Children's Health Insurance: Recent HHS-OIG Reviews Inform the	 
Congress on Improper Enrollment and Reductions in Low-Income,	 
Uninsured Children (09-MAR-06, GAO-06-457R).			 
                                                                 
The Congress passed legislation creating the State Children's	 
Health Insurance Program (SCHIP) in 1997 to reduce the number of 
uninsured children in families with incomes that are too high to 
qualify for Medicaid. For SCHIP, the Congress appropriated $40	 
billion over 10 years, with funds allotted annually to the 50	 
states, the District of Columbia, and the U.S. commonwealths and 
territories. States' participation in SCHIP is voluntary. States 
that do participate have three options in designing their SCHIP  
programs: expand the Medicaid program to include SCHIP-eligible  
children, develop a separate child health insurance program, or  
maintain a program that combines both of these options. Financed 
jointly by the states and the federal government, SCHIP offers a 
strong incentive for states to participate by offering a higher  
federal matching rate--that is, the federal government pays a	 
larger proportion of program expenditures--than the Medicaid	 
program. While this incentive encourages efforts to reduce the	 
number of uninsured children through state participation in	 
SCHIP, there have been concerns that states might inappropriately
enroll Medicaid-eligible children in SCHIP and thus obtain higher
federal matching funds than allowed under Medicaid. In addition, 
there has been interest in assessing the progress states made to 
reduce the number of uninsured children, including the extent to 
which states met the objectives and goals established in their	 
SCHIP programs. In particular, states must report their progress 
in reducing the number of low-income, uninsured children and may 
rely on certain national data sets, such as the Current 	 
Population Survey (CPS), or conduct their own surveys, to do so. 
In the Medicare, Medicaid, and SCHIP Balanced Budget Refinement  
Act of 1999 (BBRA), the Congress directed the Department of	 
Health and Human Services (HHS) Office of Inspector General (OIG)
to conduct a series of studies on two issues--determining the	 
number of children who were enrolled in separate SCHIP programs  
but were eligible for Medicaid and assessing states' progress in 
reducing the number of low-income, uninsured children--every 3	 
years, beginning in fiscal year 2000. This provision required the
OIG to only include in its studies states with separate SCHIP	 
programs. BBRA directed that we review and report on the OIG's	 
work. The OIG issued its initial reports in February 2001, and	 
our assessment of the OIG's work was published in March 2002. The
OIG's most recent set of reports on these issues was published in
2004 and 2005. This report reflects our evaluation of the OIG's  
recent reports. Specifically, we assessed the OIG's efforts to	 
inform the Congress on (1) the number of Medicaid-eligible	 
children enrolled in separate SCHIP programs and (2) states'	 
progress in reducing the number of uninsured children, including 
the progress they have made in meeting the objectives and goals  
initially established in their SCHIP programs.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-457R					        
    ACCNO:   A48641						        
  TITLE:     Children's Health Insurance: Recent HHS-OIG Reviews      
Inform the Congress on Improper Enrollment and Reductions in	 
Low-Income, Uninsured Children					 
     DATE:   03/09/2006 
  SUBJECT:   Children						 
	     Disadvantaged persons				 
	     Federal/state relations				 
	     Health care programs				 
	     Health insurance					 
	     Medicaid						 
	     Performance measures				 
	     Reporting requirements				 
	     State-administered programs			 
	     Statistical data					 
	     Program goals or objectives			 
	     Census Bureau Current Population Survey		 
	     State Children's Health Insurance			 
	     Program						 
                                                                 

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GAO-06-457R

     

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March 9, 2006

Congressional Committees

Subject: Children's Health Insurance: Recent HHS-OIG Reviews Inform the
Congress on Improper Enrollment and Reductions in Low-Income, Uninsured
Children

