Democratic Leaders Seek Investigation into Role
of Scandal-Tainted Lobbying Group
From the Office of House Democratic Leader Nancy Pelosi
January 25, 2006
Washington, D.C. - House Democratic Leader Nancy Pelosi,
House Democratic Whip Steny Hoyer, and Congressman Henry Waxman,
senior Democrat on the Government Reform Committee, sent the following
letter to Speaker Hastert today asking for a congressional investigation
into the role of the Alexander Strategy Group, a lobbying firm
closely linked to Congressman Tom DeLay (R-TX) and Jack Abramoff,
in the passage of the Medicare Prescription Drug Act and the drafting
of the budget reconciliation bill currently before Congress.
Below is the text of the letter:
January 25, 2006
The Honorable J. Dennis Hastert
Speaker of the House of Representatives
Washington, DC 20515
Dear Mr. Speaker:
We are writing to ask you to open an investigation into the role
that the Alexander Strategy Group, a lobbying firm closely linked
to Tom DeLay and Jack Abramoff, played in crafting the Medicare
Prescription Drug Act of 2003 and the budget reconciliation bill
currently pending before Congress.
The Medicare Prescription Drug Act, which has caused so much
confusion and havoc since January 1, was a product of a corrupt
legislative process. When the bill passed, we knew that Democratic
members had been denied opportunities to offer amendments and
that the vote had been held open for hours in the dead of night
to twist arms. Afterwards, we learned that crucial cost estimates
were illegally withheld from Democratic members; that the key
Administration official responsible for writing the bill was simultaneously
negotiating a high-paying job representing drug and insurance
companies; and that the Republican chairman responsible for steering
the legislation through Congress subsequently accepted a lucrative
job in the pharmaceutical industry. We further learned about a
Republican member who had alleged that a bribe had been offered
him on the House floor.
Recently, with the indictments of Tom DeLay and Jack Abramoff,
new questions have arisen about the role of the Alexander Strategy
Group in this dishonest process. We know from lobby disclosure
forms that the largest single client of the Alexander Strategy
Group was the pharmaceutical industry, which paid the small firm
over $2.5 million, including nearly $1 million in 2003 when the
prescription drug law was being written. We also know from these
records that the primary lobbyist for the drug industry at Alexander
Strategy Group was Tony Rudy, who previously worked for both Mr.
DeLay and Mr. Abramoff and who is identified as "Staffer
A" in Mr. Abramoff's indictment. And we know from multiple
accounts in the news media that the Alexander Strategy Group has
been deeply implicated in the scandals now sweeping through Washington.
These facts, taken together, provide more than a sufficient basis
for further investigation. We therefore ask you to direct a congressional
committee of jurisdiction to examine the process that produced
the Medicare Prescription Drug Act, with a special focus on the
role of the Alexander Strategy Group.
The Medicare Prescription Drug Act symbolizes all that has gone
wrong in Congress. The bill's monstrous complexity frustrates
nearly everyone, and its high drug prices enrich the pharmaceutical
industry at the expense of seniors and taxpayers. The primary
beneficiaries of the legislation have become the special interests
that gave millions to Republicans in Congress, not the millions
of seniors and persons with disabilities that the legislation
was supposed to help. We have an obligation to the public - and
especially to the seniors of America - to find out how the legislative
process went astray and to hold those responsible to account.
We also urge you to extend this investigation to examine the
role of the Alexander Strategy Group in the pharmaceutical provisions
of the pending budget reconciliation legislation and to delay
the final vote on the reconciliation bill until this investigation
is complete.
The Medicare Prescription Drug Act of 2003
The Medicare Prescription Drug Act, which went into effect on
January 1, is a product of the culture of corruption that has
infected Washington. Over a year ago, senior Democrats in the
House and the Senate asked you and Senate Majority Leader Frist
to investigate some of the serious irregularities in the process.[1]
You both failed to respond, and there has been no official investigation
into the how the bill was enacted. Even so, there is abundant
evidence that the process was dishonest and deeply flawed.
