# Amicus Curiae Brief — Sullivan v. Zebley > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385012_0469%3A13 ## Record - **Collection:** Supreme Court brief - **Document type:** Amicus Curiae Brief - **Published:** January 1, 1990 - **Citation:** 493 U.S. 521 ## Text No. 88-1377. JOSEPH ©. SPAMIOL, JR. In the Supreme Court of the United States. OctToser Term, 1989 LOUIS W. SULLIVAN, Secretary or HEALTH AND HUMAN SERVICES. PETITIONER, *. BRIAN ZEBLEY, eT AL.., RESPONDENTS ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS POR THE THIRD CIRCUIT Brief of the Commonwealths of Massachusetts and Pennsylvania, the States of Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, Illinois, Indiana, lowa, Kansas, Louisiana, Maryland, Minnesota, Missouri, Montana, Nebraska, New New York, Rhode Island, South Dakota, Tennessee, Texas, Utah, Vermont and W yoming, and the District of Columbia, Amici Curiae in Support of Respondents. JaMES M. SHANNON, Attorney General, SUZANNE E. DURRELL,* JUDITH FABRICANT, Assistant Attorneys General, One Ashburton Place, Boston, Massachusetts 02108 (617) 727-2200 *Counsel of Record See inside cover for additional counsel BATEMAN @& SLADE. Ie BOSTON. MASSACHUSETTS Don Siegelman, Attorney Genera! State of Alabama Douglas B. Bailey, Attorney Genera State of Alaska Robert K Corbin. Attorney Genera State of Anzona john Steven Clark. Afforney Genera State of Arkansas Clarme Nardi Riddle, Acne Amorn State of Connecticut Charlies M. Oberty, III. Attorney Gener State of Delaware Herbert ©. Rend. Sr 4ctine ( orporati Charlies L. Reichel, Deputy Corpora Appellate Division. District of Columba Neil F. Hartigan. Attorney Genera State 1 Iilino Lime Pearsor arr Ne en State of Indiana Thomas | Mille 4 | vie ‘serie? State of lowa Robert T. Steph 1 rive en. State of Kansas Stat { Marviand TABLE OF CONTENTS TABLE OF AUTHORITIES INTEREST OF AMICI CURIAE SUMMA ’.Y OF ARGUMENT ARGUMENT I. THE SOCIAL SECURITY ADMINISTRATION'S UNDULY RESTRICTIVE APPROACH TO SSI ELIGIBILITY DETERMINATIONS FOR CHILDREN SHIFTS TO THE STATES COSTS THAT CONGRESS HAS DECIDED SHOULD BE BORNE AT THE FEDERAL LEVEL. A. Welfare Programs. 1. Aid to Families With Dependent Children. 2. General Assistance. B. Specialized State-Funded Health Care Programs. C. Other Health Care Costs. D. Additional Long-Term Costs. II. THE COURT NEED NOT DEFER TO THE SOCIAL SECURITY ADMINISTRATION'S ERRONEOUS INTERPRETATION OF THE GOVERNING STATUTE. CONCLUSION Page 10 31 37 Cases Alfred L. Snapp & Son, Inc. v. Puerto Rico, 458 U.S. 592 (1982) American Tobacco Co. v. Patterson, 456 U.S. 63 (1982) 34, 35, Avery v. Heckler, 584 F.Supp. 312 (D. Mass. 1984), aff'd, 762 F.2d 158 (lst Cir. 1985) Batterton v. Francis, 432 U.S. 416 (1977) Bethesda Hosp. Ass'n v. Bowen, 485 U.S. 399, 108 S. Ct. 1255 (1988) Board of Governors, FRS v. Dimension Financial Corp 474 U.S. 361 (1986) Burlington Northern R. Co. v. Oklahoma Tax Commission, 481 U.S. 454 (1987) 35, 35n, Chevron U.S.A... Inc, v. Natural Resources Defense Council, Inc., 467 U.S. 837 (1984) 32, 12 22 35 34 36 34 City of New York v. Heckler, 578 F.Supp. 1109 (E. D. N. I.), aff'd, 742 F. 2d 729 (2d Cir. 1984), aff'd sub nom., Bowen v. City of New York, 476 U.S. 467 (1986) 11 DeLeon v. Secretary of Health and Human Services, 734 F.2d 930 (2d Cir. 1984) 5n Dickerson v. New Banner Institute, Inc., 460 U.S. 103 (1983) 35n Dixon v. Heckler, 589 F.Supp. 1512 (8. D. N. I. 1984) 12 a Band of Mission Indians, 466 U.S. 765 (1984) 35n ＋ Griffin v. Oceanic Contractors, Inc 458 U.S. 564 (1982) 35n Holden v. Heckler, 584 F.Supp. 463 (N.D. Oh.), remanded, 754 F.2d 372 (6th Cir. 1984) 12 INS v. Cardoza-Fonseca, 480 U.S. 421 (1987) 32, 33 Lukhard v, Reed, 481 U.S. 368 (1987) 4n iii Page Lyng v. Castillo, 477 U.S. 635 (1986) 5n Marcus v. Bowen, 696 F. Supp. 364 (N. D. 111. 