The Congress passed legislation creating the State Children's Health
Insurance Program (SCHIP) in 1997 to reduce the number of uninsured
children in families with incomes that are too high to qualify for
Medicaid.1 For SCHIP, the Congress appropriated $40 billion over 10 years,
with funds allotted annually to the 50 states, the District of Columbia,2
and the U.S. commonwealths and territories. States' participation in SCHIP
is voluntary. States that do participate have three options in designing
their SCHIP programs: expand the Medicaid program to include
SCHIP-eligible children, develop a separate child health insurance
program, or maintain a program that combines both of these options.
Financed jointly by the states and the federal government, SCHIP offers a
strong incentive for states to participate by offering a higher federal
matching rate-that is, the federal government pays a larger proportion of
program expenditures-than the Medicaid program.3 While this incentive
encourages efforts to reduce the number of uninsured children through
state participation in SCHIP, there have been concerns that states might
inappropriately enroll Medicaid-eligible children in SCHIP and thus obtain
higher federal matching funds than allowed under Medicaid. In addition,
there has been interest in assessing the progress states made to reduce
the number of uninsured children, including the extent to which states met
the objectives and goals established in their SCHIP programs.4 In
particular, states must report their progress in reducing the number of
low-income, uninsured children and may rely on certain national data sets,
such as the Current Population Survey (CPS), or conduct their own surveys,
to do so.

1Medicaid is a federal-state program that provides health care coverage to
certain categories of low-income adults and children. SCHIP was
established as title XXI of the Social Security Act by the Balanced Budget
Act of 1997, Pub. L. No. 105-33, S: 4901, 111 Stat. 251, 552, and is
codified at 42 U.S.C. S: 1397aa, et seq.

2The District of Columbia is included among our discussion of states for
purposes of this report.

3Federal funds are allotted to states for SCHIP programs up to a specified
amount each year. See 42 U.S.C. S: 1397dd.

4The SCHIP statute includes a provision requiring states, in establishing
their programs, to specify strategic objectives and performance goals for
providing child health assistance. See 42 U.S.C. S: 1397gg.

In the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999 (BBRA), the Congress directed the Department of Health and Human
Services (HHS) Office of Inspector General (OIG) to conduct a series of
studies on two issues-determining the number of children who were enrolled
in separate SCHIP programs but were eligible for Medicaid and assessing
states' progress in reducing the number of low-income, uninsured
children-every 3 years, beginning in fiscal year 2000.5 This provision
required the OIG to only include in its studies states with separate SCHIP
programs. BBRA directed that we review and report on the OIG's work. The
OIG issued its initial reports in February 2001, and our assessment of the
OIG's work was published in March 2002.6

The OIG's most recent set of reports on these issues was published in 2004
and 2005.7 This report reflects our evaluation of the OIG's recent
reports. Specifically, we assessed the OIG's efforts to inform the
Congress on (1) the number of Medicaid-eligible children enrolled in
separate SCHIP programs and (2) states' progress in reducing the number of
uninsured children, including the progress they have made in meeting the
objectives and goals initially established in their SCHIP programs.

To assess the OIG's work, we reviewed the OIG's methodologies and
findings. We also interviewed the OIG officials who conducted these
studies to clarify questions and to discuss their response to our prior
recommendations.8 Finally, we examined the OIG's recommendations to the
Centers for Medicare & Medicaid Services (CMS), which administers SCHIP.
Our work was conducted from December 2005 through March 2006 in accordance
with generally accepted government auditing standards.

Results in Brief

The OIG's most recent set of reports on improper SCHIP enrollment and
states' progress in reducing the number of low-income, uninsured children
informed the Congress about these issues and included improvements from
its initial studies. For example, in evaluating the number of children who
were enrolled in separate SCHIP programs but were eligible for Medicaid,
the OIG broadened the scope of its initial study to include a random
sample of children's case files from the 34 separate SCHIP programs with
available data. In its initial study responding to the BBRA mandate, the
OIG only examined case files from 5 separate SCHIP programs. In its most
recent report, the OIG estimated that only 1 percent of children were
improperly enrolled in separate SCHIP programs. The confidence interval
the OIG calculated for its enrollment error rate, which provides an
estimated range of values that is likely to include the true error rate,
was 0.3 to 2.6 percent. We believe that this confidence interval is
relatively wide for such an analysis and is likely the result of the small
sample of case files reviewed by the OIG. However, we recognize that even
at its upper bound, the enrollment error rate for the population would be
2.6 percent. In addition, 7 percent of separate SCHIP case files did not
include enough information to support enrollment decisions, but the OIG
did not find any evidence in these case files to indicate that the
enrollment decisions were inappropriate. In part to respond to our earlier
recommendation that the OIG expand its scope beyond the separate SCHIP
programs, the OIG further informed the Congress about improper SCHIP
enrollment by conducting an additional study in 29 states with Medicaid
expansion programs. This study, which also evaluated the enrollment
decisions in a random sample of case files, identified 7 percent of
sampled children as not meeting the state eligibility criteria for
Medicaid expansion and 10 percent of case files as having missing
documentation.

