State by State Data for Aged and Disabled: Institutional Bias? Information Bulletin #383 (October 2013) For the past ten years, we have tracked Medicaid funds by State by comparing community versus institution expenditures for people with disabilities. The FY 2011 data is finally available. This Information Bulletin will focus only on Older Adults and People with Physical Disabilities from both a six year (FY 2006-2011) perspective with a more detailed look at FY 2011. The “good” news is that in FY 2006, the national average of community versus institutional Medicaid expenditures was 29.6% to the community and 70.4% to the nursing homes. In FY 2011, it was 38.1% to 61.9%. Yes, it’s a slow, incremental change. And yes, inherent in the lethargy and pace are people being discriminated against in violation of the ADA. Without a serious national litigation attack, the arc of history will continue to bend, but very slowly. The nursing home industry is very powerful and contributes a lot of money to State elected officials. Given that most people want to live in the community and not nursing homes, the quid pro quo is obvious. The nursing home industry “contributes” to your elected State officials, who in return continue to raise the per diem nursing home reimbursements and continue to allocate Medicaid funds in a discriminatory manner. Unlike the for people with Developmental Disability, where 23 States spend more than 80% of their Medicaid expenditures in the community and only 7 States spend less than 50% in the community, for the Older Americans and People with Physical Disabilities only 1 State spent more than 80% in the community and 44 spent less than 50% in the community. Quite a difference! Here are the States that spent the least in the community in FY 2011 for A/PD, and therefore spent the most in the nursing homes. The worst/least Medicaid expenditures in the community was Rhode Island, followed by North and South Dakotas, Alabama, Delaware, Kentucky, New Hampshire, Mississippi, Indiana, Utah, and Pennsylvania. Six of these “worst” A/PD states either have an exceptionally strong nursing home industry or the State elected officials have a particular dislike of Old Adults and People With Physical Disabilities. Compare their community-based Medicaid expenditures for people with Developmental Disabilities versus Older Adults and People with Physical Disabilities. The following six states spent more than 72% of the Medicaid funds in the community for people with DD, while spending less than 22% in the community for people with A/PD: Alabama, Kentucky, Delaware, New Hampshire, Utah, and Pennsylvania. Quite a difference! Here are the States that spent the most in the community in FY 2011 for A/PD, and therefore spent the least in the nursing homes. New Mexico was far and away the best, followed by Minnesota, Washington, Alaska, Oregon, California, Texas and Wisconsin. These States are the winners. Advocates for Older Adults and people with Physical Disabilities should sit down in your State with the advocates for people with Developmental Disabilities to discuss their successful strategies. Advocates should ask their attorneys why they are not banging down the courthouse doors with lawsuits under the ADA and Olmstead. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.

DOJ’s ADA Lawsuit Regarding Children in Nursing Homes. Information Bulletin #383 (8/2013) The U.S. Department of Justice, Disability Rights Section, filed a very important ADA/Olmstead lawsuit against the State of Florida on behalf nearly 200 children with disabilities. USA v. The State of Florida http://www.ada.gov/olmstead/olmstead_cases_list2.htm#fla. These children “entered nursing facilities as children and grew up in these institutions” and were “unnecessarily segregated from their communities.” This lawsuit also claimed that “children with significant medical needs who reside in the community” face “serious risk of unnecessary institutionalization” because of “repeated service reductions and lengthy and unduly burdensome recertification processes.” While the lawsuit focused on children, DOJ’s legal claims apply as well to adults in nursing facilities and at risk of institutionalization. Also, because many States have very similar ADA/Olmstead issues, we will point out some very important handles you might want to consider. 1. “Denial or Reduction of Medically Necessary Services.” DOJ asserted that Florida “in recent years unduly restricted the availability of many in-home services … through a state regulation that requires Medicaid services to ‘be furnished in a manner not primarily intended for the convenience of the recipient or recipient’s caretaker.” DOJ asserted that there were children in nursing facilities as a result of Florida’s limits on in-home services and/or a failure to provide such services. 2. “Stagnant Reimbursement Rates for Home Health Services.” DOJ noted that many people were unable to access home health services due to the low Medicaid rates paid for such services. One comparison that is very helpful was DOJ noting that the rate paid to nursing homes for these children increased in the last 9 years by 28%, but home health rates have not increased comparably. 