At this point, we know:
(1) Key Cost Estimates Were Withheld from Democrats. During
the legislative debate, President Bush, Secretary of Health and
Human Services Tommy Thompson, and Centers for Medicare and Medicaid
Services (CMS) Administrator Tom Scully repeatedly assured Congress
and the public that the Medicare drug benefit would not cost more
than $400 billion over ten years.[2] In fact, the Medicare actuary,
Richard Foster, was correctly predicting that the legislation
would cost far more, perhaps as much as $600 billion.[3] Mr. Scully
threatened Mr. Foster with the loss of his job if he shared this
information with congressional Democrats.[4] According to the
Government Accountability Office, this action and the withholding
of the cost estimates violated multiple federal laws.[5]
(2) Democrats Were Denied Opportunities to Offer Amendments.
On June 26, 2003, the House passed H. Res. 299, the rule for consideration
of H.R. 1, the Medicare Prescription Drug Act. In this rule, Democrats
were allowed to introduce only one amendment, an amendment in
the nature of a substitute.[6] No other amendments were permitted,
effectively denying Democratic members the opportunity to address
the deficiencies in the bill.
(3) The Vote Was Held Open for Three Hours in the Dead of
Night. H.R. 1 was brought before the House for final passage
at 3 a.m. on Saturday, November 22, 2003. Instead of the 15 minutes
usually reserved for roll call votes, the House Republican leadership
held open the vote for an unprecedented three hours while pressuring
Republican members to change their votes.[7] During the vote,
the Republican leadership abandoned the traditions of the House
by permitting a member of the President's cabinet, HHS Secretary
Thompson, to be present on the floor to persuade members.[8]
(4) The Lead Administration Negotiator Was Simultaneously
Pursuing Job Representing Drug and Insurance Companies. During
the time the Medicare bill was being drafted and considered, the
Bush Administration's lead negotiator, CMS Administrator Tom Scully,
was negotiating possible jobs representing the pharmaceutical
and insurance industries.[9] These negotiations were sanctioned
by the Administration, which granted Mr. Scully a waiver from
the normal ethics rules.[10] After the legislation was signed
into law, Mr. Scully left CMS to take a job at Alston & Bird,
a firm that represents multiple pharmaceutical companies, where
he registered as a lobbyist for these companies.[11]
(5) Key Republican Chairmen Accepted Lucrative Jobs with the
Pharmaceutical Industry. Two key Republican chairmen also
accepted jobs representing the pharmaceutical industry after passage
of the Medicare Prescription Drug Act. Former Rep. Billy Tauzin,
who was the Chairman of the House Energy and Commerce Committee
and the lead House sponsor of the bill, left Congress to become
the president of the Pharmaceutical Research and Manufacturers
of America (PhRMA), the drug industry's biggest trade group.[12]
Former Rep. James Greenwood, who was the Chairman of the House
Energy and Commerce Oversight and Investigations Subcommittee,
left Congress to become the president the Biotechnology Industry
Organization, the trade association of the biotechnology industry.[13]
(6) A Republican Member Said He Was Offered a Bribe on the
House Floor. Former Rep. Nick Smith alleged that during the
floor vote, former Majority Leader Tom DeLay offered him a bribe
in return for his vote on the bill. According to Mr. Smith, Mr.
DeLay offered campaign support for Mr. Smith's son, who planned
to run for Rep. Smith's seat upon his retirement.[14] Mr. DeLay
was later admonished by the Ethics Committee for his role in this
incident.[15]
The final bill reflects this deplorable breakdown in the legislative
process. The extraordinary complexity of the legislation is a
direct result of political decisions made by Republicans in Congress.[16]
These choices benefit the drug and insurance industries, but they
are profoundly disruptive for seniors. Moreover, because the Republican-controlled
Congress rejected Democratic proposals to allow Medicare to negotiate
for low drug prices, the legislation has produced exceptionally
high pharmaceutical prices. According to one study, the drug prices
currently available under the Medicare drug plans are over 80%
more expensive than those negotiated by the federal government
and over 60% more expensive than in Canada.[17]
In effect, millions of seniors and the U.S. taxpayer are paying
a costly "corruption tax." The triumph of the special
interests produced a drug benefit that is far more complicated
than necessary and far less helpful to seniors than possible.