5Pub. L. No. 106-113, App. F., S: 703, 113 Stat. 1501A-321, 1501A-401-402.

6GAO, Children's Health Insurance: Inspector General Reviews Should Be
Expanded to Further Inform the Congress, GAO-02-512 (Washington, D.C.:
Mar. 20, 2002).

7Department of Health and Human Services Office of Inspector General,
SCHIP: States' Progress in Reducing the Number of Uninsured Children
(Washington, D.C.: August 2004); Determining if Children Enrolled in
Separate SCHIPs Were Eligible for Medicaid (Washington, D.C.: June 2005);
and Determining if Children Classified as SCHIP Medicaid Expansion Meet
Eligibility Criteria (Washington, D.C.: October 2005).

8See GAO-02-512. In that report, we noted that the OIG's findings could
not be generalized to all SCHIP programs because sample cases were limited
to five states' separate SCHIP programs. Therefore, we recommended that
the OIG (1) expand its scope when conducting subsequent mandated studies
and (2) review enrollment practices in states with Medicaid expansion
programs, in addition to separate SCHIP programs, to further inform the
Congress about the appropriateness of enrollment. Because state
evaluations of reductions in the uninsured had limitations, we also
suggested that the OIG review other available literature on changes in the
uninsured population for its next study.

Similarly, for its most recent review of states' progress in reducing the
number of low-income, uninsured children, the OIG expanded its scope to
include the 46 states that submitted SCHIP annual reports for fiscal year
2002. In its initial study responding to the BBRA mandate, the OIG only
examined the annual reports of 5 states with separate SCHIP programs. The
OIG also supplemented its most recent review by examining several national
data sources on the uninsured. The OIG noted that states continue to face
challenges in their efforts to measure the change in the number of
low-income, uninsured children, and only 22 of the 46 states that
submitted reports directly measured their progress in this area. One of
the biggest challenges in measuring progress is the limitation in data
sources-including the often-used CPS, which for various reasons, such as
small sample sizes, has not produced reliable state-level estimates in the
past. In light of these obstacles, the OIG recommended that CMS continue
to work with states to address concerns about data sources used to measure
such progress. We concur with this recommendation. In addition, absent
state submission of data directly measuring changes in low-income,
uninsurance rates through their SCHIP annual reports, the OIG suggested,
and we concur, that CMS could itself measure such reductions by completing
its own analysis of available CPS data, which now include the results of
broader state samples.

In commenting on a draft of this report, the OIG did not comment on our
findings. The OIG provided technical comments, which we incorporated as
appropriate.

Background

Medicaid and SCHIP, joint federal-state programs to finance health care
coverage for certain categories of low-income individuals, represent the
primary source of health insurance coverage for low-income, uninsured
children. Although Medicaid has provided coverage to children since 1965,
SCHIP is a relatively new program, established in 1997. As of January
2006, 11 states had expanded their Medicaid programs to include children
eligible for SCHIP, 19 states had separate SCHIP programs, and 20 states
had combination programs.9,10 (See fig. 1.)

Figure 1: States' Design Choices under SCHIP, January 2006

9Prior to September 30, 2002, Tennessee had a Medicaid expansion program
under SCHIP, which covered children born before October 1, 1983, and who
were under age 19 with family incomes up to 100 percent of the federal
poverty level. After September 2002, Tennessee discontinued its SCHIP
program because all enrolled children had aged out of the program.

10At the time of the OIG's review, New York had a combination SCHIP
program. New York's program changed to a separate SCHIP program as of
April 1, 2005, when all of the children enrolled in the state's Medicaid
expansion aged out of the program.

Medicaid program expenditures are shared between states and the federal
government, and the share is determined using a formula that is based on a
state's per capita income in relation to the national average. Federal
matching rates for SCHIP are "enhanced"-they are established under a
formula that takes 70 percent of a state's Medicaid matching rate and adds
30 percentage points, with an overall federal share that may not exceed 85
percent.11 In fiscal year 2006, the enhanced federal match rates for SCHIP
ranged from 65 to about 83 percent while the federal match rates for
Medicaid programs ranged from 50 to about 76 percent.

