Chapter 6, Part III: Medicaid, Family Planning and a “Health Care Home”

“The traditional health insurance industry will ‘disappear’–Medicaid, the tax-supported insurance program for the poor would merge into the main health care system–[Ira] MagazinerÂ? said.” [1]

“The key elements of the Missouri plan would: –allow people who now make too much money to qualify for Medicaid to buy into the system, essentially turning Medicaid into a state insurance plan.” [2]

“Each school will keep health records for each student and will ‘case manage’ each student, not just those who are Medicaid eligible.” [3]

A

t least 16 states: Arizona, California, Delaware, Georgia, Hawaii, Maine, Maryland, Minnesota, Missouri, New Hampshire, New York, Vermont, Virginia, Washington, West Virginia, and Wisconsin, have taken advantage of congressional waivers.Â? In 1989, OBRAÂ? (Omnibus Budget and Reconciliation ActÂ? lifted MedicaidÂ? income eligibilityÂ? requirements (for)–youths aged 11-20.”[4]

Missouri’s Committee on Legislative Research Oversight Division wrote the Performance Audit: Schools Becoming Medicaid� Providers.� It explains that a component of OBRA� “outlined new and increased goals for the number of Early Periodic Screening Diagnosis and Treatment (EPSDT) screenings per year.� States are expected to adhere to these new goals within a particular time frame, or risk having their Medicaid funding capped.”

In some cases, such as I’ve found in researching the issue of school/community-linked services� and school Medicaid, the earlier version of some government documents are more obvious about their intent and purpose.� As debate, concern, and objections are raised, the document is reworded to delete the “troubling” wording but done in such a way so as not to change the original document’s intent and purpose.� Citizens seem to be kind of like the frogs that will jump out of a pan of boiling water, but if you put them in water that is tolerable, and gradually raise the temperature, they will boil to death without attempting to jump out.

Such is the case with the family planningÂ? component of the school Medicaid Agreement.Â? The 1994 version of the Agreement specifically stated, “prenatal care services–this activity includes the provision of outreach coordination and preventionÂ? services–” among those activities the school agreed to provide.Â? The 1995 version of the Agreement no longer lists this activity.Â? However itÂ? DOES state that the school agrees to coordinate–“referralÂ? to ANY needed services” as well as “arrange and coordinate prenatal, post-partum, and newborn medical services, making referrals to providers of targeted prenatal case management.”Â? State documents define “prenatal care services” to include “coordinating prepregnancy risk preventionÂ? activities.”Â? The only prepregnancy risk prevention activities I know of are abstinenceÂ? and contraception, and Medicaid doesn’t reimburse for abstinence. (See the chapter titled “Medicaid Questions and Answers.”)

A federal Medicaid chart from the United States Department of Health and Human Services� titled Medicaid Services State by State says that EVERY Medicaid recipient in the country who receives federally-supported financial assistance must receive, at least, the ten� following services:� inpatient hospital services, outpatient hospital services, rural health clinic services, other laboratory and x-ray services, nurse practitioners’� services, nursing facility services, and home health services for individuals age 21 and older, early and periodic screening, diagnosis, and treatment (EPSDT) for individuals under age 21, family planning� services and supplies, physicians’ services, medical and surgical services of a dentist, and nurse-midwife services.[5]� Each state may choose additional health services to provide under Medicaid.

Vision, hearing, and scoliosis screenings are included in the Early, Periodic Screening and Diagnostic Tests (EPSDT) and have traditionally been provided by school nurses who already receive a salary.Â? The EPSDT, also called Healthy Children and YouthÂ? (HCY reimbursable program for children from aged birth to age 21.Â? The Medicaid

� Manual states that the EPSDT program includes “prenatal care” which is defined to include “pre-pregnancy risk education activities and family planning.” [6]� Missouri’s Medicaid program has added reimbursement for Norplant� due to the lobbying efforts of Judith Widdicombe, foundress of Missouri’s largest abortion� clinic and director of Health Policy Institute.[7]� Health Policy Institute was a major player in the formation of Missouri’s universal health care reform legislation and policies.