The Involvement of the Alexander Strategy Group
On January 9, 2006, the Alexander Strategy Group announced that
it would shut its lobbying operations at the end of January 2006
because of extensive reporting linking the lobby firm to Tom DeLay
and Jack Abramoff, both of whom have been indicted in political
corruption cases.[18] As one paper reported, "the firm had
fallen victim to the ever expanding lobbying and corruption scandal."[19]
The Alexander Strategy Group was formed in 1998 by Ed Buckham,
a licensed minister who also served as Chief of Staff and personal
pastor to then-House Majority Whip Tom DeLay.[20] The group's
startup was funded through a large contract that Rep. DeLay secured
from Enron.[21] Among the individuals with close ties to Mr. DeLay
who worked for the Alexander Strategy Group were Tony Rudy, a
former deputy chief of staff to Mr. DeLay; Karl Gallant, a former
director of Americans for a Republican Majority PAC (ARMPAC),
Mr. DeLay's leadership PAC; and Mr. DeLay's wife, Christine, who
was on the Alexander payroll for four years.[22] The wives of
other prominent Republican members, including Rep. John T. Doolittle,
were also hired at various points by the Alexander Strategy Group.[23]
Alexander Strategy Group has been described as "one of the
crown jewels of the ... 'K Street project.'"[24] Other reports
have linked the firm or its lobbyists to an expanding number of
scandals. These include suspect arrangements involving Indian
gambling,[25] the U.S. Family Network,[26] the Northern Marianas
Islands,[27] defrauding clients,[28] and corrupt schemes to stop
legislation involving internet gambling and to oppose postal rate
increases.[29] Tom DeLay and Jack Abramoff figure prominently
in these scandals.
What has not been explored, however, is the relationship between
the Alexander Strategy Group and its largest client, the pharmaceutical
industry. In particular, there has been little investigation of
the role played by the Alexander Strategy Group in passage of
the Medicare Prescription Drug Act. We do know enough, though,
to raise serious questions.
According to lobby disclosure reports, the pharmaceutical industry
has been the largest client of the Alexander Strategy Group over
the last six years. During this period, the industry's trade association,
PhRMA, paid $1.7 million to Alexander Strategy Group,[30] while
individual drug companies have paid an additional $840,000.[31]
During 2003 alone, the year the Medicare Prescription Drug Act
passed, Alexander Strategy Group received $960,000 from the drug
industry, representing 15% of the firm's revenue.[32] According
to the disclosure forms, the Alexander Strategy Group was hired
specifically to lobby the House and Senate on prescription drug
issues and Medicare.[33]
Not only was the drug industry the largest client of the Alexander
Strategy Group, the group was also the drug industry's most highly
paid outside lobbyist. In 2003, PhRMA paid the Alexander Strategy
Group $720,000, far more than PhRMA paid any of the other seven
lobby firms it hired that year.[34] These payments represented
nearly 50% of PhRMA's annual budget for outside lobbyists.[35]
Moreover, the lobby disclosure forms reveal that the primary
lobbyist representing PhRMA and Eli Lilly during consideration
of the Medicare Prescription Drug Act was Tony Rudy.[36] Mr. Rudy
is perhaps the Alexander Strategy Group lobbyist most implicated
in scandal. In addition to being the former deputy chief of staff
for Mr. DeLay, Mr. Rudy worked for Mr. Abramoff from 2001 to 2002,
where he helped raise the funds that were diverted to pay for
a golfing trip to Scotland, which included Rep. Bob Ney, indicted
former White House procurement chief David Safavian, and Republican
activist Ralph Reed.[37] In Mr. Abramoff's indictment, Mr. Rudy
is identified as "Staffer A." According to several news
reports, he used his position in Mr. DeLay's office to influence
internet gambling legislation and postal rates in exchange for
$50,000 payments to his wife.[38] Criminal investigators are also
looking into possible conflicts of interest during the time Mr.
Rudy was negotiating his departure from Rep. DeLay's office to
work for Mr. Abramoff.[39]
The Need for a Congressional Investigation
These facts urgently call for further investigation. The Medicare
Prescription Drug Act is deeply tainted legislation, and the Alexander
Strategy Group, the lobby firm most mired in the on-going corruption
scandals, was intimately involved in its passage. The millions
of American seniors who are confounded by the Act's complex provisions
and are paying inflated drug prices deserve to know what went
wrong and what role the Alexander Strategy Group played in the
process.
There are multiple committees in Congress that could undertake
this investigation, including the Energy and Commerce Committee,
the Ways and Means Committee, the Government Reform Committee,
and the Committee on Standards of Official Conduct. These Committees,
however, have all resisted Democratic requests to examine the
legislative process that led to passage of the Act.[40] They will
not act on their own initiative.