Under SCHIP, each state is required to submit a SCHIP plan and an annual
report, which must include a description of the state's progress in
reducing the number of low-income, uninsured children. States may rely on
the CPS, which is a monthly survey of a sample of American households
conducted by the Census Bureau and collects information on characteristics
of the labor force, to report progress in reducing the number of
low-income, uninsured children.12 In particular months, the Census Bureau
supplements its survey by incorporating additional questions. For example,
the March Supplement historically asks respondents about their health
insurance status and provides the only nationwide source of information on
uninsured children by state.

The OIG's Assessment of Improper

Enrollment Identified Few Errors

By broadening the scope of its initial study, the OIG's most recent set of
reports on the number of children who were enrolled in separate SCHIP
programs but were eligible for Medicaid more fully informed the Congress
on this issue. In contrast to its initial study in which the OIG reviewed
case files for five separate SCHIP programs, the OIG's most recent work
included a review of a sample of case files from all separate SCHIP
programs for which data were available. Similar to its initial study, the
OIG identified only 1 percent of children as being improperly enrolled in
separate SCHIP programs. The confidence interval the OIG calculated for
its enrollment error rate is relatively wide; however, even at its upper
bound, the error rate would be 2.6 percent for the population. The OIG
augmented this work by also evaluating enrollment decisions in a random
sample of case files from 29 Medicaid expansion states.

The OIG's Assessment of Improper Enrollment

Broadened to Include Nearly All SCHIP Programs

The OIG broadened the scope of its initial study from a review of 5
separate SCHIP programs to a review of the 34 separate SCHIP programs for
which data were available.13 From these programs, the OIG selected a
random sample of 400 case files to assess enrollment decisions. After
eliminating cases that did not fit study criteria, the OIG ultimately
reviewed 386 case files. The OIG reviewed documentation within the case
files, including the SCHIP application or the most recent eligibility
redetermination; supporting income documentation; and calculation sheets
states used to determine family income. The OIG did not verify the
accuracy and completeness of the state case files; rather, it focused on
whether the information in each file supported the eligibility
determination reached by the state. If case files were missing
documentation, the OIG determined if the files included any information
that indicated enrollment decisions were inappropriate. Using the same
methodology, the OIG also reviewed a random sample of case files in 29
Medicaid expansion programs with available data.14 Of the 400 case files
randomly selected for this study, 357 met study criteria and were
reviewed. This additional work was undertaken in part to respond to our
earlier recommendation that the OIG expand its review to include Medicaid
expansion programs. The OIG's review of enrollment decisions in both
separate SCHIP and Medicaid expansion programs went beyond the BBRA
mandate and more fully informed the Congress on this issue.

11For example, a state with a 50 percent Medicaid match receives a 65
percent match under SCHIP.

12The CPS is the primary source of information on the labor force
characteristics of the U.S. population, and estimates obtained from the
CPS include employment, unemployment, earnings, and hours of work.

The OIG's sample of case files was drawn from over 80 percent of all
separate SCHIP and Medicaid expansion programs with available data.
Nevertheless, our assessment is that this sample was small compared to the
total SCHIP population, as it represented 0.01 percent of total separate
SCHIP enrollees and 0.04 percent of Medicaid expansion enrollees. The
small sample size resulted in a less precise estimate of the number of
cases of inappropriate SCHIP enrollment. In discussing our assessment of
the sample size, the OIG emphasized the increased work associated with
broadening its scope from 5 to 34 separate SCHIP programs and reviewing
the additional 29 Medicaid expansion programs. The OIG also explained that
the size of its sample was influenced, in part, by available resources and
competing priorities.

The OIG's Reviews Identified Few Examples

of Inappropriate Enrollment

The OIG's findings regarding the number of children improperly enrolled in
separate SCHIP programs paralleled its earlier study on this topic, with
only 1 percent of children (4 of 386 cases) identified as being
inappropriately enrolled. In each of these 4 cases, the children were
eligible for the respective state's Medicaid program. In its Medicaid
expansion study, the OIG identified 7 percent of sampled children (24 of
357 cases) as not meeting the state eligibility criteria for Medicaid
expansion. Of these cases, 21 had family incomes that were too low to
qualify for Medicaid expansion, and the remaining 3 had family incomes
that were too high to qualify. For both separate and expansion programs,
enrollment errors were due to a variety of reasons, including caseworkers
misinterpreting income information, multiplying daily wages by the wrong
number of days, or basing a family's income on weekly as opposed to
biweekly pay.

13Two separate SCHIP programs-Michigan and Rhode Island-were unable to
provide necessary data to the OIG.

14Michigan's Medicaid expansion program was unable to provide necessary
data to the OIG.