Schools may enter into a Medicaid� Interagency Agreement� with the state Department of Social Services.� The Interagency Agreement “does not vary from school to school.� A school does not write their own agreement.� Schools may not necessarily provide services, but will make arrangements for linking the student to an appropriate Medicaid provider for the service.”[8]

“The program in non-publicÂ? schools will be operated in much the same manner as the program described in the administrative case managementÂ? manual …”[9]

“Schools participate in Medicaid through three major options:

1. Administrative Case Management� which centers on the process of identification of children with health care needs, making and following up on referrals, and completing the loop of identifica­tion-examination-diagnosis-treatment.� Department of Social Services, Division of Medical Services� (DMS� processes the invoices for the program.� School districts submit invoices quarterly, billing is based on percentage of staff time spent, percentage of Medicaid eligible students, and an applicable percentage of 50% or 75%, depending upon whether the administrative function was performed by a skilled or a non-skilled employee.

2. Direct Service can be provided through the EPSDT� (HCY) pro­gram.� Occupational, physical and speech therapies, as well as psychological counseling� and social worker services, are the treatment categories for which reimbursement can be sought.� Services must be medically necessary.� To process payment of claims for direct service, DMS contracts with a fiscal agent, GTE� Data� Services.� Once a therapist has enrolled and has been approved by DMS as a Medicaid provider, the therapist/provider receives a packet of various billing forms from GTE Data� Services.� GTE Data Services processes all Medicaid claims for various programs.� The therapy services provided in the school districts comprise less than one percent of the total Medicaid claims processed by GTE Data� Services.

3. Primary Care relates to a clinic located on-site at the school.� As of this audit, only one school district, Independence [MO], has such a clinic.”[10]

Schools, hospitals, health care providers, etc. who are Medicaid providers, may choose not to provide FAMILY PLANNING SERVICES if it violates their conscience.� However, they ARE OBLIGATED to provide REFERRALS to Medicaid recipients for ALL services for which the recipient is eligible, INCLUDING FAMILY PLANNING SERVICES AND SUPPLIES, even if providing referrals� also violates their con­science (per this author’s conversation with the U.S. Department of Health and Human Services� regarding Catholic� hospitals and others not wishing to provide Medicaid family planning services and/or referrals for reasons of conscience and morality).

This policy could be referred to as the “Pontius Pilate Syndrome” which says in effect that, “I wash my hands of the affair.� I haven’t, don’t, and would never provide family planning� services or supplies.� HOWEVER, in exchange for Medicaid dollars, I WILL REFER you to a Medicaid provider who WILL provide family planning services and supplies, who then ALSO collects Medicaid reimbursement.”� This is an undue tax burden!

Medicaid providers such as Catholic� institutions should choose NOT to be Medicaid providers, and should choose not to allow those working for the state in their institutions to provide contraceptive services and/or referrals� used for population control� purposes, based on grounds of morality, conscience, and health.� See the chapter titled “Is Family Planning ‘User-Friendly’?”

Father Dennis Brodeur, stewardship vice president for the Sister of St. Mary Health Care System in St. Louis, “discussed government Medicaid� contracts as a special problem for Catholic� hospitals because they involve care of the poor.� Hospitals who enter into these contracts must agree to provide contraceptive services and in certain cases abortions, he said.� Since Catholic hospitals do not perform these procedures, administrators of the Catholic facilities must think through the way this will be handled to minimize cooperation with immoral actions.� For some, any arrangement may be viewed as ‘cause for scandal’ and present a problem for the local bishop.� Father Brodeur said physicians and others working in Catholic hospitals sign contracts agreeing to abide by the ‘Ethical and Religious Directives’ issued by the National Conference of Catholic Bishops.� Courts had ruled these contracts could not be used to control what physicians did at other locations.”[11]

The Medicaid Interagency AgreementÂ? between schools and the Missouri Department of Social ServicesÂ? also includes locating a “health care home” for every child in the district.Â? A “health care home” is defined as, “a primary care provider who manages a coordinated, comprehensive, continuous health care program to address the child’s primary health needs.Â? The health care home should provide or make arrangements for after hours care, and coordinate the child’s specialty needs.Â? The health care home should follow the screening periodicity schedule and perform interperiodic screens when medically necessary.”[12],[13]Â? “A health care home is a primary care provider such as a private physician or medical clinic.Â? At this time there is no computerÂ? program developed by the government for statewide use among schools and health care providers to trackÂ? children’s screenings, services, and referrals.Â? However, individual schools and health care providers have developed their own computerÂ? programs to track this dataÂ? or are utilizing commercial computer programs–Each school will keep records for each student and will ‘case manage’ each student, not just those who are Medicaid eligible (emphasis added).Â? As students are linked to a health care homeÂ? and referrals for services are made, the school will provide that link to the medical community.Â? That information would be kept in the school health records as well as in the records of the ‘health care home’.”[14]

Hasn’t this traditionally been the private responsibility of parents?� The government need not become a surrogate parent.

