NEST Act

— 501 — Department of Health and Human Services 54. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Office of Civil Rights, and Office of the Secretary, “Special Responsibilities of Medicare Hospitals in Emergency Cases and Discrimination on the Basis of Disability in Critical Health and Human Service Programs or Activities,” draft of Proposed Rule, January 14, 2021, https://www.hhs.gov/sites/default/files/infants-nprm.pdf (accessed March 17, 2023). 55. H.R. 26, Born-Alive Abortion Survivors Protection Act, 118th Congress, introduced January 9, 2023, https:// www.congress.gov/118/bills/hr26/BILLS-118hr26pcs.pdf (accessed March 17, 2023). 56. H.R. 7, No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2023, 118th Congress, introduced January 9, 2023, https://www.congress.gov/118/bills/hr7/BILLS-118hr7ih.pdf (accessed March 17, 2023). 57. S. 401, Conscience Protection Act of 2021, 117th Congress, introduced February 24, 2021, https://www.congress. gov/117/bills/s401/BILLS-117s401is.pdf (accessed March 17, 2023). 58. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, and Office of the Secretary, “Nondiscrimination in Health Programs and Activities,” Notice of Proposed Rulemaking; Notice of Tribal Consultation, Federal Register, Vol. 87, No. 149 (August 4, 2022), pp. 47824–47920, https://www.govinfo. gov/content/pkg/FR-2022-08-04/pdf/2022-16217.pdf (accessed March 17, 2023). 59. Ibid., p. 47916. 60. The regulation was not finalized before the end of the Administration. U.S. Department of Agriculture, Food and Nutrition Services, “Revision of Categorical Eligibility in the Supplemental Nutrition Assistance Program (SNAP),” Proposed Rule, Federal Register, Vol. 84, No. 142 (July 24, 2019), pp. 35570–55581, https:// www.federalregister.gov/documents/2019/07/24/2019-15670/revision-of-categorical-eligibility-in-the- supplemental-nutrition-assistance-program-snap (accessed March 17, 2023). 61. 45 Code of Federal Regulations § 75.300(c) and (d), https://www.ecfr.gov/current/title-45/subtitle-A/ subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.300 (accessed March 17, 2023). 62. H.R. 1750, Child Welfare Provider Inclusion Act of 2021, 117th Congress, introduced March 10, 2021, https:// www.congress.gov/117/bills/hr1750/BILLS-117hr1750ih.pdf (accessed March 17, 2023), and S. 656, Child Welfare Provider Inclusion Act of 2021, 117th Congress, introduced March 10, 2021, https://www.congress.gov/117/bills/ s656/BILLS-117s656is.pdf (accessed March 17, 2023). 63. S. 3949, Trafficking Victims Protection Reauthorization Act of 2022, Public Law No. 117-348, 117th Congress, January 25, 2023, https://www.congress.gov/117/plaws/publ348/PLAW-117publ348.pdf (accessed March 17, 2023). 64. Kelsey Y. Santamaria, “Child Migrants at the Border: The Flores Settlement Agreement and Other Legal Developments,” Congressional Research Service In Focus No. IF11799, April 1, 2021, https://crsreports.congress. gov/product/pdf/IF/IF11799 (accessed March 17, 2023). 65. Report, Building a Happy Home: Marriage Education as a Tool to Strengthen Families, Social Capital Project Report No. 1-22, March 2022, p. 17, https://www.jec.senate.gov/public/_cache/files/3d102525-6f0d-48ed- 92f4-d71edd468ad6/building-a-happy-home.pdf (accessed March 17, 2023). The cover of the report reflects that the Social Capital Project is “[a] project of the Joint Economic Committee – Republicans.” 66. See, for example, Alan J. Hawkins, “Are Federally Supported Relationship Education Programs for Lower-Income Individuals and Couples Working? A Review of Evaluation Research,” American Enterprise Institute, September 2019, https://www. congress.gov/117/plaws/publ228/PLAW-117publ228.pdf (accessed March 17, 2023). 67. H.R. 8404, Respect for Marriage Act, Public Law No. 117-228, 117th Congress, December 13, 2022, https://www. congress.gov/117/plaws/publ228/PLAW-117publ228.pdf (accessed March 17, 2023). 68. Madison Marino, “Over 1,000 Safety Violations Mar Head Start. Children Deserve Better,” Heritage Foundation Commentary, November 10, 2022, https://www.heritage.org/education/commentary/over-1000-safety- violations-mar-head-start-children-deserve-better. 