3. “Insufficient Capacity in HCBS Waiver Programs.” After pointing out that most of these children are eligible for Waiver services in the community, due to lengthy waiting lists children have been forced to enter nursing homes. Even with additional State Waiver funds in 2013, more than95% of the people on waiting lists will not receive community-based services. 4. “Lack of Sufficient Community-Based Alternatives.” DOJ stated there were “very few providers of care to children with significant medical needs” in non-institutional settings. 5. “Failure to Offer Meaningful Opportunities to Move to the Community.” DOJ stated that “many of the Institutionalized Children remain in facilities for very long periods of time, even when it is apparent that their medical conditions would permit return to the community with appropriate supports. The continued stay of most of these children is the direct result of the State’s failure to actively identify more integrated service options for them.” Related to the ADA/Olmstead arguments and claims, DOJ noted that “providing services in integrated settings can be accommodated through reasonable modifications to the State’s existing services.” These five problems exist in many other States and cause adults (and children) to be unnecessarily segregated in nursing homes and other institutional settings, as well as to be at serious risk of institutionalization. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.

HUD Issues Olmstead Guidance – Let’s Use It! Information Bulletin #382 (6/2013) On June 4, 2013 HUD released a “Statement … on the Role of Housing in Accomplishing the Goals of Olmstead.” Here is the link to HUD’s Statement: http://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2013/HUDNo.13-086 Then click on “Read HUD’s new guidance” for the full Statement. This Information Bulletin quotes some points and suggests what advocates should look for and what can be done if your local and State recipients of HUD funds do not comply. HUD emphasizes the critical role housing plays in implementing the Olmstead and the ADA’s “most integrated setting” mandate by “increasing the housing opportunities for individuals with disabilities who are transitioning from, or at serious risk of entering, institutions, hospitals, nursing homes, adult care facilities, and other restrictive, segregated settings.” Advocates throughout the country have repeatedly testified that the lack of affordable, integrated, accessible housing is and has been a very significant barrier for people institutionalized (who cannot afford or locate housing because they have no money or their money goes to the institution) and people at risk of institutionalization (who, to stay out of an institution, must have accessible units in the community). Advocates know that HUD funded programs, in the past, have not focused on and have not required public recipients of HUD funds to focus on Olmstead and the ADA mandates for integration. The HUD Statement is intended to ensure compliance with Olmstead and the ADA. HUD recognizes that “a critical consideration in each state is the range of housing options available in the community for individuals with disabilities and whether those options are largely limited to living with other individuals with disabilities, or whether those options include substantial opportunities for individuals with disabilities to live and interact with individuals without disabilities.” HUD provides three examples of integrated housing: 1. “scattered-site apartments providing permanent supportive housing [that could be rented with Section 8 vouchers], [2] tenant-based rental assistance [a housing voucher authorized in the HOME Investment Partnership program, administered nationally at both the State and local levels] that enables individuals with disabilities to lease housing in integrated developments, and [3] apartments for individuals with various disabilities scattered throughout public and multifamily housing developments.” HUD told “public housing agencies and other HUD-assisted housing providers to work with state and local governments to provide integrated, affordable and accessible housing options for individuals with disabilities who are transitioning from, or at serious risk of entering, institutions or other segregated settings.” (Let’s hope they will work also with advocates and people with disabilities.) In another example [#4], HUD reminded both public housing agencies and other recipients of HUD assistance that “certain preferences [both with regards to actual housing and housing vouchers] that will enable individuals with disabilities … are permissible.” No more excuses that HUD-funded programs cannot establish preferences to assist institutionalized persons to return to the community or to prevent the institutionalization of people who are at risk of such institutionalization. A fifth example focused on “reasonable accommodations/ modifications (e.g., increasing the payment standard for Housing voucher for accessible units, or an extra bedroom for equipment or live-in aide). The Statement pointed out that “HUD requires recipients of HUD assistance [that includes public housing agencies, housing vouchers, the HOME