Pages 3-6 of the Medicaid Interagency AgreementÂ? lists activities the school district agrees to provide as an extension of the Department of Social Services.Â? These activities are referred to as Administrative Case ManagementÂ? or ACM.Â? As explained earlier, the agreement is between the school/district and the state Department of Social Services, Division of Medical Services.Â? The following are additional services the Interagency Agreement lists:

1. Providing EPSDT� Administrative Case Management� as an instrument for the Department of Social Services, Division of Medical Services� to aid in assuring the availability, accessibility, and coordination of required health care resources to Medicaid eligible children and their families residing within the district’s boundaries.� EPSDT Administrative Case Management consists of:

a. Assisting children and families to establish MedicaidÂ? eligibilityÂ? by making referralsÂ? to the Division of Family ServicesÂ? for eligibility determination, assisting the applicant in the completion of the Medicaid application forms, collecting information, and assisting in reporting any required changes affecting eligibility.

b. Outreach Activities:

(1) informing foster care providers of all Title IV-E eligible children enrolled in DESE [Department of Elementary and Secondary Education] operated programs of the HCY/EPSDTÂ? program.

(2) informing Medicaid eligible students who are pregnant or who are parents and attending DESE operated programs about the availability of HCY/EPSDTÂ? services for children under the age of 21, and

(3) Outreach activities directed toward providers, recruiting them to become Medicaid providers, and to accept Medicaid referrals.

c. Coordination of HCY/EPSDTÂ? Screens and Evaluations:

Assistance will be provided to eligible children and their families in establishing a medical care home–The health care homeÂ? should provide or make arrangements for after-hours care, and coordinate a child’s specialty needs.Â? Coordination activities include, but are not limited to:

(1) making referralsÂ? and providing related activities for EPSDT/HCY screens–screens include comprehensive healthÂ? and development, mental health, vision, hearing and dental screens.

(2) making referrals� and providing related activities for evaluations that may be required as a result of a condition identified during the child’s screen.

d. Case Planning and Coordination:

This activity includes assistance to the client and the family in developing and carrying out a case or service plan.Â? Activities include, but are not limited to:

(1) identifying and arranging for medically necessary services to correct or ameliorate conditions identified in the child’s Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP)

(2) identifying and providing assistance for medically necessary and educationally relevant services required as the result of any regular, interperiodic, or partial EPSDT/HCY screen.

(3) developing and coordinating the meetings of any interdisciplinary teamsÂ? that may be able to assist in the development and periodic review of the case plan, (IEP or ISFP)[sic]

(4) coordinating the closure of the case, � to any needed services, and realignment of the case plan (IEP� or ISFP)[sic] (“Any needed services” may include family planning.� See the chapter titled “Medicaid Questions and Answers.”)

(5) assisting children and families in accessing immunizationÂ? services and scheduling appointments.

(6) arranging and coordinating prenatal, post-partum, and newborn medical services, making referralsÂ? to providers of targeted prenatal case management.

“Examples of prenatal care services� are given on page 39 of the Medicaid EPSDT� Administrative Case Management� Manual draft.� In this instance, prevention� refers to coordinating pre-pregnancy risk prevention activities.”[15]

“Just as it can provide enhanced services for at-risk� infants, EPSDT� can link at-risk adolescents to pre-pregnancy risk education, family planning, pregnancy testing, and prenatal care.”[16]

In English, this means that schools agree to link adolescents to health care providers and schedule transportation� arrangements to obtain prevention� services; i.e., family planning� and contraception.� The County Health Department, which is a Medicaid provider, has a Teen Clinic� which provides contraceptives� to minors� without parental consent.� Schools which state they work ONLY with parents, may be providing parents with referrals� to be passed on to their minor children.� See Healthy Missourians 2000� for information regarding the state’s use of schools to implement and meet government population control� goals.

