Ridge Medicaid plan eliminates "spend-down" for many PWAS
State holds hearings on HealthChoices proposal
Little action follows NAPWA "summit"
Report: change federal AIDS research policy
Parents halt use of Magic Johnson AIDS book
Critical Path Prevention Page expands
Hepatitis B vaccination low among young gays
More pregnant women determining HIV status
Senate in favor of repealing HIV discharges
NGA welfare, Medicaid proposal revised
Crixivan, third in the most powerful class of drugs developed to combat HIV and AIDS, will compete against Abbott Laboratories' Norvir and Hoffmann-La Roche Inc.'s Invirase.
The FDA approved Norvir two weeks ago and Invirase in December. The Merck and Abbott drugs are considered more potent than Invirase because they are more easily absorbed and used by the body.
"The Clinton Administration is committed to the fight against AIDS, including the President's ultimate goal of a cure for this disease," said HHS Secretary Donna E. Shalala. "Rapid FDA action on important new drugs is one important part in reaching the long-term goal."
"The pharmaceutical companies that have led the development of protease inhibitors deserve a lot of credit," said Commissioner of Food and Drugs David A. Kessler, M.D. "It's been an historic period in the fight against AIDS. This accelerated approval -- a new record for the agency -- is further confirmation of our commitment in the fight."
Protease inhibitors work by blocking the protease enzyme that infected cells use late in the reproductive life cycle --essentially crippling the virus. The other five drugs approved for HIV and AIDS are nucleoside analogues, which work by interrupting early reproduction.
The approval of the protease drugs is based on analyses of surrogate endpoints in short studies, of up to 24 weeks in duration. At present, there are no results from controlled clinical trials evaluating the effect of therapy with Crixivan on clinical progression of HIV infection, such as survival or the incidence of opportunistic infections.
Crixivan can be taken in combination with other anti-HIV therapies or alone. Crixivan was reviewed by FDA in 42 days; the New Drug Application for Crixivan was submitted by Merck on Jan. 31. Crixivan will be available by March 25, initially through a temporary special distribution system.
"Crixivan embodies our commitment to AIDS research and a decade of tireless work by scientists and others at Merck to discover and develop an effective AIDS medication," said Edward Scolnick, M.D., President of Merck Research Laboratories. "We believe protease inhibitors provide a significant advance in HIV therapy."
Crixivan is the first drug to emerge from Merck's AIDS research program, which began in 1986.
Clinical studies with Crixivan
In clinical trials, treatment with Crixivan caused substantial improvements in the surrogate markers for HIV disease -- CD4 cell counts and viral load, the indicators of disease status in people with HIV, on which the indication for Crixivan is based. Crixivan was also generally well tolerated. It produced increases in CD4 cell counts, an important measure of immune system function, and significant reductions in viral load, or levels of HIV in the bloodstream. However, the clinical relevance of changes in viral load induced by Crixivan has not been established. As noted above, Crixivan's effect on the development of opportunistic infections and survival has not yet been shown, although such studies are under way.
Crixivan has been studied in more than 2,000 people in 14 studies to date, including several ongoing studies. One recent multicenter trial (035) studied Crixivan alone and in combination with two other antiviral drugs, zidovudine and lamivudine (Retrovir (AZT) and Epivir (3TC)) in patients who had previously been treated with zidovudine. At 24 weeks in this "triple-therapy" trial, mean decreases observed in viral load were 1.77 log10(A) (98 percent) in 22 patients taking the triple combination of Crixivan with zidovudine and lamivudine, 0.95 log10(A) (89 percent) in 20 patients taking Crixivan alone, and 0.67 log10(A) (78 percent) in 19 patients taking zidovudine and lamivudine. The clinical relevance of changes in viral load effected by Crixivan has not been established.