tenant-based rental assistance vouchers, CDBG, and lots of other recipients] to take affirmative steps to further fair housing. The affirmative furthering fair housing (AFFH) obligation offers an opportunity for HUD and the recipients of HUD assistance to support Olmstead implementation by engaging in activities that will benefit individuals transitioning from institutions or at serious risk of institutionalization by providing integrated, affordable and accessible housing options in community-based settings.” What advocates should do to find out if HUD really means it. Here are a few possible strategies: 1. Do your local and state Consolidated Plans show that all of the above five examples are being implemented? Or even planned for the future? For example, are there “preferences” in both actual housing and housing choice vouchers (aka Section 8) for people institutionalized or at risk? 2. Do your local and/or State recipients of HOME Investment Partnership federal funds provide for tenant-based rental assistance for people institutionalized or at risk? Have any been actually provided in the past to end institutionalization? Are they needed in your State? 3. Has your public housing authority provided for scattered-site accessible housing throughout your community? Are more needed? Planned for? If there are people in institutions whom you, the advocates, know are institutionalized because of housing – either because they do not have funds for rent, security deposits, etc., or because they cannot locate accessible units they can afford, then your local and State recipients of HUD funds have failed to “affirmatively further fair housing.” These local and State recipients of HUD funds are in violation of the federal Fair Housing Act. HUD should be notified of these violations so it can remedy the situation and ensure people are not unnecessarily institutionalized. File a Complaint (be as specific as possible) with HUD Office of Fair Housing and Equal Opportunity in Washington, D.C. and send a copy of your Complaint to Jeanine Worden, Associate General Counsel, Jeanine.M.Worden@HUD.gov, or to Sara Pratt, Deputy Assistant Secretary for Enforcement, Sara.K.Prattt@HUD.gov. All italicizations are added. Steve Gold, The Disability Odyssey continues. Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.

Managed Care Long-Term Services and Supports. Information Bulletin #381 (6/ 2013) The Center for Medicare and Medicaid Services, the federal agency that funds Medicaid on 5/20/2013 issued “Guidance to States using 1115 Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports Programs” (MLTSS). A copy of this important new federal guidance can be found at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf We are quoting extensively from this CMS document because, for those States contemplating using Managed Care as the mechanism for Medicaid Expansion, as well as for those States that already include MLTSS, this document provides important advocacy handles. Before a State can have a 1115 Demonstration or 1915(b) waiver, CMS must review and approve a State’s application. If your State does not include and really provide for the following, then advocates should let CMS know their opposition to MLTSS. Here are some points that disability and elderly advocates might want to keep in mind. 1. CMS points out that LTSS includes “both home and community based services and institutional-based services.” The guidance encourages states to include both home and community based services and institutional programs in the managed care capitation rate. If your State is contemplating MLTSS, make sure both home and community services as well as institutional services are included and are the responsibility of the Managed Care Organization (MC0). Make sure that institutional-based services are not “carved out” in any way. Our assumption is if a managed care agency is financially responsible for institutional-based services, the MCO will figure out how to serve the person in the community, where on average it’s less expensive. If the MCO is not responsible for institutional services, the MCO will have a financial incentive to dump people with disabilities, especially with severe disabilities, into the institution. 2. The ADA and Olmstead requirements for services apply to MLTSS. CMS points out that “under the law [ADA], MLTSS must be delivered in the most integrated fashion, in the most integrated setting, and in a way that offers the greatest opportunities for active community and workforce participation.” Such a setting “enables individuals with disabilities to interact with non-disabled persons to the fullest extent possible.” CMS writes that “States are encouraged to include in their benefit packages supports to enable workforce participation such as personal assistance services, supported employment and peer support services, as appropriate and desired by the participant.” If these kinds of supports are not included in your State’s managed care program, then you should advocate with CMS and State officials to get your State to include them. If CMS is not responsive to your concerns, please let us know asap! 3. Under “alignment of payment structures and goals,” CMS