For the separate SCHIP study, the OIG projected its error rate estimate to
the population, and a 95 percent confidence interval was estimated as 0.3
to 2.6 percent.15 The confidence interval, which we consider to be
relatively wide in light of the enrollment error rate of 1 percent, is
likely a result of the small sample size.16 However, even at its upper
bound, the error rate would be 2.6 percent for the population. The OIG did
not project to the population for Medicaid expansion programs because of
problems identified with population data provided by certain states, such
as data that mistakenly included children who were enrolled in states'
traditional Medicaid programs.

In addition to the definitive cases of inappropriate enrollment identified
above, the OIG noted that some case files-approximately 7 percent of the
386 separate SCHIP and 10 percent of the 357 Medicaid expansion case
files-did not include complete documentation to support enrollment
determinations. However, the OIG reviewed the documentation included in
these case files and did not identify any information that indicated
enrollment decisions were inappropriate. Further, the OIG explained that
for the case files with missing documentation, income levels were toward
the middle of the SCHIP eligibility range, as opposed to near the lower
bound of the range closer to Medicaid eligibility levels. Therefore,
errors in documentation or calculations of resources would have needed to
be extensive for the children to be eligible for traditional Medicaid as
opposed to SCHIP. We concurred with the OIG's reasoning.

The OIG Identified Challenges States Face in

Determining the Number of Uninsured

and Opportunities for CMS Assistance

To assess states' progress in reducing the number of low-income, uninsured
children, the OIG also broadened the scope of its mandated review to
include all states that submitted SCHIP annual reports for fiscal year
2002 by June 1, 2003. The OIG's review of these annual reports indicated
that states continue to experience challenges when determining their
progress in reducing the number of low-income, uninsured children,
primarily with data sources. We agree with the OIG's recommendation that
CMS continue to work with states to address concerns about data sources
used to measure their progress in reducing the number of low-income,
uninsured children.

15The OIG did not report confidence intervals for its initial review of
inappropriate SCHIP enrollment.

16A confidence interval provides an estimated range of values, within
which the true error rate for the population will likely fall. For this
study, the OIG calculated that the true enrollment error rate could be
from 0.3 to 2.6 percent, which is 70 percent below and 160 percent above
the estimated error rate.

The OIG's Review Indicated States' Efforts to Report Progress

in Reducing Uninsured Children Are Hindered by Data Limitations

Similar to its most recent work on inappropriate enrollment in SCHIP
programs, the OIG expanded its review of state efforts to measure changes
in the number of low-income, uninsured children. The OIG reviewed the
fiscal year 2002 SCHIP annual reports of the 46 states that submitted them
by June 1, 2003. In its initial report, the OIG reviewed reports from 5
states' separate SCHIP programs.17 The OIG reviewed the annual reports to
determine states' progress in meeting the strategic objective of reducing
the number of uninsured children. While 22 states used CPS or state survey
data to demonstrate changes in the uninsured population of children, the
remaining 24 states did not respond directly to the objective.18 Instead,
19 of these 24 states used SCHIP enrollment data as a proxy for
demonstrating their progress in reducing the number of uninsured children.
Of the remaining states, 3 provided responses that did not measure
insurance coverage or enrollment, and 2 did not respond. Further, the OIG
augmented its assessment of state efforts by also reviewing national data
on the uninsured-including data from the CPS, the National Health
Interview Survey, and the Urban Institute. These sources were consistent
with the majority of states' annual reports that indicated a reduction in
the number of uninsured children. By expanding its scope, the OIG went
beyond BBRA's requirements to inform the Congress on states' progress in
reducing the population of uninsured children.

The OIG emphasized, and we acknowledge, that efforts to measure progress
in reducing the number of low-income, uninsured children in states
continue to be hindered by multiple factors, such as limitations in data
sources and the often prohibitive cost of conducting state surveys. For
example, CPS data used by many states have well-established
shortcomings-particularly with regard to state-level estimates-which can
be unreliable and exhibit volatility from year to year because of small
sample sizes. This is particularly true in states with smaller
populations. Also, children who are enrolled in Medicaid are often
undercounted in CPS data and may be mistakenly counted as uninsured.
Finally, as noted in the OIG's recent report, the manner in which the
Census Bureau asks respondents about their health insurance coverage
during the past year may lead to respondents incorrectly answering the
question. As a result, CPS data may overestimate the number of uninsured
children.19

17Four of the five states excluded from the most recent OIG
review-Connecticut, Hawaii, Minnesota, and Nevada-were excluded because
they did not submit their SCHIP annual reports by June 1, 2003. The
remaining state, Tennessee, was not required to submit an annual report
because there was no one enrolled in its SCHIP program.