At 24 weeks, 20 of 22 patients (91 percent) taking Crixivan with zidovudine and lamivudine had HIV levels in their blood (viral RNA copies) below the limit of detection of the test used (500 copies/mL). In the same study, 7 of 20 patients (35 percent) taking Crixivan alone, and 0 of 19 (none) of the patients taking zidovudine and lamivudine had HIV levels below the limit of detection of the test used (500 copies/mL). Patients receiving the triple combination and patients taking Crixivan alone had mean increases at 24 weeks of 100 cells/mm3(B), compared to mean increases of 33 cells/mm3(B) in patients taking zidovudine and lamivudine.
"The critical goal of therapy should be to reduce viral replication as much as possible, for as long as possible, and in as many people as possible, using the most potent and tolerable medications," said Roy Gulick, M.D., of The New York University School of Medicine, the study's lead investigator. "Although further study is needed, the ability of Crixivan to dramatically reduce viral levels demonstrates its potential usefulness in this approach and may indicate a new direction in the management of HIV disease."
Ridge Medicaid plan eliminates "spend-down" for many PWAS
The Medicaid "reform" plan speeding through the state legislature will eliminate the option for some poor and disabled people with AIDS to qualify for Medical Assistance coverage when their medical expenses become overwhelming.
Under the current Medicaid regulations, low-income people whose medical expenses bring their monthly incomes down to about $580 are able to qualify for Medicaid reimbursement for medical services received during that month. This "spend-down" provision has made it possible for people with AIDS who are still working for very low incomes, or who are receiving small disability pensions from private companies, to obtain health insurance coverage during periods when their medical expenses are higher.
The Medicaid legislation, expected to be passed by the full Pennsylvania Senate on Monday after less than a week of consideration, has been proposed by Governor Ridge as part of a massive withdrawal of state financial support for long-standing medical and cash assistance programs for the poor.
Under the Ridge plan, over 260,000 Pennsylvanians will lose all health insurance coverage.
The only people exempted from the elimination of the "spend-down" provision will be people who are receiving Social Security Disability (SSD) payments, and adults with children in the Aid to Families with Dependent Children program. SSI recipients, who receive a monthly cash payment of about $500 per month, are automatically eligible for Medicaid because their incomes fall under the maximum allowed.
Because city and state epidemiologists do not report income or health insurance information for people who have AIDS, it is unknown how many people with AIDS will be affected by the new provision. We The People Living with AIDS/HIV of the Delaware Valley, the nation's largest coalition of low-income people with HIV and AIDS, said it believes that at least 10% of its 4,000 members are "working poor" or living on private disability plans, and that each of them would lose all access to health insurance coverage if the Ridge plan is adopted.
"This is simply another signal from Tom Ridge that people with AIDS do not deserve to live," said Joe Cronauer, executive director of We The People. "And now he's punishing the very people he says he's trying to protect -- those who are working and those who have worked and built up their private pension benefits. The very 'middle class' taxpayer whose taxes he's claiming to save are the ones who will be forced to go without basic health insurance coverage at the time in their lives when they need it most -- and the rest of the taxpayers will have to pay the bill in higher insurance premiums, as hospitals and doctors shift their losses from Medicaid to private citizens and employers."
Ridge Administration officials have sought to downplay attention to the "spend-down" issue as they push their welfare changes through the Republican-controlled legislature without debate. Many Democrats in the legislature have complained that they are not being informed about the real nature of the Ridge plan, nor are they being given sufficient notice of hearings and votes on the plan by the GOP leadership in the state House and Senate.
Advocates believe that the Ridge plan will easily pass the state Senate next week, and that it will only be stopped in the House of Representatives if the entire Democratic delegation and a few Republican legislators vote against it.
Ridge intends his plan to be implemented beginning with the new fiscal year on July 1st.
State holds hearings on HealthChoices proposal
State welfare officials held a public hearing this week on the draft version of the "request for proposals" from health maintenance organizations set to replace the state Medical Assistance program beginning this summer.