The agreement continues with:

“(7) arranging and coordination dietary counseling� or medical services for children with medical needs including, but not limited to, gross obesity, diabetes, anorexia, or bulimia, and

(8) arranging for and coordinating transportationÂ? for children and families to obtain medical screenings and services.

e. Anticipatory guidance to caretakers relating to specific medical needs of a child.”� (Medicaid forms provided in the Case Management Billing Instructions manual� states that anticipatory guidance� includes “family planning� services, and contraceptives!”)

The state document titled Case Management Billing Instructions� includes various Missouri Medicaid Bulletins.� Attachments dated 7/93 contain the Medicaid� Healthy Children and Youth Screening forms for children ages newborn-2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 3-4 years, 5-6 years, 7-10 years, 11-14 years, 16 years, 18 years and 20 years of age.� Each form for children aged birth through age 20 has numerous categories including “unclothed physical exam,” LAB/Immunizations, and “anticipatory guidance.”� The anticipatory guidance section of the form for newborns-2 weeks includes “family planning.”� The form for 24 months includes “masturbation” under anticipatory guidance.� Beginning with the form for 7-10 year olds, and the forms for every age group thereafter through age 20, the anticipatory guidance section includes “values, sex education, family planning SERVICES, contraception, STDs suicide, firearms/homicide,” etc.� Beginning with the form for 11-14 year olds, the Lab/Immunization portion of the form includes “PAP if sexually active.”� At all ages the unclothed physical exam� includes examination of “external genitals”[17] (emphasis added).� Many aspects of family life are included in these forms.

The 1994 version of the Medicaid Manual included health education that was deleted in the 1995 version.Â? Health education included child care and development, safety, accident and disease preventionÂ? (read condoms, safe sex, and contraceptives), and healthy lifestyles and practices (read abstinenceÂ? is best but if your lifestyle includes sex, be sure to use condoms and contraceptives.)

The 1994 and 1995 versions of the MedicaidÂ? Interagency AgreementÂ? between the state and school district continue with:

2. Account for the activities of staff providing EPSDTÂ? Case Management.Â? Develop and submit time study methodologyÂ? with initial invoice.

3. Provide as requested by the Division of Medical ServicesÂ? the information necessary to request federal fundsÂ? available under the state Medicaid match rates.

4. Maintain the confidentialityÂ? of client records and eligibilityÂ? information received from DSS (Division of Social Services) and use that information only in the administrative, technical assistance, and coordination.Â? [Editorial note: agencies participating through an interdisciplinary teamÂ? may have access to these records.]

5. Certify to DSS the provisions of the non-federal share for HCY Administrative Case Management� via completion of DMS “Certification of General Revenue” form.

6. Accept responsibility for disallowances and incur the penalties of same resulting from the activities associated with this agreement.Â? Return to DSS any federal fundsÂ? which are deferred and/or ultimately disallowed arising from the administrative claims submitted by DSSÂ? behalf of the [school district.]

7. Consult with the Division of Medical ServicesÂ? [DMS] on issues arising out of this agreement.

8. Conduct all activities recognizing the authority of the state MedicaidÂ? agency in the administration of state Medicaid Plan on issues, policies, rules, and regulations on program matters.

9. Maintain all necessary information for a minimum of five (5) years to support the claims and provide HCFA [Health Care Financing Administration i.e. Region VIIÂ? office] any necessary dataÂ? for auditing purposes.

10. Submit claims on a quarterly basis.[18]

Page three of the Medicaid Interagency Agreement� states the school district “will develop and submit within 90 days of the signing of this agreement, for approval by DMS, an internal process for measuring the progress of the district toward attainment of the ACM Program goals.”

While page two of the Interagency Agreement� lists some ACM goals under “Mutual Objectives,” there are two more documents of� detailed instruction from the Division of Medical Services.� They are called “Administrative Case Management� Task Force Goals/ Outcomes” and the “ACM Program Evaluation Plan” which also includes a “Medicaid Suggested Program Evaluation Plan Format” on the back.� These are “guidelines districts may use to measure progress toward goals.� Schools have some flexibility in establishing an internal process for measuring progress.”[19]

The ACM Program Evaluation PlanÂ? states that “Each school district that participates in the MedicaidÂ? Administrative Case ManagementÂ? Program must submit a program evaluation plan (PEP) to the Division of Medical ServicesÂ? within 90 days of signing an Interagency Agreement.Â? This plan should provide district specific–goals and measurable outcomes–This plan is important to the Division of Medical Services in that the Division will use its content to determine if the Interagency Agreement should be continued or renewed.