69. American Hospital Association v. Becerra, 596 U.S. ___ (2022), https://www.supremecourt.gov/ opinions/21pdf/20-1114_09m1.pdf (accessed March 17, 2023). 70. U.S. Department of the Treasury, Internal Revenue Service; U.S. Department of Labor, Employee Benefits Security Administration; and U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, “Coverage of Certain Preventive Services Under the Affordable Care Act,” Notice of Proposed Rulemaking, Federal Register, Vol. 88, No. 22 (February 2, 2023), pp. 7236–7281, https://www. govinfo.gov/content/pkg/FR-2023-02-02/pdf/2023-01981.pdf (accessed March 17, 2023). — 502 — Mandate for Leadership: The Conservative Promise 71. 42 U.S. Code § 238n, https://www.law.cornell.edu/uscode/text/42/238n (accessed March 17, 2023). 72. U.S. Department of Health and Human Services, Health Resources and Services Administration, “Early Childhood Health,” last reviewed October 2022, https://mchb.hrsa.gov/programs-impact/focus-areas/early- childhood-health (accessed March 17, 2023). 73. American Pregnancy Association, “Having a Doula—What Are the Benefits?” https://americanpregnancy. org/healthy-pregnancy/labor-and-birth/having-a-doula/#:~:text=Other%20studies%20have%20shown%20 that%20having%20a%20doula,massage%20to%20reduce%20stress%20and%20anxiety%20during%20labor (accessed March 17, 2023). 74. S. 2372, VA MISSION [Maintaining Internal Systems and Strengthening Integrated Outside Networks] Act of 2018, Public Law No. 115-182, 115th Congress, June 6, 2018, https://www.congress.gov/115/plaws/publ182/ PLAW-115publ182.pdf (accessed March 17, 2023). 75. U.S. Department of Health and Human Services, “Securing Updated and Necessary Statutory Evaluations Timely,” Final Rule, Federal Register, Vol. 86, No. 11 (January 19, 2021), pp. 5694–5764, https://www.govinfo. gov/content/pkg/FR-2021-01-19/pdf/2021-00597.pdf (accessed March 22, 2023). 76. U.S. Department of Health and Human Services, Office of the Secretary, Office of the Assistant Secretary for Health, “Compliance with Statutory Program Integrity Requirements,” Final Rule, Federal Register, Vol. 84, No. 42 (March 4, 2029), pp. 7714–7791, https://www.govinfo.gov/content/pkg/FR-2019-03-04/pdf/2019-03461.pdf (accessed March 18, 2023). 77. U.S. Department of Health and Human Services, Office of the Secretary, Office of the Assistant Secretary for Health, “Ensuring Access to Equitable, Affordable, Client-Centered, Quality Family Planning Services,” Final Rule, Federal Register, Vol. 86, No. 192 (October 7, 2021), pp. 56144–56180, https://www.govinfo.gov/content/ pkg/FR-2021-10-07/pdf/2021-21542.pdf (accessed March 18, 2023). 78. S. 624, Title X Abortion Provider Prohibition Act, 118th Congress, introduced March 2, 2023, https://www. congress.gov/118/bills/s624/BILLS-118s624is.pdf (accessed March 18, 2023). 79. 50 U.S. Code Chapter 55, https://www.law.cornell.edu/uscode/text/50/chapter-55 (accessed March 22, 2023). 80. 18 U.S. Code § 13, https://www.law.cornell.edu/uscode/text/18/13 (accessed March 18, 2023). 81. Bowen v. American Hospital Association, 476 U.S. 610 (1986), https://tile.loc.gov/storage-services/service/ll/ usrep/usrep476/usrep476610/usrep476610.pdf (accessed 22, 2023). 82. U.S. Department of Health and Human Services, Office of the Secretary, “Notification of Interpretation and Enforcement of Section 1557 of the Affordable Care Act and Title IX of the Education Amendments of 1972,” Federal Register, Vol. 86, No. 99 (May 25, 2021), pp. 27984–27985, https://www.govinfo.gov/content/pkg/FR- 2021-05-25/pdf/2021-10477.pdf (accessed March 18, 2023). 83. U.S. Department of Health and Human Services, Office for Civil Rights, “HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy,” March 2, 2022, https://www.hhs.gov/sites/default/files/hhs- ocr-notice-and-guidance-gender-affirming-care.pdf (accessed March 18, 2023). 84. Heckler v. Chaney, 420 U.S. 821 (1985), https://caselaw.findlaw.com/us-supreme-court/470/821.html (accessed March 18, 2022). 