18Of the 22 states that directly demonstrated changes in the uninsured
population of children, 12 states used CPS data and 10 states used state
survey data.

19Although the CPS asks respondents if they had health insurance coverage
within the past year, the question is asked at a specific point in time
and may result in respondents answering incorrectly. For example, those
who had health insurance at some time during the year, but who are
uninsured at the time of the survey, may mistakenly answer the question
with their current uninsured status, which can lead to an overestimate of
the uninsurance rate.

In addition to data source problems, the OIG noted that some states use
changes in SCHIP enrollment to demonstrate progress in meeting this
objective. However, we agree with the OIG that increases in SCHIP
enrollment are not a valid measure of reductions in the number of
low-income, uninsured children. For example, an increase in SCHIP
enrollment can be the result of children moving from private health
insurance coverage to public insurance under SCHIP. In addition, declines
in the economy and increased unemployment can lead to some children losing
their private health insurance coverage and enrolling in SCHIP, and others
becoming uninsured because they are ineligible for SCHIP.

The OIG Suggested CMS Assist States in Future

Efforts to Estimate Uninsured Children

In its most recent report, the OIG recommended, and we agree, that CMS
should continue to work with states to determine whether ongoing CPS
sample size improvements have alleviated concerns about limitations in the
CPS data. In 1999, the Congress appropriated $10 million annually for the
Census Bureau for fiscal year 2000 and subsequent fiscal years to improve
the reliability of CPS data for estimating the uninsured population of
low-income children. Specifically, in response to concerns about the
reliability of state-level estimates, the Census Bureau increased the
survey sample size for each state, which may improve the accuracy of CPS
estimates of low-income, uninsured children.20 Although these improved
data were available in March 2002, not all states used these data in their
fiscal year 2002 SCHIP annual reports. Of the 12 states that used CPS data
to determine their progress in reducing the number of low-income,
uninsured children, only 4 used the March 2002 data in their reports. The
remaining 8 states relied on data from prior years. The OIG did not
explore the reasons why these 8 states did not incorporate the March 2002
data in their reports.

Further, CPS data are easily accessible and are available at no cost.
Therefore, absent state submission of data measuring changes in
low-income, uninsurance rates through their SCHIP annual reports, the OIG
officials suggested, and we concur, that CMS could itself measure such
reductions by completing its own analysis of CPS data.

Agency Comments

We received comments on a draft of this report from the HHS-OIG (see the
enclosure). In commenting on a draft of this report, the OIG did not
comment on our findings, but the OIG did provide technical comments, which
we incorporated as appropriate.

20When reporting uninsurance rates, the Census Bureau reports 3-year
averages. Therefore, at least 4 years of data will need to be collected to
measure the full impact of the expanded sample. The 4 years of data will
allow for a comparison of the change in the rate of low-income, uninsured
children from two consecutive 3-year averages.

                                   - - - - -

We are sending a copy of this report to the Inspector General of HHS and
other interested parties. In addition, the report is also available at no
charge on GAO's Web site at http://www.gao.gov .

If you or your staffs have questions about this report, please contact me
at (312) 220-7600 or [email protected] . Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. Susan Anthony, Assistant Director; Kevin Milne; Dae
Park; and Sari B. Shuman made key contributions to this report.

Leslie G. Aronovitz

Director, Health Care

Enclosure

List of Committees

The Honorable Arlen Specter

Chairman

The Honorable Tom Harkin

Ranking Minority Member

Subcommittee on Labor, Health and Human Services,

Education, and Related Agencies

Committee on Appropriations

United States Senate

The Honorable Charles E. Grassley

Chairman

The Honorable Max Baucus

Ranking Minority Member

Committee on Finance

United States Senate

The Honorable Ralph Regula

Chairman

The Honorable David R. Obey

Ranking Minority Member

Subcommittee on Labor, Health and Human Services,

Education, and Related Agencies

Committee on Appropriations

House of Representatives

The Honorable Joe Barton

Chairman

The Honorable John D. Dingell

Ranking Minority Member

Committee on Energy and Commerce

House of Representatives

           Comments from the Department of Health and Human Services

(290512)

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