000 Days ADAP Advocacy Association AARP AFL-CIO ACA Consumer Advocacy African American Health Alliance

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Aging Life Care Association Global Justice Institute, Metropolitan Community Churches AIDS United Go2Foundation for Lung Cancer Allergy & Asthma Network Health Care for American Now (HCAN) American Academy of Pediatric Dentistry Health Over Profit for Everyone American Association of Public Health Dentistry HealthConnect One American Association on Health and Disability Healthy Schools Campaign American Federation of State, County & Municipal Hispanic Federation Employees HIV Medicine Association American Federation of Teachers Human Rights Campaign American Medical Student Association International Ventilator Users Network American Muslim Health Professionals Jewish Federations of North America American Physical Therapy Association Justice in Aging American Public Health Association Labor United for Class Struggle/Labor Today American Speech-Language-Hearing Association Lakeshore Foundation Americans for Democratic Action (ADA) Little Lobbyists Asian & Pacific Islander American Health Forum Lupus and Allied Diseases Association, Inc. Association of Asian Pacific Community Health Organizations Lutheran Services in America Association of Asthma Educators March for Moms Association of School Business Officials International Meals on Wheels America Asthma and Allergy Foundation of America Medicare Rights Center Autism Society of America Ministry Across Generations Team, Disciples Home Missions, Autistic Self Advocacy Network Christian Church (Disciples of Christ) Bazelon Center for Mental Health Law MomsRising Bruderhof Movement for Peoples’ Democracy Campaign for America's Future MoveOn Caring Across Generations NAACP Center for Law and Social Policy (CLASP) NALLTCO (National Association of Local Long Term Care Center for Medicare Advocacy Ombudsman) Center for Public Representation NASTAD Center for the Study of Social Policy National Academy of Elder Law Attorneys Child Welfare League of America National Adult Day Services Association (NADSA) Children's Defense Fund National Advocacy Center of the Sisters of the Good Children's HealthWatch Shepherd Children's Hospital of Philadelphia National Alliance for Caregiving Children's Trust Fund Alliance National Alliance on Mental Illness Coalition for Disability Health Equity National Association for Children's Behavioral Health Coalition of Labor Union Women National Association for Home Care and Hospice Coalition on Human Needs National Association of Area Agencies on Aging (n4a) Community Access National Network (CANN) National Association of Councils on Developmental Community Catalyst Disabilities Congregation of Our Lady of the Good Shepherd, U.S. National Association of Pediatric Nurse Practitioners Provinces National Association of School Nurses Cystic Fibrosis Foundation National Association of Social Workers Disciples Center for Public Witness National Association of State Long-Term Care Ombudsman Easterseals Programs (NASOP) Faith in Healthcare National Center for Transgender Equality First Focus on Children National Coalition for the Homeless Friends Committee on National Legislation National Coalition on Health Care Futures Without Violence National Consumer Voice for Quality Long-Term Care