The proposed new system, called "Health Choices," would eliminate "fee for service" payments to Medicaid health providers and require all Medicaid recipients to join health maintenance organizations.
Most of those testifying at the hearing, or submitting testimony separately, condemned the new plan because it contains few standards for quality of care and encourages insurance companies and providers to deny care in order to enhance their profit margins.
AIDS advocates have been particularly critical of the failure of the plan to require a minimum standard of care for AIDS or guaranteeing that each plan will have sufficiently experienced physicians and health care practitioners.
The new Medicaid managed care plan proposed by Governor Ridge for needy Pennsylvanians "will have a deadly -- and expensive -- impact on people with AIDS and Pennsylvania taxpayers," Joseph Cronauer, executive director of We The People Living with AIDS/HIV.
A similar Medicaid managed care plan in New York has been delayed by New York Governor George Pataki because the participating insurance companies were unable to guarantee a minimum standard of care for AIDS patients. Pataki is spending $2 million on an effort to design a new Medicaid managed care approach which assures an adequate supply of AIDS specialists and which streamlines access to services to avoid the delays and bureaucracy usually associated with HMO plans.
Cronauer said that the "Health Choices" plan is "doomed to fail unless people with AIDS and other chronic diseases are entitled to "opt out" of participation and get care wherever they need it."
Cronauer said that the Ridge plan "is so badly thought-out that it only works to keep people with AIDS sick and keep the cost of their care high -- the exact opposite impact that Governor Ridge says he's looking for.
"It fails to guarantee that Medicaid insurers will have enough infectious disease and other specialists to provide the complex care most people with AIDS need.
"It fails to require that the managed care plans meet the minimum standards of care that will keep people healthy and alive.
"It fails to recognize that the historically cumbersome and time-consuming referral and review process that typifies HMOs can have a deadly impact on people with chronic, complicated conditions involving frequent life-threatening emergencies.
"The Ridge plan ignores the clear history of the AIDS epidemic and fails the simple test of common sense," Cronauer said.
PWA advocate Arnold Jackson, testifying on behalf of the AIDS Law Project of Pennsylvania, told the hearing that "the inescapable reality is that people like me -- people with AIDS and HIV -- cost. It is also the inescapable reality that financial incentives...to contain costs and maximize profits have resulted in a lack of quality care and adequate care for many of us with chronic life-threatening illnesses."
Jackson said that in order for HealthChoices to work in caring for people with HIV/AIDS cost-effectively, it needs to "pay managed care providers what it really costs to take care of us." He said that the plan needs to guarantee a sufficient number of primary care physicians experienced in AIDS care, allow people with HIV/AIDS to choose AIDS specialists as primary care physicians, and guarantee a minimum standard of care monitored by a qualified panel able to keep it updated and cognizant of treatment advances.
Jackson said that the AIDS Law Project would be convening an advisory committee to monitor and address concerns related to AIDS care in the HealthChoices project, and asked the state officials to endorse those efforts.
HIV and mental health consumer advocate Mark Davis, a board member of We The People, told the group that "people living with disabilities need to be hired to monitor and survey consumer satisfaction and coordinate consumer planning, education and technical assistance."
Criticizing Ridge Administration proposals to limit eligibility for Medicaid under the new plan, Davis said that "people are going to have to choose between food and shelter and medication."
"Unless major changes are made to this proposal, Medicaid HMOs will be given incentives to deny care to needy people with chronic and expensive illnesses," Cronauer said. "The result will be that hospitals and physicians will simply shift these costs to employers and taxpayers who have private insurance. As Medicaid costs go down private insurance premiums will skyrocket to take up the slack.
"The Governor's plan might save a couple of dollars in his budget, but it will place an enormous burden on the household budgets of the very people who elected him."
