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PRESEN?
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ADVISORY LOMSS ION OR INTERGOVERth REUTst 2"
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Washington. D. C.
20575
WENTer INT}! .IEETING
5L. Francis Hotol
San Francisco, Californll
September 20. 1968
Farris Bryant. Chairman
Price Daniel, Vice Chairman
Spiro T. Agnew
Neal 5. Blnludull
Dorothy I. Cline
John F. Dover
L. 5. Fountain
Angus Nrnonald
Jack Haltauter
Arthur Naftalln
nelnon A. Rockefeller
Gladys N. Spellman
A1 Lllmon
willlam F. Ralsh
Regrcrontatlves of Members
Mr. Gerald Adams, Asslstont to Governor Buford Blllngton
Mr. Martin chhnnn, Deputy Abalstant Attorney General (representing
Attorney General Ramsey Clark)
Mr. Robert A. Wallace. Assistant Secretary of tho Treasury
(representing Secretary Henry Fowler)
Staff
Mr. Ru. 6. Colman. Executive Director
3:. Elton choary. Abolstant Director (Program Implementation)
Hr. John Shannon, Asslstant Director (Taxation and Finance)
Xr. Davld 3. Walker, Assistant Diroctor (Governmnntal Structure Ind
Functions)
3:. James H. Pickford, Senior Analyst
Mr. Albert J. Richter. Senior Anllylt
SI:L ruulf-mvnts {or Liens Recoveries and vantlvo Rea nslbili
152;? Llla- vacd. with a Iccond by anyar Haltostor. approval of
5.:omnunuaLlcn a. Alternntivo B, recommending that Congress make no
tunu;:. in La. provision. of TLLlu l9 with respect to lien and recovery
lac relative rcdponSLbility. A motion by Governor Agnew, seconded by
Commissioner Spellmdn. urged substitution of Altornativo A. amended to
4clcrr thr words "and relative responsibility." The rubutitutc motion
LL!
'Uno adopted 5 (allows, with 8-0. Cline, Commissioner Davur. and Hoyt:
nitalin voting "no":
Tic Commission recommends thng Congress amend Title 19 of the
Scotlal Securzzv Art to worst: the States greater latitude in determina-
tion of isua ann recover: grovisiuns.
niuval Critnrln fo
Requlrrmnnts
Rucrnncndallan 7 was moved by Governor Daniel. secondad by
038
Governor Agnew, and adopted:
Tnu Commission rccommagda that Congress naggd Suction l902§az§lZQ
of the ScCLal Security Act to establish uvstcmntic criteria for evaluating
:hosc gorzzons of Stntg Elana relating to rosourco limitations (cosh or
in unset: used in establishin eli ibillt of t o medianll
other lieu
necdv.
Extension of Eli iblllt
5nd Maggl Instiguglgnt
A motion by anyor Blaiadcll, Intended by Congressman Ullnnn.
proposed ILrlking Recommendation 8 calling for nmondiug the Social Sorority
Act to place patients in mental and tuberculosis institutions on tho some
basis as patient: in other medical institutions with respect to Podornl
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participation in public assistance and medical assistance paymonts.
11M
.hu motion ta:::~d, thh III. Cline and ayor Haluh voting in the
negative.
Flacnl Res onslbillt Batvoo State and Local
4"!lt 3Li 3:.
l'.w.-:;1::. ntu
Hit; a 50:10 by Mayor nish and a nocond by Mayor Naftnltn.
Commitaian npproVal uns£::3:::¥:r Recommendation 9, Alternative A.
amcndlna Titic 19 to require Status to oildmo the full non-Federal
.harc of :cnxcnl assistance costs. Subsequently, a motion by Governor
Daniel. attended by conmLstLonor Spollnan, was offered to auhutltute
Alternative 3. recanmcncinx retention of present sharing of State-local
tcponSLbLllty but amcnuco to leave the deciaion on local sharin3_up to
{he SCBEQb. Thu substitute motion carried. with 91. Cline. Mayor
ainlsdell. gnu anot Ha.sh dissenttng; it reads an follaus:
Thu Cunnitlxon recommends that Can teas amend Title 19 of the
Sottal Scuutitv Act with respect to State and local Bovotnmmnt reanonsi-
biiitv it: :h; nnn-?cdc:al share 9f medical assistancg Eggggnts after
Jui 1 1935 av allowin ouch State to determine whether it will assume
the full unn-choral cal: or r uiro that thorn be a local ttion such
portion :o be outcralncd bx a State-atusctibod formula.