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National Council of Jewish Women United Church of Christ Justice and Witness Ministries National Council on Independent Living United Way Worldwide National Crittenton URGE: Unite for Reproductive & Gender Equity National Equality Action Team Voices for Progress National Family Planning & Reproductive Health Association National Latina Institute for Reproductive Health Women for Racial and Economic Equality National Multiple Sclerosis Society Young Invincibles National Partnership for Women & Families ZERO TO THREE National WIC Association National Women's Health Network Alabama National Working Positive Coalition AIDS Alabama NETWORK Lobby for Catholic Social Justice Alabama Academy of Pediatric Dentistry Network of Jewish Human Service Agencies Health Services Center, Inc. NMD United, Inc. Lighthouse Community Development Corp Nurse-Family Partnership National Association of Social Workers, Alabama Chapter One Health Resource Company Party of Communists USA Alaska Pathways for Rare and Orphan Studies Alaska Children's Trust Patient Advocate Bristol Bay Area Health Corporation Planned Parenthood Federation of America National Association of Social Workers, Alaska Chapter Positive Women's Network-USA Power to Decide Arizona Prevent Blindness Children's Action Alliance Provincial Council Clerics of St. Viator National Association of Social Workers, Arizona Chapter Public Advocacy for Kids West Valley Neighborhoods Coalition Public Citizen Raising Women's Voices for the Health Care We Need Arkansas Redstone Global Center for Prevention and Wellness Arkansas Advocates for Children and Families RESULTS Arkansas Community Institute Service Employees International Union Arkansas Community Organizations SIECUS: Sex Ed for Social Change National Association of Social Workers, Arkansas Chapter Sisters of Charity, BVM Sisters of Mercy of the Americas Justice Team California Sisters of St. Joseph of Cluny USA/Canada APLA Health Social Security Works Asian Law Alliance Society for Public Health Education Brighter Beginnings Society of Saint Vincent de Paul California Association of Food Banks SocioEnergetics Foundation California Consortium of Addiction Programs & Professionals The AIDS Institute California Coverage & Health Initiatives The Arc of the California Health Advocates The Augustinians California Pan-Ethnic Health Network The Coelho Center for Disability Law, Policy and Innovation County Welfare Directors Association of California The Global Justice Institute Equality California The Leadership Conference on Civil and Human Rights Jewish Family Service LA The National Alliance to Advance Adolescent Health Long Term Care Ombudsman Services of San Luis Obispo The National Center for Children in Poverty County Treatment Communities of America Los Angeles LGBT Center Trust for America's Health National Association of Social Workers, California Chapter Union for Reform Judaism NextGen California

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Orange County United Way Idaho PathPoint Idaho Interfaith Roundtable Against Hunger San Francisco AIDS Foundation National Association of Social Workers, Idaho Chapter The Los Angeles Trust for Children's Health Illinois Colorado AgeOptions Center for Health Progress Champaign County Health Care Consumers Colorado Cross-Disability Coalition EverThrive Illinois Colorado School Medicaid Consortium Health & Medicine Policy Research Group Disability Law Colorado Heartland Alliance Hunger Free Colorado Illinois Association for Behavioral Health National Association of Social Workers, Colorado Chapter Illinois Society for the Prevention of Blindness LINC Inc. Connecticut National Association of Social Workers, Illinois Chapter ArtBra New Haven Protect Our Care Illinois Ashford Senior Center Shriver Center on Poverty Law Collaborative Center for Justice Thresholds Connecticut Association of Area Agencies on Aging Disability Rights Connecticut Indiana National Association of Social Workers, Connecticut Chapter Indiana Association of Area Agencies on Aging Universal Health Care Foundation of Connecticut Marion County Commission on Youth, Inc. National Association of Social Workers, Indiana Chapter Delaware Sisters of St. Francis, Clinton, Iowa Delaware Ecumenical Council Tippecanoe County Council on Aging, Inc. National Association of Social Workers, Delaware Chapter Iowa Florida Child and Family Policy Center Catalyst Miami Franciscan Peace Center Democratic Disability Caucus of Florida National Association of Social Workers, Iowa Chapter Disability Rights Florida Florida Agencies Serving the Blind Kansas Florida Chapter of the American Academy of Pediatrics Kansas Association of Area Agencies on Aging & Disabilities Florida Impact to End Hunger National Association of Social Workers, Kansas Chapter Florida Supportive Housing Coalition Florida Voices for Health Kentucky National Association of Social Workers, Florida Chapter Jewish Family & Career Services of Louisville, Inc The Support Coordination Association of Florida (SCAF) Kentucky Equal Justice Center The Family Cafe, Inc. Kentucky Protection and Advocacy Kentucky Voices for Health Georgia Lake Cumberland Area Development District Georgia Watch Lake Cumberland Area on Aging Georgians for a Healthy Future National Association of Social Workers, Kentucky Chapter National Association of Social Workers, Georgia Chapter Louisiana Hawaii CADA of Northwest Louisiana Hawaii Disability Rights Center Lawyer's Reentry Consulting National Association of Social Workers, Hawaii Chapter Louisiana Partnership for Children and Families National Association of Social Workers, Louisiana Chapter