requires States “establish rates that support the goals and objectives of their MLTSS program… In keeping with the intent of the ADA and Olmstead decision, payment structures must encourage the delivery of community-based services and not provide disincentives, intended or not, for the provision of services in home and community-based settings.” A number of advocates have voiced serious concerns that the more severely disabled persons will not be able to live in the community because the capitation rates (the dollar amount per person the MCO receives) are too low to cover all the community needs and supports. CMS requires that “State payment structures, systems and review mechanisms must ensure that participants at all levels of need and all types of disabilities have the opportunity to choose their MLTSS providers and have appropriate access to community-based services.” There cannot be any doubt that “States must employ financial incentives that achieve desired outcomes, [such a] provision of services in the most integrated settings and consumer satisfaction.” It is a failure for States not to set rates that ensure the most severely disabled persons have a meaningful choice to reside in the community. States that fail will have “financial penalties… or return of a payment if a MCO does not achieve required outcomes for the provision of services in the most integrated settings.” 4. The State Medicaid agency has the legal duty to “evaluate whether payment rates and structures are adequate to achieve participant access to quality providers for covered services.” 5. “Person-centered” needs assessment, service planning and service coordination are required. CMS urges that MLTSS “should encourage participant self-determination and provide opportunities for self-direction of services.” If your State provides self-direction in its existing fee for service Medicaid program, CMS states that the MLTSS “programs are expected to continue them,” and if your State does not currently offer self-direction, “it should consider providing the opportunity for self-direction within their MLTSS program. 6. “Stakeholders” [which includes us – disability and elderly advocates] must be formally involved, including cross-disability representatives, in the planning, implementation and oversight of the MLTSS. You must be at the table when the State Medicaid agency is developing the contract for MLTSS. The contract sets the enforceable requirements. ALL of the above five points are just words if the contract does not require the provision of these points. In addition to these six points, the State’s contracts with managed care organization should include requirements that managed care staff working with MLTSS programs receive Olmstead training to understand the importance of serving persons outside of the institution. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.

Are Nursing Homes Referring People to the Community? Information Bulletin # 380 (May, 2013) Several years ago, the disability and elder communities and the Centers for Medicare and Medicaid Services worked to revise the Minimum Data Set questionnaires. The MDS must be completed quarterly by each nursing home for each resident and then electronically submitted to CMS. The famous “Q1a” was the focus of the revisions that very much concerned the disability and elder communities. One of the primary goals was to change the system to help people transition to the community. Here are some national findings for the 1,322,697 people in nursing homes on 3/31/13. The following data is from what CMS collected from the nursing homes. 1. MDS Questions 100A-C report on the percentages of people in nursing homes who “Participated in the Assessment and Goal Setting”. Nationally, 84.48% of the residents participated. Nationally 31.73% of “family or significant others” participated, and 10.08% had a “guardian or legally authorized representative” participate. 2. MDS Questions 300A-B focus on “Residents’ Overall Expectation” and the “Goal Established During the Assessments.” The results show that nationally 27.63% of the residents “expect to be discharged to community.” That means 365,461 nursing home residents wanted to leave and expected to live in the community. While we do not have a breakdown, we know that residents themselves made up 62.27% of these respondents and another 30.23% were family or significant others. 3. Proceeding to question MDS 400A, nationally there were 84.85% of these 365,461 residents (that equals 310,093 people in nursing homes) had an “Active Discharge Plan” in place to return to the community. We have no idea why the 15.15% (55,367 people) did not have a plan since they wanted to leave the nursing homes and had an expectation they would leave. But when asked in MDS 400 B, “What determination was made by the resident and the care planning team regarding discharge to the community,” no data is provided. CMS writes “please be patient. This may take a few seconds to load.” It never loaded. It is not clear what “determination” had to be made for the 310,093 people who had an “active discharge plan.” Nor is it clear whether a nursing home “planning team” could trump a resident’s decision to move to the community. Are community advocates present when such a determination is made? Does the nursing home “planning team” have any knowledge of what community-based services could be provided? 