1 m'I' f.
xNinmLtuu by Cummiuttonnt Spellman. socondod by Congressman
Ullman, notommondatlou 10 was adopted as-folloui:
1mg Commilsion recommends that States eliminate conntltuttggnl
42d losislntivc barriers to the establighgggt of nraggid tong gtoctho
of health care.
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RkiHAfu.3.3C ?o:mula for Inuatient Ho Eta! Servicus
0L rullun by Sayer alaiadcll. uucond by Commissioner Dcvnr.
i;~a:;n... .. an adnptod an fallovs:
,Lsnan rccnmmcnun LhuL Lhu Scorctor Health ,
14 welfars :vcind rc~ulatlnnn that re uirc reimbursumants {at has ital
.nw;:1;nt JvtviCtl under Mudlcnid to be an the same basis as such
Edinburiasunzs under Hedicarc.
In¢::a3£d Efficzauc and Ecnnnm of Health Services
On matiun by Congtosaman Ullmon. second by Commissioner Duvar,
Recommendation 12 was adoptad with tho addition at the end of "(6) use
at copaynonta for tha purchase of Ipectfied health care services. and
(e) improved techniques of utilization roviow." The recommendation reads
as follows:
Commtnnion rcconmands that snout to Section: 237 and £02
'11; .1
of Chc 1967 anvndmct to the Social Secutltx.Act, the States move
Vzgarouglv to exggrtmen: with methods of tncrgaaing tho agficiegcz and
scannmg of health tervices under the Medicaid grogram. Such cxngrimunto
:hould inrludc a c u a x o: 1 a cautl cut on t ch o -rat£
undo an narnntab a s rd of
prior outhortxaglog go: uloctivu surgical grocadures, (c2 gggggnt for
ghzsiclana 0LTV1COB an a basis other than usual and cultaulrx charges..
use of 'nts fur the rchasc of a clfiud health care services
agg {a} ignrovud tothnigucs of utilization review.
5 IIWJ
Fl ;b.1iL~ in Allocation of Medical Services Amen 211 ible
On :u;.vn Ly 8E5. Cline, with a secund by Mayor Blulsdcll.
Hacummund".;3u 11 u. adapLud as follows:
-Lh,:un rcdumvas that Convross modlf Sec ion 1902 n 10
comn:rab.1i:~ ni survic;:" rc utrcment suhect to 5 oval of thu
Secretarv : alsh
Educatian and welfare.
l-I__
5.¢11Liv1nv Procadurol {qr QQCurmtnlgg llgibtlttz
On nation by Cavernt Daniel, occondcd by Congressman Ullmun,
accomcncution 1!. was adopted. with Kayo: Maiden. m. Cline,
buyer Xaftalin, and Hayo: Hclsh voting "no." Thu recammcndation reads
as fallow":
71c Comm :sian acomncnds hat Sta as
azgrizcn: with aim lifxcd toccdures for escahilahln
financial
nu411f1cn:isan far tedical asutstnnce nude: Mcdtcnid. The Commission
-urzhcr r<.7:wnds that Countess amend tho Internal Revenua Code in
m
rszaulish a I ecif c rocedure where
State medical assistance
~ff£c1n13 would haw: access-con rogust--to individual gederal income
:Jx gecurcs f0: grogram (naggction grogruus.
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Sclcction .-: ha. To 1: for the C.misnion't Hark Pro ram
having, completed its deliberations on the Medicaid report, tho
Cucmiaaion a: this point turned to the remaining seven items on its
nguuda oi wolnono. Chairman Bryant oxplainod that completion of tho
l-Luicald trier: made staff the available for a new auignmnt in the
governmental Structure and iunctions section. He directed Comicsion
membert' attention to Tab C in the Docket Book. which described four
Sodium-scale projccts and three Imllvscale project: for consideration.
Support we: voiced for undcrtciking "State-local responsibilities for
laboremadcmant relations in public mploymnt," "Tho intergovern-
mantel dimnaionn of State public utility regulatory activities." and
"ac laticnaaips between school boards and units of general local savan-
ncnts." Alt was unanimst agreed to undertake study of labor-
oanngemunt relationsin public caploymnt.