1988), appeal pending, No. 89-2717 (7th Cir.) 32, 37 NLRB v. United Food and Commercial Workers Union, 484 U.S. 112, 105 S.Ct. 413 (1987) 32, 33 Regents of University of California v. Public ions Board, 485 U.S. 589, 108 S. Ct. 1404 (1988) 33, 34 Rodriguez v. U.S., 480 U.S. 522 (1987 35n Schweiker v. Gray Panthers, 453 U.S. 34 (1981) 11 Wyman v. James, 400 U.S. 309 (1971) 2 zebley v. Bowen, 855 F. 2d 67 (3d Cir. 1988) passim iv « Federal Statutes and Legislative Sources 42 U.S.C. § 602(a)(7) (1982) 42 U.S.C. § 602(a)(24) (1982) 42 U.S.C. § 603 (1982) 42 U.S.C. § 607 (1982) 42 U.S.C. § 607(b), as amended by Act of Oct. 13, 1988, Pub. L. 100-485, Title IV, and Act of Nov. 10, 1988, Pub. L. 100-647, Title VIII 42 U.S.C. §§ 1381-1383c (1982) 42 U.S.C. § 1382 (1982) 42 U.S.C. § 1382c(a)(3) (A) (1982) 15, 36, 42 U.S.C. § 1396a(a) (10) (A) (ii) (1982) 42 U.S.C. § 13963 (a) (10) (A) (i) (11 (1982) Act of Sept. 19, 1984, Pub.L. No. 98-460 1984 U.S. Code Cong. & Ad. News 3046-62 Page l7n 18 17 21 2In 10 17n 37n 22 13 5n 5n Federal Statutes and Legislative Sources (continued) H.R. Rep. No. 231, 92nd Cong., 2d Sess., reprinted in 1972 U.S. Code Cong. & Ad. News 4989 3. 12, H.R. Rep. No. 231, 92nd Cong., 2d Sess., reprinted in 1972 U.S. Code Cong. & Ad. News State Statutes Mass. Admin. Code Tit. 106, § 312 (1988) 20 Mass. Gen. Laws ch. 117, §§ 1-25 (1986) 20 Mass. Gen. Laws ch. 118E, § 6B (Supp. 1988) 27n Mass. Gen. Laws ch. 118F, §§ 15, 17 (Supp. 1988) 27 Mass. St. 1989, c. 240, § 2, items 0321-1600 and 0321-2000 5n Md. Ann. Code Art. 88A, §§ 65A, 65B 20 Miscellaneous N. Hobbs, et al., Chronically Ill Children and Their Families, pp. 62-10) (1985) 29, 30 »- 73 « - Miscellaneous (continued) "Survey of Disabled Children Under SSI Program”, Social Security Bulletin, January, 1980, Vol. 43, No. l, p. 10 17 United States Department of Health and Human Services, Characteristics of State Assistance Programs for SSI Recipients, (1989) 13, 14, 19n United States Department of Health and Human Services, Characteristics of State Plans for AFDC (1988) 2 In Urban Systems Research and Engineering, Inc., Characteristics (U.S. Department of Commerce, National Technical Information Service, 1983) 20n - wii - No. 88-1377 IN THE SUPREME COURT OF THE UNITED STATES October Term, 1989 Louis W. Sullivan, Secretary of Health and Human Services, Petitioner, v. Brian Zebley, et al. Respondents. ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT Amici curiae submit this brief Support of respondents. Amici urge this in Court to affirm the judgment de lo, which invalidated the Social Security Administration's ("SSA's") policy’ te- garding eligibility of disabled children for Supplemental Security Income ("SSI") benefits. As this Court has recognized, each state has a “quasi-sovereign interest in the health and well-being - both phys- ical and economic - of its residents in general.” Alfred L. Snapp & Son, Inc. vy. Puerto Rico, 458 U.S. 592, 607 (1982). Where the interests of children are concerned, the states’ interest is particularly strong; indeed, “[(t)here is no more worthy object of the public's concern” than protection and aid for de- pendent children. Wyman v. James, 400 U.S. 309, 318 (1971). The states’ interest in the welfare of their children is most acute with re- spect to those whose needs are greatest, and whose families are least able to provide for them, so that they are most dependent on the benefits provided by the various levels of government. As Congress expressly recognized in enact- ing the Social Security Amendments of 1972, children who are both poor and disabled, and the families of such chil- dren, are among the neediest and most disadvantaged. H.R. Rep. No. 231, 92nd Cong., Ind Sess., seprinted in 1972 U.S. Code Cong. & Ad. News 4989, 5133-34. Amici therefore have a strong interest in these children's access to the bene- fits