85. U.S. Department of Health and Human Services, Office for Civil Rights, “Guidance to Nation’s Retail Pharmacies: Obligations Under Federal Civil Rights Laws to Ensure Access to Comprehensive Reproductive Health Care Services,” content last reviewed July 14, 2022, https://www.hhs.gov/civil-rights/for-individuals/ special-topics/reproductive-healthcare/pharmacies-guidance/index.html (accessed March 18, 2023). 86. H.R. 3103, “Health Insurance and Portability and Accountability Act of 1996, Public Law No. 104-191, 104th Congress, August 21, 1996, https://www.congress.gov/104/plaws/publ191/PLAW-104publ191.pdf (accessed March 18, 2023). 87. U.S. Department of Human Services, “HIPAA Privacy Rule and Disclosures of Information Relating to Reproductive Health Care,” content last reviewed June 29, 2022, (accessed March 18, 2023). See also “Protecting the Privacy and Security of Your Health Information When Using Your Personal Cell Phone or Tablet,” content last reviewed June 29, 2022, https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/ cell-phone-hipaa/index.html (accessed March 18, 2023).

— 299 — Department of Agriculture largely hidden. There are means-tested food-support programs in the USDA (specially FNS), whereas most means-tested programs are at the Department of Health and Human Services (HHS). All means-tested anti- poverty programs should be overseen by one department—specifically HHS, which handles most welfare programs. Reform SNAP. Ostensibly, SNAP sends money through electronic-bene- fit-transfer (EBT) cards to help “low-income” individuals buy food. It is the largest of the federal nutrition programs. Food stamps are designed to be supplemented by other forms of income—whether through paid employment or nonprofit support. SNAP serves 41.1 million individuals—an increase of 4.3 million people during the Biden years.55 In 2020, the food stamp program cost $79.1 billion. That number continued to rise—by 2022, outlays hit $119.5 billion.56 The next Administration should: l Re-implement work requirements. The statutory language covering food stamps allows states to waive work requirements that otherwise apply to work-capable individuals—that is, adult beneficiaries between the ages 18 and 50 who are not disabled and do not have any children or other dependents in the home.57 Even in a strong economy, work expectations are fairly limited: Individuals who are work-capable and without dependents are required to work or prepare for work for 20 hours per week.58 The work requirements are then implemented unless the state requests a waiver from the USDA’s Food and Nutrition Services.59 Waivers from statutory work requirements can be approved in two instances: an unemployment rate of more than 10 percent or a lack of sufficient jobs.60 The Trump Administration bolstered USDA work expectations in the food stamp program. In February 2019, FNS issued a modest regulatory change that applied only to able-bodied individuals without dependents— beneficiaries aged 18 to 49, not elderly or disabled, who did not have children or other dependents in the home (ABAWD).61 The FNS rule changed when a state could receive a waiver from implementing the ABAWD work requirement. Under the new rule, in order to waive the work requirement, the state’s unemployment rate had to be above 6 percent for more than 24 months. The rule also defined “area” in such a way that states would be unable to combine non-contiguous counties in order to maximize their waivers.62 Of

— 299 — Department of Agriculture largely hidden. There are means-tested food-support programs in the USDA (specially FNS), whereas most means-tested programs are at the Department of Health and Human Services (HHS). All means-tested anti- poverty programs should be overseen by one department—specifically HHS, which handles most welfare programs. Reform SNAP. Ostensibly, SNAP sends money through electronic-bene- fit-transfer (EBT) cards to help “low-income” individuals buy food. It is the largest of the federal nutrition programs. Food stamps are designed to be supplemented by other forms of income—whether through paid employment or nonprofit support. SNAP serves 41.1 million individuals—an increase of 4.3 million people during the Biden years.55 In 2020, the food