Alternatiwe Acm Roles in a National Forum on Federalism
The Executive Director noted thot at it: June 21 mating. the
Cumiaaion had tentatively agreed to sponsor a forum on the American
{adorn}. syltem during the current fiacal year an a new of focusing
notional attention on the changing nature of federalism. The staff
had been instructed to prepare a propoul for consideration at this
meeting. The Executive DirecLut referred to Tab D in the Docket Book
containing the staff report. and tamarind its contents. 'lllo staff
recamaended that:
(l) ACIR encourago and assist-oust without direct involvement--
other organizations that are interested in holding national meetings of
various kinds of which "here end now" problm are ditcusud.
(2) the naviuury Commission encourage and assist in every way
\iucluding cospansershlp. if appropriate) the American Assembly. the
American Political Schmu- Association and others to organize md
conduct conmrcnces that hitett attention tn the fut-ere course of
federalism 17. its broadest aspects.
(3) Tue Dominion not Stage this kind of conference on its own
during the tux-rent fiacal year because of problem of staff time and
preparation required and. the fact that for the first six month; of 1969
the Comiss;on will be occupiud with effecting a' satisfactory
accauodetiun to and Bid! A nev Administration.
After diecuuuun. Mayor Malia moved-with s second by Myer
madman} acceptance of the staff recoenendetions. The motion
carried. Mayor Saftulin stared. however. that he wished to reserve the
right to bring up again the issue of s national formant: at least s
Camissien muting on broad issues involving the federal system-qt the
, .
I! A
next Coniesion meeting-.knw. [IV-Mu" "
: 11": ;- t
Cumissmn's Entimtud Budget for Piece! Year Ending Juno 30I 1970
The Executiw: Diractor called emission mhers' attention to
Tab [-1 of the Docket Book. containing a my of the emission's
animated budget {or FY 1970. He noted that it was desirable to bring
the estimates more tormlly to the Cmissions notice this year
because of tho siteahle increase in estimated expenditures, the edVent
of a new administration in January, and the sddition of an intern
training program. After brief discussion, Comiuioner McDonald moved
with a second by Mayor h'elsh that the Couniuion approve the proposed
buget. The motion carried.
Pro"rcss Rcdti on Commiseian Stud of State Aid 0 al Governnon
The Chu.twuu Lhen directed mcnbcte' attention to tho ptogreoo
report of the study on State aid. which is scheduled for presentstion
at tho next Comiasion muting.
.fo _atica 'nwwrt on Sources of State Government Tax Revenue Growth
The Executive Director at this point explained that Tab 6
contained 3 ptoposcd information report which attempts to isolate the
gortiont of State tax tchnuc growth attributable to economic growth
on one hand and political decisions on the other. He noted that release
of tho report is planned for the near future. The report contains no
rccoccnndations.
Resolution of Agprecintion
The following resolution in appreciation of the hospitality
of xoyor Alioto and other officials of the City and County of Son
Frsncisco was unanimously adopted:
UHEKEAS. the initial decision of the Advisory
Commission on Intergovornmontel Relations to accept
the gracious invitation of Mayor Joseph Alioto to
hold its September 1968 coating and hearing on
Bouicaid in the City and County of San Franciaco
has proven to be a fortuitous and fruitful one; and
WHEREAS, the resplendent hoSpitality. invaluable
help. and unstinting cooperation of the City, its
Mayor. his high caliber staff and official family
have been a prime factor in assuring the success of
thcsc Commission proceedings; and
HEREAS. the natural and non-node attractions of
this Bay Area and this municipality have had a salutary
effect on our deliberations.
305 Therefore Be It Resolved. that the Advisory
Connissica on Intergovernmental Relations expresses its
sincere appreciation to Mayor Alioto and other officials
of Lhc City and County of San Francisco for their kind
invitation, choir complete cooperation. and their cordial
hospitality.
Date of Sex: eeting
The date of the next mooning was tentatively act for January
17 and 18 in Washington, D. 6., subject to a nail check of thoaa not
pro-ant.
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3r.
3:.
W.
Mr.
3:.
8r.