Under the Ridge proposal, the present "fee-for-service" Medicaid system would be eliminated, and all eligible Medicaid recipients would be required to join health maintenance organizations which will receive a monthly per capita payment to provide for their health care needs. Under the proposal, the HMOs would only make money if they keep their costs as low as possible. Unlike a similar plan proposed by former Governor Casey two years ago, profits of the Medicaid HMOs licensed by the state would not be capped or restricted under the Ridge proposal.
"It doesn't take a rocket scientist to see that the only way an HMO will be able to protect it's bottom line is to deny care to people whose care is expensive. That means that they'll have no incentive to have the staff available to provide good care to people with AIDS -- and every incentive not to," Cronauer said.
"The Governor's plan may be called HealthChoices, but it offers no real choice at all," Cronauer said. "For a poor person with AIDS, under the current rules of HealthChoices, the only real choice will be to die more quickly and more painfully."
"It's a known fact that there are already not enough qualified infectious disease physicians to meet the current need for AIDS care, " Cronauer said. "There's simply no way for each managed care company to build the individual capacity to meet all of the medical needs their AIDS clients will have. It is critical that people with AIDS be allowed to opt out of the HealthChoices if the plans cannot guarantee them a humane and responsible level of care."
He continued, "It's also been documented that the lengthy delays and complex bureaucracy of most HMOs already have the impact of making care for people with AIDS more expensive, as people get sicker waiting for appointments and referrals that often come too late, if at all.
"The Governor's proposal only works for people who don't get sick. If you have the bad grace to get sick, especially sick with AIDS, the Governor's plan simply makes it too difficult to get the care you need to stay alive."
Cronauer said that "if Governor Ridge wants a plan that makes sense, he needs to allow people with AIDS and other chronic diseases to get their care wherever it is available at the cheapest cost. Under this plan, no HMO would be required to guarantee that it can provide appropriate care, and many people with AIDS will be forced into HMOs that simply don't have the capacity to help them."
"HealthChoices as currently planned is so poorly conceived that it's doomed to fail," Cronauer said.
Cronauer said that his 4,000-member coalition will "campaign actively and aggressively to make sure that the present HealthChoices proposal will never be implemented. This is a direct attack on our right to life. We cannot allow either the Governor or the Legislature to have any peace if they care so little about our right to life."
Little action follows NAPWA "summit"
After inviting hundreds of people with HIV/AIDS and service providers to a "national AIDS leadership and mobilization summit" in January, the National Association of People with AIDS has failed to act on most of the "action steps" agreed to at the conference.
We The People board members Karen Lyons, Gregory Hardy, Mark Davis and Ted Kirk attended the conference, as did new WTP executive director Joseph Cronauer. They were among only a few of conference participants identifying themselves as living with HIV infection, with most of those participating -- even those living with HIV/AIDS -- representing AIDS service organizations.
According to Davis, NAPWA was, by the end of February, supposed to convene teleconferences among the chairs of five committees organized at the summit to come up with an action strategy with five major objectives:
-- to find a cure for AIDS;
-- to prevent new HIV transmission;
-- to provide for basic needs of people infected with and affected by HIV/AIDS;
-- to protect the human and civil rights of people living with HIV/AIDS;
-- to mount grassroots community organizing efforts.
"Most people at the summit represented large AIDS organizations or the beltway mentality and were far removed from the grassroots," Davis said. "I was proud to be with fellow WTP members who shared real experience living with HIV. We brought the street realities of the HIV/AIDS epidemic to a table that didn't seem to want to hear it."
Davis said that he has made several phone calls to NAPWA headquarters in Washington to find out how the organization was following up on the summit, but that none of the calls have been returned. Late this week, one PWA participant was informed that there was going to be a meeting of the committee chairs in Washington, but because the meeting was only 48 hours later, he was not going to be able to attend.
Because of the expense and difficulty that many PWAs would have in attending meetings in the nation's capital, the summit has agreed that the follow up meetings would be held by teleconference.