Your personal intervention is needed to spur action. We therefore
urge you to direct one of these committees to commence an immediate
investigation into the involvement of the Alexander Strategy Group's
role in the development and passage of this legislation.
Congressional Investigation of the Budget Reconciliation Bill
The Medicare Prescription Drug Act is not the only major piece
of pharmaceutical legislation with which the Alexander Strategy
Group has been involved. In the first six months of 2005, the
group was paid $180,000 to represent PhRMA to lobby on Medicare,
Medicaid, prescription drug issues, and the budget process.[41]
Alexander Strategy Group was also paid an additional $300,000
during the first six months of last year to lobby on prescription
drug issues by pharmaceutical companies Eli Lilly, AstraZeneca,
and Amgen.[42] During this period, the primary legislation affecting
prescription drugs, Medicaid, and the budget process was the budget
reconciliation legislation.
The budget reconciliation bill has not yet been passed by Congress.
But its final contours are known, and the conference report is
scheduled for imminent floor action, perhaps as soon as next week.
Like the Medicare legislation, the reconciliation bill sacrifices
the interests of low-income families to preserve drug industry
profits.
The Senate version of the budget reconciliation bill had several
provisions that would have required drug companies to share the
burden of reducing Medicaid's costs. These provisions would have
increased the minimum rebate for brand-name drugs and extended
the rebate to drugs dispensed through Medicaid managed care plans.
In total, these provisions would have saved over $10 billion over
10 years.[43]
These provisions were mysteriously dropped from the conference
agreement, however. Instead, the legislation takes the budget
savings directly from the pockets of the low-income beneficiaries
served by Medicaid. The legislation specifically authorizes states
to raise the co-payments Medicaid beneficiaries have to pay for
prescription drugs to up to 20% of the total prescription costs.
These provisions are estimated to cost low-income beneficiaries
up to $5.3 billion.[44]
We believe that any investigation into the Alexander Strategy
Group should also examine what role the firm played in the budget
reconciliation bill, specifically with regard to the prescription
drug provisions. We further urge you not to bring the reconciliation
bill before Congress until after this investigation is completed.
The lobbying disclosure filings that cover the period of the conference
will be available on February 15. At a minimum, Congress should
not consider the legislation until these filings have been studied.
Conclusion
The image and integrity of Congress have been called into serious
question. To restore public faith in Congress, the institution
must initiate a careful examination of how corrupt practices have
influenced the legislative process. Understanding what went wrong
is a prerequisite to accountability and reform.
For these reasons, we urge you to direct an immediate investigation
into the legislative process that produced the Medicare Prescription
Drug Act, the drafting of the pharmaceutical provisions in the
pending budget reconciliation bill, and the role of the Alexander
Strategy Group.
Sincerely,
Nancy Pelosi
Democratic Leader
Steny Hoyer
Democratic Whip
Henry A. Waxman
Ranking Minority Member
Committee on Government Reform
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[1] Letter from Sen. Tom Daschle, Rep. Nancy Pelosi, Sen. Edward
M. Kennedy, Rep. Henry A. Waxman, Sen. Bob Graham, Rep. John D.
Dingell, Sen. Frank Lautenberg, Rep. Charles B. Rangel, Sen. Hillary
Rodham Clinton, Rep. Fortney Pete Stark, Sen. John D. Rockefeller
IV, Rep. Steny H. Hoyer, Rep. Sherrod Brown, and Sen. Tim Johnson
to Senate Majority Leader William H. Frist and House Speaker J.
Dennis Hastert (Sep. 8, 2004).
[2]See. e.g., The White House, President Bush Meets With Congressional
Leaders on Medicare (Nov. 17, 2003); House Committee on Energy
and Commerce, Testimony of the Honorable Tommy Thompson, Secretary,
U.S. Department of Health and Human Services, Hearing on Review
of the Administration FY2004 Health Care Priorities, 108th Cong.,
24 (Feb. 12, 2003) (Serial No. 108-8). See also, e.g., The White
House, President Announces Framework to Modernize and Improve
Medicare (March 4, 2003); Special Report With Brit Hume, Fox News
Network (Nov. 24, 2003); The White House, Ask the White House
(Sep. 25, 2003); House Committee on Ways and Means, Testimony
of Mitchell J. Daniels, Director, White House Office of Management
and Budget, Hearing on the President's Fiscal 2004 Budget With
OMB Director Daniels, 108th Cong., 43 (Feb. 5, 2003) (Serial No.