Observers
John .2. Blampuln. .~ dical World News
Jame: Enrusworth, Number. xichigen House of Representatives;
S.~.ccu:iVe Committee XCSLL
k'illlgm anigen. an; Crose Association
Ron fronkum, Governor'u Office. State of California
John Garrison. Governor's Office. State of New York
Jane ;. Gibson. Member, ovede State Senate
help; (I. Goldberg. Stair. House Subcommittee on intergovernmental
eletione
Thoma Crawb 3:. Bureau of the Budget
John Gunther, {rec term. 3. Conference of any;
Randy Eleniitdla. Executive Director. Institute for Local Self-
Ggycrnmnt. Berkeley
Poweely. Executive Director. National league of Cities
Arthur iiintt. Blue Crou Association
Victor Jun-:8, Professor, University of California. Berkeley
Vernon Konfmnn, Mayors Office, City of Sen Francisco
James Lena. Consultant, California Assembly Comittee on Public
Health
Jack nerelmnn, Rational Association of Counties
Robort McCall. Education Comiuion of the State:
Carol 5. H. Mulder, Director, Office of Health Care Services,
California
D. x. O'Celle an. Regional Director. U. 8. Office of urgency
Planning,.u' wane.
Hillier. Roddy. anyor's Office. City of San Francisco
Don Sampson, Director. wellington State Legislative Cmncil
Claude Shostnl. Governor's Office, State of New York
Cherlce H. Shreve. Regional Director, Departunt of Beelth.
Education, and welfare, Sen Francisco
George Kym, Conduioner, Row York Department of Social Services
C. D. ward. Aide to Governor Agnew
Presiding
Farris Bryant. Chairman
In 1:12 opening remarks, Chairman Bryant noted that the Omission
report, FlJdl Balancu in the Amoricdg Endoral Sxatnn. had just been
rslclbud am: had received prominent trcamnnt in tho prcsn. He also
called attention to :hc fact that a five-titlc Intergovernmental
Cooperation Act had passed the House after four years of effort. The
ExecutiVe Director briefly commented on the differences between the
ance-panacea and Senate-passed Versions of the Intergovernmental
Cooperation Act. and on the status of the conference regarding these
two Versions.
Minutes of Previous Heating
Tao Connisaion approved the minutes of its June 21, 1968 meeting
on they appeared in Tab A of tin Dockct Book.
Consideration of Draft 122011, Intergovernmental Problems in Medicaid
The Chairman initially called mnbers' attention to a letter
from Senator Mundt regarding the draft report on Hedicaid. Thu Chairman
then reviewed the background relating to the Comission's selection of
this topic. and noted that tho report was confined to the intergovern-
mental problems arising in the policies and implmntation of the Hodicaid
program. In:- this point. but Executive Director as askod to sunmrizc
the basic definitions of groups covered by tho Kedicnld program. since
on understanding of these definitions was necessary in considering the
proposed rococrnnndations. reviewed the major findings and
conclusions. and Ell/it than 14 reconnandations were grouped into
{our "families": Goals; Allocation of Rnoponsibility between Federal
-3.
and State GuVurnments; Allocation of Fiscal Responsibility between State
and Local Governments; and;0thet attera Requiring Federal and State
ConstiCUIlonal. Ingislatlve, or Adniniltratlva Change.
Hod Cilia]:-
Governor Rockefeller moved. seconded by Mayor alalsdell. adoption
of Reconnrnuatlon 1. Alternative A. Governor Daniel suggested inserting
the notes. "along with the Stato and localities. after the word "they"
on the fourth line, and this was accepted without objection. Governor
Rockefeller ointdd that to roach Hodicnid'l 1975 goal of eonprohoneiv.
rare {or substgntinlly all the needy and medieolly needy would require .r'
I ' .t. (1' u, '.