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Maine National Association of Social Workers, Missouri Chapter Maine Equal Justice Places for People, Inc. National Association of Social Workers, Maine Chapter SeniorsPlus Montana National Association of Social Workers, Montana Chapter Maryland Summit Independent Living Galvanize Maryland Green Earth Goods Nebraska Maryland Citizens' Health Initiative Education Fund Inc. National Association of Social Workers, Nebraska Chapter Maryland National Organization for Women Nebraska Appleseed National Association of Social Workers, Maryland Chapter Pemberton Pharmacy & Gift Nevada Public Justice Center Family TIES of Nevada, Inc National Association of Social Workers, Nevada Chapter Massachusetts Nevada Disability Advocacy & Law Center Advocates for Authenticity Silver State Equality-Nevada Health Care For All Massachusetts Massachusetts Home Care New Hampshire National Association of Social Workers, Massachusetts National Association of Social Workers, New Hampshire Chapter Chapter The Food Bank of Western Massachusetts New Jersey Michigan National Association of Social Workers, New Jersey Chapter Baldwin Family Health Care New Jersey Academy of Pediatric Dentistry Community Living Options New Jersey Association of Mental Health and Addiction Health Emergency Lifeline Programs Agencies, Inc. Indivisible Livingston County MI New Jersey Citizen Action Michigan League for Public Policy New Jersey Policy Perspective National Association of Social Workers, Michigan Chapter New Jersey Tenants Organization OLHSA Newark Organization of Women

Minnesota New Mexico Minnesota Academy of Pediatric Dentistry Health Action New Mexico Minnesota Association of Area Agencies on Aging National Association of Social Workers, New Mexico Chapter Minnesota Oral Health Coalition National Association of Social Workers, Minnesota Chapter TakeAction Minnesota Amida Care Center for Disability Rights Mississippi Children's Defense Fund - New York Fannie Lou Hamer Center For Change Commission on the Public's Health System Mississippi Human Services Coalition Disability Rights New York Montgomery Citizens United for Prosperity (MCUP) Disabled in Action of Greater Syracuse Inc. National Association of Social Workers, Mississippi Chapter Gay Men’s Health Crisis Grand Street Settlement Missouri Greater New York Labor Religion Coalition Empower Missouri National Association of Social Workers, New York State Missouri Academy of Pediatric Dentistry Chapter Missouri Budget Project New York Legal Assistance Group Missouri Health Care For All R and W Livery Service, Latino Ambulette

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The Children's Agenda Pennsylvania Council of Churches YWCA Elmira & the Twin Tiers Pennsylvania Health Access Network National Association of Social Workers, Sisters of Saint Joseph of Chestnut Hill, Philadelphia, PA Chapter The 99% Pennsylvania