"We need national leadership to be more effective locally," Davis said. "How can we respond to this crisis if those we entrust with leadership don't follow up or let us know what's going on? In the absence of that leadership I call on the HIV-positive people in the Philadelphia region to create our own advocacy agenda that is responsive to our needs."
Report: change federal AIDS research policy
U.S. government-sponsored AIDS research needs more scientific oversight and review by outside scientists and a speedier system to award research grant, a government-appointed panel said in a report released this week.
However, the group of 114 scientists and representatives from academia, the drug industry, community organizations, and AIDS advocates rejected the idea for an institute especially for AIDS.
Arnold J. Levine of Princeton University, led the panel, which found "numerous incidents" when the government's process "unfortunately appears to have failed in identification of the most promising research projects." The panel said a better method was needed to track the money the government invests in AIDS research. The panel said research should focus on drug and vaccine development, clinical trials, immunology, and basic research. It also said the Office of AIDS Research, which commissioned the study, should be strengthened.
Most advocates for people living with HIV/AIDS are applauding a report by top scientists that calls for shaking up the federal AIDS research program.
The report calls for major changes in the way the National Institutes of Health has conducted research, drug trials and vaccine development for the $1.4 billion federal AIDS program.
"We are very excited about the report," said Wayne Turner of the Washington chapter of ACT-UP, a national AIDS activist organization. "We have been pushing for a Manhattan Project approach for AIDS and this may be it. "We just wonder what took so long," he said.
Mark Harrington, policy director for the Treatment Action Group, a New York AIDS activist group, said that if Dr. Harold Varmus, the NIH director, supports and implements suggestions in the study, "the American people can be sure that, for the very first time, every dollar spent on AIDS research is being spent on critical research of the very highest quality."
NIH Director Harold Varmus said he "welcomed" the report. "It was clearly time for a review."
"It's kind of astonishing how un-tame (the report) is," said Gary Rose, a spokesman for activists at the AIDS Action Council in Washington. "They gored a lot of oxes in this report."
The report is based on more than a year of fact-gathering by a select group of about 100 scientists. The committee includes two Nobel laureates and many members of the National Academy of Sciences.
The review of the NIH's $1.4 billion AIDS research program was requested at a time of pessimism, or at least a taking stock, of the slow progress in the war against AIDS.
At the time many experts believed that researchers had to go back to very basic science, and the Working Group in its report does stress the importance of basic research to develop better understanding of the complex virus, HIV, which causes AIDS.
Although many facets of AIDS remain perplexing and no cure is imminent, the past year has seen some important advances. Those include a better understanding of how the virus takes hold in the body from the start and the recent approval of several new types of drugs, known as protease inhibitors, that may prolong the lives of people with AIDS.
The NIH has kept an unusually large chunk of research money under its own tight control instead of encouraging ideas from outside investigators, and AIDS research has suffered for this centralization, said the panel's report.
Among the findings by a blue-ribbon committee of scientists:
-- NIH research programs now discourage recruitment of new, young scientists and tends to deflect original and innovative research ideas. The report calls for doubling funds for unsolicited research proposals, a move that an official said could bring "new blood into the field." The report suggested that student loans could be canceled for young postdoctoral scientists who take up AIDS research.
-- Efforts to develop an AIDS vaccine have been underfunded and unsuccessful, although it "is among the highest priorities," the report said. The committee called for a crash program under a new committee controlled by non-government scientists.
-- Some research financed by AIDS funds at NIH actually has little to do with the disease, and some is duplicative and wasteful. And some promising proposals are not funded because evaluators lack expertise. The committee called for restructuring the way research grants are evaluated and approved.
-- Various agencies and departments at the NIH now sponsor more than a dozen clinical trials of HIV drugs and therapies, and the report found "there has been overlap and, in some instances, unnecessary competition between these diverse programs." It called for combining the trials and putting them under the control of the National Institute of Allergy and Infectious Diseases.
-- More research into the human immune system is essential, the report said, noting that much of what is now known comes from research on laboratory mice and may not apply to human beings.