. I 1. a
use of a compulsory health insurance plan, as he had proposed in Xev
Yort State. The Chairman noted that otudy of such proposal: was outside
the scape of the present report. Governor Rockefeller suggested amending
Reconmundartnn l. AlternatiVe.A, to cell {or a study of the feeaibility
oi broadening the present basis of financing Medicaid. including the
possibility of none form of employer-employee contributory health
insurantc. warm oat-Moitheaecond. Mayor~nleiadcih the-notion
mwmded. Finally. Governor Denial proposed that the phrase "among
other possibilities" be inserted after the word "including" on line nine
of the ruconaendation with a View to indicating that private sector
invoIVemunt might take seweral forms. This was agreed to and the
recommendation, no amended. was adopted as follows:
Thu Commission recommends that Congretl and the Administration
adhere to the goal of comgrohcnllvo core for "subltantlallz all" the
need! and medicallv needy escablished in Section 120352} of the Social
Seturitv Act, and that the!I along with the State. and localities, take
-4-
such steps q; nuucasurv to move toward that goal; hocher, tho Commis-
nus that Can'tcnu and the Administration stud the
5inn further vacuum
the financial base of the to ram throu h
broadeniu'
L-J~lbill:\i Hf
rivatc sector, including among other
form of on Lo er-cmolo cc contributor health
a; waned LAanJcmcnt of the
wousibilit.oa acme
Igu" ante I
Now Rucnwmonuatlnn
Congressman Fountain submitted a proposed new recomendation
in two alternative: relating to another Medicaid goal:
Alternative A. "The Comission rccowends that Congress amend
the Social Security Act to postpone for two years the 1970 target date
by which States must initiate a Medicaid program for the categorically
needy and some of the categorically related needy, if they are to
continue to receive Federal assistance for any medical vendor payments."
Alternative B. "The Cmiuion toemnd! that Congress amend
the Social Security Act to permit States not participating in Medicaid
to continue receiving Federal assistance for medical vendor payments
until January 1. 1972, provided that they have submitted a proposed
State plan to the Department of Health, Eduction, and welfare by 1970,
and provided further that such plan must be operative by 1972.
Congressman Fountain moved. secondbe Comissimcr Ncnonold,
adoption of Alternative A. Congrcumn Ullman moved. second by Mayor
Maltcstur, substitution of Alternative B. Congressman Fountain moved,
second by Governor Daniel to mend the substitute notion by changing
1970" to "1971." 'ihe amendment you adopted, and the substitute motion
as amended was approved. with £40. Cline, Mayor Raftalin, and Governor
Bockoiuller voting 'o." The approved tecomendction reads as follows:
-5-
Th: Umuuiasinn rocnmmcnda that gonggoss amend the Social Securitz
in Medicaid to continue roceiv
:zn: of Hraizh. Education, and welfare bx 1971I and grovided further
that inch Elan must be oaorativo bx 1972.
New Recommendation
4. Cline aid that at tho Comissiona public hearing an the
previous day. the regional director of the Dopartuont of Baaith.
ducation. and welfare reported that Alaska ondArizona had not initiated
a Medicsid program as yet. because of the fiscal and other problems
surrOunding medical care for Eskimos and Aleuta in Alaska and indiana
in Arizona. These problema. she acted. are related.to the special
responsibilities for those groups exercised by tho Departmentt.of BER
and Interior. On motion of are. Cline. seconded by are. Spoilnan. the
following new recommendation was adopted:
11'": Cominion rocomcndl that the President diroct tho
Secretarie: oi Interior and iioaithI Education. and Noltaro to groggro
and submit a loin: rogort and rccommondutioas to clarify the relation-
shin between Medicaid and the ggical services gravided Indiana. Eskimos,
and other indigonOus scones b1 the Doggrtmant of RealthI EducationI and
U 1 o
Eligibilitv Standards
,g .
nayor Naitaiin moVod-vwith a second by Ron. Cline--approva1 of
accommcadation 2, Alternative A, ceiling for a uniform national-standard
of eligibility. A suostitute motion was offered by Couniosioner
-6-
Spellmon and seconded by Congressman Ullman. endorsing Alternative 3
providing for continuation of present arrangements tor setting eligibility
standards. At this point. Governor Rockefeller proposed modification
oi the oubeiitutc motion recOmnenoing that Congress freeze st lSO percent
the income limitation for medically needy for whom Federal matching
funds are available. and not reduce this level of participation as is
now scheduled. Governor Agnew seconded the amendment and a majority of
the members approvec it with Congressman Fountain, Congressman Uilmen,
x
(9"
and ns. Cline voting "no." At this point. Congressman Ullmsn urged.
with schral other Commission members concurring. that the amended
substitute recommendation include language indicating the desirability
of achiev;ng greater uniformity in the long run among the States in
their respective eligibility standards. An amendment incorporating
this goal was developed by the Executive Director and approved
unanimously. Subsequently. the substitute motion as amended was adopted,
1
with rs. Cline. Congressman Fountain. and Hayor Nsitslin registering
dissents. The recommendation reads as follows:
Although supporting greater interstate uniformity in eligibilitz
roguircmonts as a long-range goal, the Commission recommends continuation
of the present policp under Title 19 whcrobx the Stores establish
standard: of income eligibilitx for the need! and the Federal Government
sets income limits for tho medicallx need! that are related to these
State escablishcd standards' in this connection however the Commission
W
recommends that Congress amend the Act to frecge the present 150 percent
income limitation and pot reduce thip level of pagticipetion as is now
scheduled.