granted them by federal statute. In addition to their concern for the welfare of their citizens, the states * have a strong interest in protecting themselves from undue fiscel burdens. Because of their commitment to the wel- fare of their neediest citizens, the states operate various partially or wholly state-funded health and welfare programs, to which applicants rejected from federally-funded programs may turn for assistance. To the extent’ that these state-funded programs fill a gap in federal coverage caused by unlawful rejections, the federal administrative policies that cause those rejections have the effect of shifting costs from the federal level to the states.+/ l/ The policy challenged in this case may be seen as part of a larger effort to shift costs of welfare programs from the feder government to the states. Although e of these efforts have been upheld, see, eg. Lukhard v. Reed, 481 U.S. 368 (1987) (plurality) (upholding (footnote continued) abe Such cost-shifting subverts the will of Congress, to the detriment of both the states themselves and their neediest citizens. Amici have strong interests (footnote continued) restrictive application ot statutory change in income standard for Aid to Families with Dependent Children); Lyng v. Castillo, 477 U.S. 635 (1986) (up- holding statutory change restricting Food Stamp eligibility), many have been overturned, eitber by court decision or by legislative enactment. See. 8.8. DeLeon vy. Secretary of Health and Human Services, 734 F.2d 930 (2d Cir. 1984) and cases cited at 937 (restricting or invalidating Social Security Adminis- tration's Continuing Disability Review program); Act of Sept. 19, 1984, pub. L. No. 98-460; 1984 U.S. Code Cong. & Ad. News 3046-62 (restricting Continuing. Disability Review program and mandating alteration in other Social Security Ad- ministration policies). In order o de- fend themselves against the fiscal im- pact of such cost-shifting, several states have found it cost-effective to fund programs of :egal assistance for persons claiming eligibility for certain federal benefits, e.g., Mass. St. 1989, c. 240, § 2, items 0321-1600 and 0321-2000, allocating funds for that purpose. * * in correcting such erroneous cuministra- tive policies. In this case, SSA has adopted an ap- proach to determining disability in children that is so rigid and restric- tive as to exclude many children who are severely disabled. The consequences of this policy are devastating to those children and their families, and harmful to the states’ interests as well. Amici therefore urge this Court to affirm the judgment below, which invalidated SSA‘s policy and enjoined its further application. SUMMARY OF ARGUMENT 1. In enacting the 881 statute, Congress intended to relieve the states of the fiscal burden of caring for the disabled, and to assume that burden at 83 the federal level. Congress include”. low-income disabled children in the SSI program in order to provide for the spe- cial costs of their care, and to ensure that those costs would not fall to the states (pp. 10 to 14). By applying an overly restrictive standard for disability determinations for children, SSA has excluded from the SSI program low-income children suffer- ing from severe disabilities. In this manner, SSA has shifted to the states certain costs of the care of such children, and has thereby thwarted the will of Congress (pp. 14 to 16). Children who are erroneously denied SSI benefits and asseciated Medicaid coverage often fall beck on Aid to Fami- lies with Dependent Children ("AFDC"), or state-funded general assistance and medical assistance programs. Such erro- neous denials thus increase the costs of these programs to the states. In addi- tion, such children may receive assistance from various specialized, state-funded health and human services programs, thereby