stamp program cost $79.1 billion. That number continued to rise—by 2022, outlays hit $119.5 billion.56 The next Administration should: l Re-implement work requirements. The statutory language covering food stamps allows states to waive work requirements that otherwise apply to work-capable individuals—that is, adult beneficiaries between the ages 18 and 50 who are not disabled and do not have any children or other dependents in the home.57 Even in a strong economy, work expectations are fairly limited: Individuals who are work-capable and without dependents are required to work or prepare for work for 20 hours per week.58 The work requirements are then implemented unless the state requests a waiver from the USDA’s Food and Nutrition Services.59 Waivers from statutory work requirements can be approved in two instances: an unemployment rate of more than 10 percent or a lack of sufficient jobs.60 The Trump Administration bolstered USDA work expectations in the food stamp program. In February 2019, FNS issued a modest regulatory change that applied only to able-bodied individuals without dependents— beneficiaries aged 18 to 49, not elderly or disabled, who did not have children or other dependents in the home (ABAWD).61 The FNS rule changed when a state could receive a waiver from implementing the ABAWD work requirement. Under the new rule, in order to waive the work requirement, the state’s unemployment rate had to be above 6 percent for more than 24 months. The rule also defined “area” in such a way that states would be unable to combine non-contiguous counties in order to maximize their waivers.62 Of — 300 — Mandate for Leadership: The Conservative Promise the more than 40 million food stamp beneficiaries, the Trump rule would have applied only to 688,000 individuals in fiscal year 2021.63 The Trump reform was scheduled to go into effect, but a D.C. district court federal judge enjoined the rule.64 The USDA filed an appeal in late December 2020,65 but the Biden Administration withdrew from defending the challenge, and the rule was never implemented.66 Beyond the able-bodied work requirement, FNS should implement better regulation to clarify options for states to implement the general work requirement. This requirement is an option states can apply to work- capable beneficiaries aged 16 to 59. If beneficiaries’ work hours are below 30 hours a week, states can implement the general work requirements to oblige beneficiaries to register for work or participate in SNAP Employment and Training or workfare assigned by the state SNAP agency.67 Increased clarity for states would include items like states being required to offer employment and training spots for those that request them—not simply budgeting for every currently enrolled able-bodied adult. l Reform broad-based categorical eligibility. Federal law permits states to enroll individuals in food stamps if they receive a benefit from another program, such as the Temporary Assistance for Needy Families (TANF) program. However, under an administrative option in TANF called broad- based categorical eligibility (BBCE), ”benefit” is defined so broadly that it includes simply receiving distributed pamphlets and 1–800 numbers.68 This definition, with its low threshold to trigger a “benefit,” allows individuals to bypass eligibility limits—particularly the asset requirement (how much the applicant has in resources, such as bank accounts or property).69 Adopting the BBCE option has even allowed millionaires to enroll in the food stamp program.70 The Trump Administration proposed to close the loophole with a rule to “increase program integrity and reduce fraud, waste, and abuse.”71 The regulation was not finalized before the end of the Trump Administration. l Re-evaluate the Thrifty Food Plan. In a dramatic overreach, the Biden Administration unilaterally increased food stamp benefits by at least 23 percent in October 2021.72 Through an update to the Thrifty Food Plan, in which the USDA analyzes a basket of foods intended to provide a nutritious diet, the USDA increased food stamp outlays by between $250 billion and $300 billion over 10 years.73