4. When the MDS goes beyond the “Active Discharge Plan” stage, it asks if the “resident asked to return to the community?”(MDS 500 A). Again, no data was provided. Also, we do not understand why the resident, who had an “expectation” to return to the community (MDS 300 A/B) and who has an Active Discharge Plan, is then asked (how many times are necessary) if the resident asked to return to the community. What if a family member asks? 5. Here’s the real kicker. When the nursing homes completed the MDS 500 B question, the nursing homes concluded that 86.55% of the people had no “possibility of returning to community.” A death sentence imposed! The nursing home concluded that only 5.75% of the residents - remember, this is according to the nursing homes – had even a “possibility’ to return to the community. What services did the nursing homes think could not be provided in the community? 6. As appalling as these numbers are, the nursing homes are supposed to refer people to a “local contact agency” which is supposed to come into the nursing home and is supposed to provide assistance for the nursing home resident to transition back to their homes and apartments with appropriate home and community-based services. 7. And now for the final blow: only 2.5% of the nursing home residents were actually referred to a “local contact agency” as reported on MDS 500B. We assume (and hope) that these 2.5% are from those residents whom the nursing home thought there was a “possibility” to return to the community. Disability and Elderly Advocates: Based on the above data, it might be hard to imagine but people in nursing homes are Not Dead Yet! What are advocates doing to help disabled and elderly in nursing homes move back into the communities? 1. Here is a link for the MDS data which is available by State. http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data-Set-3-0-Frequency-Report.html 2. There are a limited number of prizes for advocates who know the name of your “local contact agency.” There are more prizes for the local contact agency that has received the most such referrals. These prizes are time-limited so please send in your responses as soon as possible. 3. Can anyone explain why CMS’ nursing home office of “Surveys and Certifications” does not check on any of the above MDS questions? Is there any doubt that if CMS included these MDS questions in its annual surveys the percentages of people who wanted to leave would increase? Maybe even more people would transition back to the communities. 4. There is a very special prize for the advocates who can identify any person in a nursing home who could not reside and be cared for in the community with appropriate services. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.

“Premium Assistance,” People with Disabilities, and Medicaid Expansion Via Insurance Exchanges. Information Bulletin #379 (4/2013) Do you reside in a State that has not agreed to expand Medicaid under the Affordable Care Act (ACA) to all persons whose incomes are under 138% of the federal poverty level? Has your Governor talked about using Medicaid’s “premium assistance” plan to purchase a health plan via an “Exchange” for people under 138% – the “Arkansas model”? This Information Bulletin attempts to clarify some of these concepts, particularly as they apply to people with disabilities. 1.The normal way most States are implementing the ACA Medicaid expansion is to provide all persons with incomes under 138% with defined Medicaid benefits delivered through one Medicaid system. The “Arkansas model” is different and is the outlier. It uses Medicaid funds as “premium assistance” payments with which a State will purchase a private health plan, through the health insurance exchange being created for each state under the ACA (run either by the state or by the federal government). This private health plan will be limited to specific covered health benefits and services. Based on the proposed federal regulations and guidance from the federal Medicaid agency, CMS, the additional benefits covered under Medicaid, and the cost-sharing protections under Medicaid, must still be provided, these are likely to be very difficult to access. However, absent a special waiver, with premium assistance payments, a State cannot mandate that anyone under 138% receive Medicaid expansion services via the private insurance market; they must all be offered the choice of traditional Medicaid. 