-- NIH currently is funding 16 AIDS research centers, mostly at major university hospitals. The committee report applauded the work done by 16 AIDS research centers, mostly at major universities, and called for funding at each center to be increased to $750,000 to $1.5 million a year, roughly doubling the current allocation.
Parents halt use of Magic Johnson AIDS book
A group of parents of students at Horace Greeley High School in Chappaqua, N.Y., have complained that Magic Johnson's book "What You Can Do to Avoid AIDS" is inappropriate for 14- and 15-year-olds. Last month the school district stopped using the book, which was a part of health classes for four years. The parents took issue with the book's written depictions of oral and anal sex. On Tuesday, the school board ruled to establish a health advisory council to review all materials used in health classes and to let parents allow their children to "opt out" of any instruction they objected to.
Critical Path Prevention Page expands
The section of the World Wide Web page of Critical Path AIDS Project dedicated to issues of HIV prevention has been expanded to include a large variety of sources and links to information throughout the Internet.
Constructed by Chris Bartlett of the SafeGuards Project of the AIDS Information Network, and We The People executive director Joe Cronauer, the web page contains information about HIV prevention needs and methods relevant to the many different constituencies affected by the HIV epidemic, including people of color, men who have sex with men, women, and other population groups.
The page can be accessed on the World Wide Web through http://www.critpath.org.
Hepatitis B vaccination low among young gays
Vaccination against hepatitis B (HBV) virus infection remains low among young men who have sex with men, despite federal recommendations in place since 1982.
According to the U.S. Centers for Disease Control and Prevention, an analysis of blood studies among 400 young gay men conducted in San Francisco and Berkeley indicated low HBV vaccination levels among gay and bisexual men between the ages of 17 and 22.
In the analysis, it was determined that 77% of those participating had not been vaccinated, although 80% of those not vaccinated reported having anal sex or injecting drugs during the preceding six months -- behaviors at high risk of HBV, as well as HIV, transmission.
"Despite the availability of an effective vaccine, the findings in this report suggest that only 3% of young MSM sampled at selected locations in San Francisco and Berkeley during 1992-1993 were adequately vaccinated against hepatitis B," the CDC said. "The results also indicate that most (86%) young MSM who were still at risk for HBV infection were not vaccinated, despite receiving medical services from one or more health-care providers."
"These findings are consistent with previous reports documenting that health-care providers in a variety of settings miss opportunities to vaccinate clients at risk for HBV infection," the report concluded.
More pregnant women determining HIV status
The number of women diagnosed with HIV before they become pregnant or during pregnancy is increasing, according to results from the European Collaborative Study, a study of 1,690 HIV-positive women. The percentage of HIV-positive women found to have HIV before they became pregnant rose from 7 percent in 1984 to 65 percent in 1994.
The study also reported that about 13 percent of the infants born to HIV-positive women who did not know they had the virus until after delivery were breast-fed, compared to 2 percent of those born to women who knew they were HIV-positive before pregnancy.
Senate in favor of repealing HIV discharges
More than half the Senate now favors repealing a law enacted earlier this year forcing military service members with HIV to be discharged, according to the Associated Press.
As of Wednesday, 54 lawmakers had signed on to the repeal effort aimed at a law written by conservative Rep. Robert Dornan, R-Calif. The measure still faces long odds in the House. But the bipartisan support for repeal in the Senate, combined with Clinton administration opposition to Dornan's measure, sets the stage for a legislative fight.
Under the measure, service members tested with HIV, the virus that causes AIDS, are to be discharged within five months. The Pentagon estimates that slightly more than 1,000 members of the armed forces have the virus.
Sens. William Cohen, R-Maine, and Edward Kennedy, D-Mass., leaders of the repeal effort, were expected to introduce their bill this week. Many Senate cosponsors signed on in the past week after Gen. John Shalikashvili, chairman of the Joint Chiefs of Staff, denounced Dornan's measure as unfair.