108-1); Senate Committee on Finance, Testimony of Thomas Scully,
Director, Centers for Medicare and Medicaid Services, Hearing
on Strengthening and Improving the Medicare Program, 108th Cong.
(June 6, 2003).
[3] White House Says Congressional Estimate of New Medicare Costs
Was Too Low, New York Times (Feb. 2, 2004).
[4] House Committee on Ways and Means, Testimony of Richard Foster,
Hearing on Board of Trustees 2004 Annual Reports, 108th Cong.
(Mar. 24, 2004).
[5] Government Accountability Office, Report from GAO General
Counsel Anthony H. Hamboa to Sens. Frank R. Lautenberg, Tom Daschle,
Edward M. Kennedy, et al., Re: Department of Health and Human
Services - Chief Actuary's Communications with Congress (Sept.
7, 2004) (B-302911).
[6] H.Res. 299, 108th Cong. (2003).
[7] Medicare Bill Squeezes Through House at Dawn, Washington
Post (Nov. 23, 2004).
[8] Time Was GOP's Ally on the Vote, Washington Post (Nov. 23,
2003). See also, House Committee on Standards of Official Conduct,
Investigation of Certain Allegations Related to Voting on the
Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (Sept. 30, 2004).
[9] Health Industry Bidding to Hire Medicaid Chief, New York
Times (Dec. 3, 2003).
[10] Id.
[11] Lobbying Disclosure Forms Filed by Alston & Bird with
the Senate Office of Public Affairs. The drug companies for which
Mr. Scully registered as a lobbyist in 2004 included Aventis,
Abbott Laboratories, and Praecis Pharmaceuticals.
[12] House's Author of Drug Benefit Joins Lobbyists, New York
Times (Dec. 16, 2004).
[13] Congressman to Lead Biotech Trade Group, New York Times
(July 23, 2004).
[14] House Ethics Panel Says DeLay Tried to Trade Favor for a
Vote, New York Times (Oct. 1, 2004).
[15] House Committee on Standards of Official Conduct, Investigation
of Certain Allegations Related to Voting on the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Sept. 30, 2004).
[16] House Committee on Government Reform, Minority Briefing
on the Implementation of the New Medicare Drug Benefit, Statement
of Jack Hoadley, Ph.D., Research Professor, Health Policy Institute,
Georgetown University (Jan. 20, 2006).
[17] Minority Staff, House Committee on Government Reform, New
Medicare Drug Plans Fail to Provide Meaningful Drug Discounts
(Nov. 2005) (online at www.democrats.reform.house.gov/story.asp?ID=975&Issue=Medicaid+and+Medicare)
[18] Lobby Firm Is Scandal Casualty, Washington Post (Jan. 10,
2006).
[19] Key Clients Quit Alexander Strategy Group; Others Weigh
Options, Roll Call (Jan. 10, 2006).
[20] DeLay and Company, Time Magazine (Mar. 21, 2005).
[21] Tom DeLay's Tammany Fall, The New Republic (June 20, 2005).
[22] Id., See also, Lobby Firm Is Scandal Casualty, supra note
18.
[23] Lobbying Firm Is Scandal Casualty, supra note 18.
[24] Officials Focus on a 2nd Firm Tied to DeLay, New York Times
(Jan. 7, 2006).
[25] See, e.g., Insiders Worked Both Sides of Gaming Issue, Washington
Post (Sep. 28, 2004).
[26] The Man Who Bought Washington, Time Magazine (Jan. 16, 2006).
[27] A Question of Influence, Los Angeles Times (May 6, 2005).
[28] Defendant's Plea Agreement, U.S. vs. Jack Abramoff, D.D.C.,
7-8 (Jan. 3, 2006).
[29] Defendant's Plea Agreement, U.S. vs. Jack Abramoff, D.D.C.,
9-14 (Jan. 3, 2006).
[30] This number was derived from analysis of Alexander Strategy
Group's lobbying disclosure forms, on file with the Senate Office
of Public Records, for PhRMA from 2000 through 2005.