North Carolina Rhode Island Disability Rights North Carolina Disability Rights Rhode Island Equality North Carolina Foster Forward Goldsboro Pediatrics, PA Mental Health Recovery Coalition of RI (MHRC-RI) National Association of Social Workers, North Carolina National Association of Social Workers, Rhode Island Chapter Chapter Protect Our Healthcare Coalition Rhode Island NC Academy of Pediatric Dentistry Rhode Island Coalition for the Homeless NC Child Rhode Island KIDS COUNT Pisgah Legal Services The Economic Progress Institute The Oasis Wellness & Recovery Centers of RI North Dakota National Association of Social Workers, North Dakota Chapter South Carolina Benedictine University Ohio National Association of Social Workers, South Carolina Cleveland Nonviolence Network Chapter Directions for Youth & Families Protection and Advocacy for People with Disabilities South National Association of Social Workers, Ohio Chapter Carolina Ohio Academy of Pediatric Dentistry SC Appleseed Legal Justice Center Ohio Alliance for Retired Americans Educational Fund South Carolina Academy of Pediatric Dentists Ohio Association of Area Agencies on Aging Ohio Consumers for Health Coverage South Dakota Ohio Nurses Association National Association of Social Workers, South Dakota Chapter Prevent Blindness, Ohio Affiliate Tennessee Oklahoma A Voice For the Reduction of Poverty in Nashville and Beyond National Association of Social Workers, Oklahoma Chapter Disability Rights Tennessee Oklahoma Policy Institute Nashville Jewish Social Justice Roundtable. National Association of Social Workers, Tennessee Chapter Oregon Tennessee Academy of Pediatric Dentistry National Association of Social Workers, Oregon Chapter Tennessee Health Care Campaign Oregon Association of Area Agencies on Aging & Disabilities Tennessee Justice Center TFP Therapeutic Services, Inc. Texas Pennsylvania Center for Public Policy Priorities Consumer Health Coalition Children’s Defense Fund - Texas HIAS Pennsylvania Coalition of Texans with Disabilities JEVS Human Services Feeding Texas Just Harvest, A Center for Action Against Hunger Food Bank of the Rio Grande Valley Liberty Resources, Inc Jay Andrews Consulting Mary House, Inc. McLennan County Hunger Coalition Maternity Care Coalition NAMI Central Texas National Association of Social Workers, Pennsylvania Chapter NAMI Gulf Coast Pantry of Plenty @ Sandy Hill Church NAMI North Texas PathWays PA National Alliance on Mental Illness (NAMI) Texas

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National Association of Social Workers, Texas Chapter National Association of Social Workers, Washington Chapter Prevent Blindness Texas Northwest Harvest Texas Academy of Pediatric Dentistry Northwest Health Law Advocates Texas Interfaith Center for Public Policy/Texas Impact Toppenish Community Chest Texas Parent to Parent Texas Pediatric Society, the Texas Chapter of the AAP Washington, D.C. UUFHC D.C. Hunger Solutions National Association of Social Workers, Metro DC Chapter Utah SOME, Inc. (So Others Might Eat) National Association of Social Workers, Utah Chapter Whitman-Walker Health Utah Health Policy Project Voices for Utah Children West Virginia National Association of Social Workers, West Virginia Chapter Vermont Prevent Child Abuse WV / TEAM for WV Children National Association of Social Workers, Vermont Chapter West Virginia Academy of Pediatric Dentistry Office of the Health Care Advocate, Vermont Legal Aid West Virginia Center on Budget and Policy Southern Vermont Area Health Education Center West Virginians for Affordable Healthcare Vermont Center for Independent Living Vermont Coalition for Disability Rights Wisconsin Citizen Action of Wisconsin Virginia Dominican Sisters of Sinsinawa Peace and Justice Office 8 Block End Domestic Abuse Wisconsin Central Virginia Health Services, Inc. Green Bay St. Vincent de Paul Voice of the Poor National Association of Social Workers, Virginia Chapter Kids Forward Social Action Linking Together (SALT) National Association of Social Workers, Wisconsin Chapter The New 21st Century Movement Association Prevent Blindness Wisconsin Virginia Academy of Pediatric Dentistry Wisconsin Association of Area Agencies on Aging Virginia Coalition of Latino Organizations Wisconsin Faith Voices for Justice Virginia Health Catalyst Virginia Organizing Wyoming Virginia Poverty Law Center National Association of Social Workers, Wyoming Chapter

Washington U.S. Territories Aging & Disability Services Advisory Council for Seattle and National Association of Social Workers, Guam Chapter King County National Association of Social Workers, Puerto Rico Chapter International Community Health Services National Association of Social Workers, Virgin Islands Chapter

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