But only about a third of the 100 Senate seats are up in next fall's election compared with all 435 House seats up for grabs.
"I think it's impossible to win the repeal in the House," Dornan said. "Will congressmen in tougher races than most senators want to give special status to a venereal disease in an election period? ... I don't think so."
According to a list provided by the Human Rights Campaign Fund, a gay rights group working on the repeal effort, 40 Democrats and 14 Republicans in the Senate favor repeal of the HIV discharge law.
NGA welfare, Medicaid proposal revised
In hopes of breathing new life into the stalled overhaul of welfare and Medicaid, the nation's governors fleshed out a proposal to overhaul welfare and Medicaid and submitted it to House and Senate leaders Thursday.
Those leaders promised to convert the proposal into legislation that would be introduced by March 25 and that House Speaker Newt Gingrich said he hoped to have on President Clinton's desk by next month or early in May.
Gingrich applauded the plan, unveiled at the Republican Governors' Association meeting with top congressional GOP leaders, as one that would "instill real values...the values of the work ethic and strengthen the family."
But few details were released of the revisions to an outline unanimously approved by the National Governors' Association in February to help break a budget impasse, which has held up a comprehensive federal budget for 5 1/2 months.
The Clinton administration has adamantly opposed past GOP-backed plans to revise welfare and Medicaid, saying congressional Republicans were seeking to slash funding from programs serving those least able to defend themselves to pay for a long-promised GOP tax cut to benefit mostly the wealthy.
And last month, Health and Human Services Secretary Donna Shalala broke a long silence to oppose the NGA proposal, saying that it failed to guarantee benefits for the poor and sick.
The administration has pushed for a welfare reform bill -- one of his goals since winning the presidency in 1992 -- but has sought a commission to study the contentious question of how to reshape Medicaid to prevent its bankruptcy in the next century.
Michigan Gov. John Engler said the nation's governors would not brook any division, warning, "We didn't spend hours in locked rooms across the country to take half a loaf."
And Senate Finance Committee Chairman William Roth Jr. said any changes in Medicaid, the nation's chief health program for the poor, went hand-in-glove with any plan to revise what most agree is a failed web of federal poverty programs that foster dependence and discourage work.
Medicaid reform is welfare reform. If the president genuinely wants bipartisan welfare reform that will work, his administration cannot separate the two proposals," Roth said.
But Roth said he did not expect to attach welfare or Medicaid proposals to legislation to raise the nation's debt ceiling and prevent a default when that ceiling is reached March 29. Republicans had considered using the debt ceiling to leverage acceptance of its reforms.
Engler said the governors had added language to strengthen a guarantee of coverage in the Medicaid proposal for poor pregnant women, children up to the age of 12, the elderly and disabled.
The administration has worried a previous version of the proposal was too weak and could permit states to cut out large needy populations, such as people infected with HIV, from the program.
The NGA also had sought to consolidate family preservation, child abuse prevention and treatment programs into a single block grant, lower the GOP's work requirements for welfare recipients, and include incentives for states to move recipients off welfare rolls.
"This will be President Clinton's last chance to reform welfare," declared House Ways and Means Chairman William Archer, R-Texas. "Congress has shown a willingness to work in a bipartisan manner to achieve meaningful welfare reform, and that's why we're prepared to give the president a third and final opportunity."
Republicans had favored, but Clinton vetoed, proposals to turn welfare and Medicaid over to the states by converting both to federal block grants that states could spend to suit their needs.
Critics argued that approach lacked the federal rules necessary to ensure that states would adequately provide protection for the poor.
Republicans had initially sought deep cuts in welfare and mandatory spending programs including Medicaid and Medicare as part of its ballyhooed plan for slashing spending and the size of government to balance the budget by 2002 while providing some tax cuts.
An extensive analysis of the National Governors' Association Medicaid proposal is available in the March edition of Alive & Kicking!