[31] This number was derived from analysis of Alexander Strategy
Group's lobbying disclosure forms, filed with the Senate Office
of Public Records, for Eli Lilly from 2002 through 2005, Amgen
from 2004 through 2005, and AstraZeneca for 2005.
[32] Analysis of Alexander Strategy Group's lobbying disclosure
forms for 2003 show that the firm was paid a total of $6,486,000
by its clients for lobbying activities, of which $960,000 was
paid by PhRMA and Eli Lilly, or 15%.
[33] Lobbying Disclosure Midyear and Year End Reports filed by
Alexander Strategy Group with the Senate Office of Public Records
(Aug. 14, 2003 and Feb. 17, 2004).
[34] Lobbying Disclosure Midyear and Year End Reports filed by
Alexander Strategy Group, Bergner Bockorny Castagnetti Hawkins
& Brain, C2 Group, Capitol Hill Strategies, Clark & Weinstock,
Gorlin Group, Murphy & Associates, and Wise & Associates
with the Senate Office of Public Records (Aug. 2003 and Feb. 2004).
[35] Id.
[36] Lobbying Disclosure Midyear and Year End Reports filed by
Alexander Strategy Group with the Senate Office of Public Records
(Aug. 14, 2003 and Feb. 17, 2004).
[37] Defendant's Plea Agreement, U.S. vs. Jack Abramoff, D.D.C.,
7-8 (Jan. 3, 2006). See also, Foundation Funds Diverted From Mission,
Washington Post (Sep. 28, 2004).
[38] Lobby Firm Is Scandal Casualty, supra note 18.
[39] As the Revolving Door Turns, BusinessWeek (July 11, 2005).
[40]Democrats have made a number of efforts to get these Committees
to investigate the illegal withholding of the Medicare cost estimates.
In the House, Democrats introduced H. Res. 776, which would have
required the Administration to turn over information relating
to the Medicare cost estimates. This resolution was rejected by
the House Committee on Energy and Commerce and the House Committee
on Ways and Means. (House Committee on Energy and Commerce, Adverse
Report to Accompany H. Res. 776 (Oct. 8, 2004) (H. Rept. 108-754);
(House Committee on Ways and Means, Adverse Report to Accompany
H. Res 776) (Oct. 7, 2004) (H. Rept. 108-754)). The Chairman of
the House Government Reform Committee also turned down a request
by the Ranking Member for an investigation (Letter from Rep. Henry
A. Waxman to Government Reform Committee Chairman Tom Davis (Mar.
17, 2004)). In addition, the Republicans on the House Ways and
Means Committee voted down motions to subpoena two key witnesses,
including Mr. Scully, who refused to appear voluntarily (House
Committee on Ways and Means Democrats, New Release, Ways and Means
Republicans Allow Scully and the White House to Avoid Answering
Questions on Medicare Estimate Coverup (Apr. 1, 2004)). In the
Senate, the Senate Finance committee never held hearings on this
issue, despite two letters from Democrats requesting public hearings.
(E.g., Letters from Senators Tom Daschle, Bob Graham, and Kent
Conrad to Senate Committee on Finance Chairman Chalres Grassley
and Ranking minority Member Max Baucus (Jan. 30, 2004); Letter
from Senators Tom Daschle, Bob Graham, John Kerry, Jay Rockefeller
et al. to Senate Committee on Finance Chairman Charles Grassley
and Ranking Minority Member Max Baucus (Mar. 26, 2004)).
[41] Lobbying Disclosure Midyear Report filed by Alexander Strategy
Group with the Senate Office of Public Records (Aug. 15, 2005).
[42] Id.
[43] Center on Budget and Policy Priorities, Assessing the Effects
of the Budget Conference Agreement on Low-Income Families and
Individuals (Jan. 9, 2006).
[44] Minority Staff, House Committee on Budget, Summary and Analysis
of Reconciliation Conference Report (Dec. 22, 2005), at 4 (online
at http://www.house.gov/budget_democrats/ analyses/06reconciliation_conference_report.pdf).
The total cost was derived by adding the provisions for increasing
cost-sharing and premiums, eliminating federal benefit standards,
and tightening asset rules and other changes to long-term care,
then subtracting the cuts that already existed in the Senate version
of the bill. See also, Center on Budget and Policy Priorities,
supra note 43.
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