“The purpose of the evaluation is to allow DMS to evaluate your district’s program development, successes, and future direction–It is important for districts to realize that even though DMS has required that specific goals and related outcomesÂ? be included in the report, each district should present goals specific to their area:

“For example, your district may have a high teenage pregnancy rate.� By assessing your district’s areas of need, you can identify ways to address these problems, develop goals, and establish outcomes� you wish to achieve.� Your district’s internal environment should also be included.� This portion should measure how the ACM program has been implemented and developed within your district.� Is the entire staff aware of the program?� Who is involved?� Do staff know who to refer children to for assistance? � Next, your district’s external environment should be included in the PEP.� This portion should include your community outreach efforts and how the district interacts with the providers in the area.� Specific barriers� to care should be addressed, such as transportation� and lack of providers.� A section on health capacity efforts should be included next and the summary section should include the district’s overall impression of success.

“Because the PEP will be updated and submitted annually, subsequent PEPs will look different than the initial plan.� Subsequent PEPs should include a description of how your district has accomplished its goals established in the previous PEP and the identification of any additional goals.� The Division of Medical Services� will be evaluating the foundation, overall development and success of the ACM program and the health capacity building efforts of the district”[20] (emphasis added).� The Health Capacity Building section of the Medicaid� Suggested Program Evaluation Plan Format includes “Report[ing) health capacity building efforts. � Include a plan to reach all the children in your district (public, parochial, private, home-schooled)”[21] (emphasis added). The Administrative Case Management� Task Force Goals/Outcomes consists of four pages which provides schools with a list of goals to meet, and activities through which to meet them. Page two lists a goal of “Establish(ing) a medical care home and link(ing) (the) child to a primary care provider for those Medicaid eligible children receiving EPSDT/HCY service coordination activities.”� The activities listed to accomplish this goal include:� “Establish partnerships� with community groups, both medical and social, Increase collaborative relationships with private and public health agencies, ESTABLISH A SCHOOL-BASED HEALTH CLINIC” (emphasis added).

Page four of this document lists a goal of “Encourag(ing) a healthier lifestyle for children by teaching them to become their own case manager.”� Among the activities are:� “Incorporate health education for preschool� through grade 12 into school’s curriculum, Provide reproductive information to adolescent students.� Record data� regarding teen pregnancy� and outcome. Get students actively involved with the process of finding health care services.”� The outcomes� listed include:� “Decline in teenage pregnancies, and (i)ncreased number/percentage of children receiving preventive health care”[22] (emphasis added).

Does this include keeping records about the number of teens using contraception, the number of pregnancies, miscarriages, abortions, live births, whether or not the teen gave birth to a low birth weight baby, and whether or not the teen went on to college?Â? IS THERE ANY DOUBT SCHOOLS ARE BEING RESTRUCTUREDÂ? TO IMPLEMENT GOVERNMENT HEALTH GOALS THAT INCLUDE FAMILY PLANNING FOR MINORS AND POPULATION CONTROL?

For those who have difficulty reading between the lines, this means implementing a SIECUS-style comprehensive sexuality education program from preschool� through 12th grade.� It means students are to be taught about contraceptives� and where in the community they can get them.� This may include the health department’s Teen Clinic� which provides contraceptives to minors� without parental consent.

In at least one district, documented proof was provided to school board members and administrators in an effort to inform them of what was taking place.� All except two failed to see “the pill” which was hidden in the “applesauce.”� See also the chapter titled “Church Convinces Public School District To Become A Medicaid� Provider.”

The following is a letter sent to school board members:

“Dear (Board President),

Enclosed is a copy of two responses (to one letter and one telephone call) regarding MedicaidÂ? for distribution to fellow board members.

1. The first is a reply from the U.S. Department of Health & Human Services, stating, ‘The answer to [my] question concerning school district [Medicaid] agreements with the Missouri Department of Social Services� is yes.’�

Â? Â? Â? A copy of my original letter is attached in which I asked whether it is necessary for a school district which enters into a Medicaid Interagency AgreementÂ? to provide required Medicaid services, such as family planningÂ? services and supplies (or referralsÂ? for Medicaid services they choose not to provide).

2. The August 31, 1995 letter from the Department of Social ServicesÂ? Division of Medical ServicesÂ? is in response to a telephone call, therefore no letter of request is enclosed.