2. There is one possible way your State may try to get around this prohibition on mandatory enrollment in premium assistance. The State may apply to CMS for a section 1115 demonstration waiver to provide premium assistance to purchase a health plan on an Exchange and to make participation mandatory. What is critical for people with disabilities to know is that, under such a waiver, “A State may not require an individual to obtain [Medicaid services and health care] benefits through enrollment” with premium assistance payments if the person fits into one of the following five categories. If you are in one of these categories, the State cannot force you into a private health plan even through a 1115 waiver. Instead, the State must provide the traditional Medicaid benefits and services that current Medicaid recipients who are disabled are eligible for and receive, and deliver them in the traditional manner. The exempted categories are: 1. Blind and disabled persons (or persons “being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits …on the basis of being blind or disable. Nationally, we estimated that 2,665,407 people with disabilities are in this category. See Information Bulletin #369 (1/2013) or http://stevegoldada.blogspot.com/ for a State-by-State breakdown. 2. Dual eligibles – i.e., persons who receive both Social Security disability and Supplemental Security Income benefits. 3. Persons institutionalized in a “nursing home, an intermediate care facility for the mentally retarded, or other medical institution, and required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs.” 4. “Medically frail and special medical needs individuals,” (as identified in accordance with regulations of the Secretary). 5. Persons who qualify for long-term care services. “The individual qualifies based on medical condition for medical assistance for long-term care services,” including Home and community-based services furnished under a 1915 waiver. These exempted categories are critical. These people are entitled to all of the Medicaid services and benefits currently available to existing Medicaid recipients who are disabled, through the existing delivery system. 3. Do you reside in a State that is considering using premium assistance payments for people on Medicaid? If you do, please make sure your State is fully aware that it will have to run two separate programs for the Medicaid 138% expansion population, even with a waiver allowing it to force some Medicaid enrollees into premium assistance. One Medicaid program will provide all the components in the State’s existing benefits and services for people in categories ## 1 -5 above, and for others who opt out of premium assistance if there is no waiver. A second and separate Medicaid expansion program will use premium assistance payments for people not exempted under a waiver, or who have not opted out if there is no waiver. We expect that most States using premium assistance without a waiver will try to convince people in categories ## 1-5 to receive services through private insurance in the Exchange paid with the premium assistance. Don’t do it! You are exempted from mandatory enrollment. Why are we so emphatic? There is no way a private insurance company that is paid to provide “Exchange” health services will provide the long-term care Medicaid services that people in categories ##1-5 need to live independent, integrated lives in their homes and apartments. Congress did not even require Exchanges to include long-term care services or benefits, and you can bet they will not. Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.

What are the Religious Communities doing in your State Re Medicaid Expansion? Information Bulletin # 377 (4/2013) Have the various religious communities in your State taken a public position with regards to Medicaid expansion for residents whose incomes are less than 138% of the federal poverty level? Last week in Pennsylvania, 1,350 Roman Catholic nuns, priests, and brothers, representing 19 different religious congregations, were individually identified, by name and religious affiliation, in a letter written to the Pennsylvania Governor in which they urged him to accept federal Medicaid funds to expand coverage to nearly 700,000 residents who lack coverage. These religious leaders noted that their “faith, tradition and justice teaching call us to advocate for the right of all human beings to have access to the basic necessities that enable them to live productive lives with dignity. Among those is the right to affordable health care.” They stated that a failure to accept these funds by the Governor would “breach the moral duty to those who are on the margins of society.” They requested a meeting with the Governor. These leaders pointed out the health benefits, cost savings on uncompensated care to hospitals, and economic stimulus which will occur with the Medicaid expansion. These religious leaders concluded that their “faith calls us to respond to the needs of the disabled, the impoverished, and the downtrodden. The Medicaid expansion is an unparalleled opportunity to provide affordable health insurance for uninsured Pennsylvanians.” In every State there are coalitions of religious congregations – Protestant, Evangelical, Jewish, Catholic, and others. Have they taken a public position regarding Medicaid expansion? Have they written to the Governor and state legislators? Have you asked them to? What have they done in North Carolina, South Carolina, Georgia, Alabama, Mississippi, Texas, Oklahoma, Nebraska, Iowa, Tennessee, Virginia, West Virginia, Kansas and Utah? Surely there are religious leaders and coalitions who recognize Medicaid expansion as a “moral duty.” Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/ To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.