Congressman Fountoln suggested substituting the word "systems"
{or standards in the last lgno of the text on page 5.21. The
Jon: A 0"~ 1
Echutlvc Dirnctor seed the change would be made.
"Own-nth!" vs. "Cloned-End" & to riatiu
Puyur Holtcster moved. seconded by Mayor welsh. adoption of
RecammanJtlon 3. Alternstlvo 3. calling for continuation of an "open-
cnd" opp:oprlation for Medicaid. Congressman Ullmnn, Govornor Agnew.
and Mr. wallacc urged the Commission to search for a middle olternativo
botwnon "open-end" and "closedond appropriationl. Tho Exocutive
Director sold that the text would reflec: the need for developing such
on alternative. The recanmandetion was odoptod.-howovor, with Congress-
O
.l':. 9'.
non Fountain. Governor Bryant, Governor Daniel. and Congressman Ullunn
voting nuuoLLV¢, and reads an follows:
{h; Commisaloa recopnnnds that thg arc-eat grovlston of Title 19
of the Ssczal $c:uri:! Act be retained whorehg congress aggrogriates for
acdlcaic on an "ogen-ch" heals. that is. without limits on the amount
of monex that now go to anv single State.
Full Federal Assumgtion of Cost go: Cntegoricollz Need:
an a mutton by Mayor Walsh, w1th a second by Mayor Malteator.
Commission approval was proposed for Rotonnnndotion a, providlng for
full Federal assumption of cost {or the categoricslly needy snd
categorically related needy. The motion failed on a tte vote. Aftlrmutlve
votoe included e. Cline. layer Blsisdoll. Kayo: Maltcster. Kayo:
Softnlin. and anyor walah; negative votes were ;:;i;;;.3ryont. Congress-
man Fountuln, Commissioner Xenonsld. Commissioner Spellnon, and Congress-
men Ullnon.
I red! IUUw-Ow'az'r,
The unit sm- instructed to draft WW-
/, 2- _
non-5W that the Federal Government, in recognition of the
sctzoua {tucal problems involved in chcrnl mandating of addttionnl
.AV ilh~utst
State and 10:33 responsibtlltias through Medicaid, 1:31! the present
allqcation a! fiscal mpommncy mg the levcls of govetmngntu ./r .I./._/
6 ,/ (on, I a V|/../ x 7rl.. ". ,4 ,,,,Air .1 III.
when the draft was prescntad. a nation 13 mayo: Walsh with a second by
Y
Cummisaionur Spellman proposed approval.oahc-draft-annadncnt.~hutaa-t-
aspasaterecoauundstinn. The nation was adopted, and the now recommend!-
Lion reada.
Recun;zinw
roblemu which arise out of thc Funeral
zandutln sf additiOnal State and local res onsibtlitlo- throu'
19 of the Social Security Act, the Commission recommnudn that Congzess
sad the Accinzatrntton study the grosent allocation of fiscal rcogggsi-
bxlxtv amcnv thn levels nf govggnmcnt with sggglal rcfarenca to the
more circumncribed revenue cagabilltx of the States 35d their localities.
F Cara} Matchin-
Hottcallv Sccdv
-l'O"
hhia racanumndation was moved by Govarnor Agnew. seconded by
for the Son-Cate oticall lated and and
I- LIpl
ComaiSSLunct Spallman, and 1:5;eod. Congressmen Fountain and Ullman
registered dissenta.
The Commisaton tccummcndl that the reggtal government gravide
matching fund to; mudgcnl assistance for the nancategoricallx related
ncudz and the non-categoricallx rglatcd mndicallz needz.
PAGE 8
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PAGE 9
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PAGE 10
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PAGE 13
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PAGE 15
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