Â? Â? Â? The enclosure from the DSS includes pages from the 1995 Medicare and Medicaid GuideÂ? regarding Family Planning Services.Â? It states that ‘State Medicaid programs must offer family planningÂ? services and supplies directly, or under arrangements with others, to individuals of childbearing age (including minorsÂ? who can be considered to be sexually active) who desire such services and supplies …’

� � � The August 17, 1995 letter from the Missouri Department of Social Services, Division of Medical Services� (page two, number 6) explains that determination of who is considered to be sexually active� takes place when an individual visits the clinic as part of the individual student’s evaluation and assessment� during an exam.

� � � Page 2 of the “Administrative Case Management� Task Force Goals/Outcomes” from DSS lists ‘establish[ing] a school-based health clinic’ as an activity associated with establishing a medical care home.� The school-based clinic is to examine, evaluate, and assess students, determining� whether or not they are sexually active.� The August 17th letter from DSS then explains that ‘The findings of the exam may result in counseling� and/or treatment (i.e. referrals� and/or services). � Another activity listed on page 4 of the ‘Administrative Case Management Task/Force Goals/Outcomes” is to ‘encourage a healthier lifestyle’ through activities such as ‘provid[ing] reproductive information to adolescent students.’� The listed outcome from this activity is ‘increased number/percentage of children receiving preventive health care.’� Since this outcome is in relation to ‘reproductive information,’ it is obvious that preventive health care means contraception.

Â? Â? Â? This is how the school district will comply with providing services and/or referrals for the basic required Medicaid service ofÂ? family planningÂ? services and supplies to individuals ofÂ? childbearing age including minorsÂ? who can be considered sexually activeÂ? as mandatedÂ? by the U.S. Department of Health and Human Services, on which the state plan is based.

Â? Â? Â? This would indicate that information provided to the district by itsÂ? legal source(s) and the state may not be consistent with the Supremacy Clause as indicated on page 6273 of the Medicare and MedicaidÂ? Guide.

� � � If the board chooses to believe these documents, it may wish to reconsider approval for our district’s participation in the Interagency Medicaid Agreement.

Thank you,”

Missouri is located in Region VII.� The U.S. Department of Health and Human Services’� Region VII� office may be contacted via:
Mr. Richard Brummel, Director
Region VII Medicaid room 227
Health Care Financing Administration
Federal Office Building
601 East 12th Street
KansasÂ? City, Missouri 64106

In an effort to be credible and accurate, it is important to document information to be shared with others.Â? One way to do that is to communicate in writing.


12 REASONS NOT TO BE A MEDICAID PROVIDER:

1. Parents ALREADY pay:

a. Health insurance premiums for private insurance.

b. Health care benefits taken from salary through employment.

c. State taxesÂ? = school foundation formulaÂ? = school support staff.

d. Federal taxes to provide health care for those in need.

2. Undue tax burden:

a. Creative financingÂ? = school foundation formulaÂ? used to draw down matching MedicaidÂ? fundsÂ? for schools.Â? This RAISES TAXES.

b. Schools collect Medicaid reimbursement for providing referrals, the service provider ALSO collects Medicaid reimbursement.

c. Medicaid funds are used for “each school (to) keep health records for each student and will ‘case manage’ each student, not just those who are Medicaid eligible.”

3. No need for schools to provide immunizations since students are not allowed to START school unless immunizations are current.

4. Public health care for those in need is readily accessible.

5. Medicaid funds may NOT be used for educational purposes.

6. Students too sick to learn should not come to school.

7. It is not the government’s responsibility to do for others what they should do for themselves, to absorb the responsibility of parents, nor to be a surrogate parent.

8. Schools should not be used to implement the government’s universal health care plan–especially family planningÂ? and population controlÂ? goals.Â? (See Healthy Missourians 2000).

9.Â? Schools should not be used to access children for contraceptive referrals (See Teen ClinicÂ? brochure).

10. Socialized medicine undermines free enterprise.

11. Encourages dependency on government programs/funds

12. “A family of four could make $28,700 and be eligible.” (Quote taken from the St. Louis Post Dispatch, June 1993.)


Â?

If Medicaid is

for the poor,

then why areÂ? Â? Â? Â? Â? Â? Â?

Â? Â? schools

collecting it?

Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? Â? -Â? Â? Marie Smith

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