draining the resources that would otherwise be available through those programs for services to others. State and local governments may also bear the costs of health care for such children through subsidies to pub- lic hospitals or to private hospital un- compensated care programs. Disabled children who do not receive care may suffer increased life-long dependency on publicly- funded services with consequent costs to the states (pp. 16 to 31). II. The Court of Appeals correctly ruled that SSA's regulations reflect an erroneous interpretation of the govern- ing statute, and are therefore invalid. In evaluating SSA's policy, the Court need not defer to the agency's interpre- tation, because congressional intent can be determined through traditional tools of statutory construction. Since SSA's regulations conflict with congressional intent as so determined, they must fall (pp. 31 to 34). The process of statutory construc- tion must begin with the plain meaning of the statutory terms. Here, the plain terms of the governing statute require that eligibility standards include each child who suffers from any impairment or combination of impairments of comparable severity to those that would disable an adult. In violation of this statutory requirement, SSA limits eligibility to those children whose impairments meet or equal its listing of impairments, with- out providing for any individual deter- mination of the functional effects of each child's impairment or combination of impairments. SSA‘s policy thus con- flicts with the plain terms of the stat- ute (pp. 34 to 37). ARGUMENT I. THE SOCIAL SECURITY ADMINISTRATION'S UNDULY RESTRICTIVE APPROACH TO SSI ELIGIBILITY DETERMINATIONS FOR CHIL- DREN SHIFTS TO THE STATES COSTS THAT CONGRESS HAS DECIDED SHOULD BE BORNE AT THE FEDERAL LEVEL. The SSI program, 42 U.S.C. §§ 1381- 1383c (1982), was established by Con- gress in 1972, to replace earlier state- 10 administered programs of aid to the ei- derly, blind and disabled. See Schweiker v. Gray Panthers, 453 U.S. 34, 38 (1981). In replacing state programs with an entirely federally-funded program, Congress indicated its inten- tion to relieve the states of the costs of providing such aid, and assumed that cost at the federal level. Fiscal relief to the states was no accidental effect of the statute; rather, one of Congress's expressly stated purposes was to relieve state and local governments of the soaring costs" of existing programs for the disabled. City of New York «. Heckler, 578 F.Supp. 1109, 1121 (E.D. N. v.). aff'd, 742 F.2d 729 (2d Cir. 1984), aff'd sub nom., Bowen v. City of New York, 476 U.S. 467 (1986), citing legis- -ll- lative history of the 1972 Act. See also Dixon v. Heckler, 589 F.Supp. 1512, 1516 (S.D.N.Y. 1984); Holden v. Heckler, 584 F.Supp. 463, 467, 486 (N.D. Oh.), remanded, 754 F.2d 372 (6th Cir. 1984); Avery v. Heckler, 584 F.Supp. 312, 316 (D. Mass. 1984), aff'd, 762 F.2d 158 (lst Cir. 1985). As established by Congress, the SSI program provides financial assistance not only to adults disabled from sub- stantial gainful employment, but also to disabled children who live in households with very low income. Congress included low-income disabled children in the SSI program, although they had not been in- cluded in earlier disability programs, in recognition of the extraordinarily high cost of their daily care. H.R. Rep. No. 231, 92nd Cong. 20 Sess., re- elie printed in 1972 U.S. Code Cong. & Ad. News 4989, 5133-34. For the low-income family of a disabled child, SSI cash benefits can meet the otherwise prohibi- tive costs of specialized day care, skilled home care, rehabilitation pro- grams, special equipment, and other es- sential goods and services necessitated by the child's condition. In addition to cash assistance for such purposes, and even more crucial for many families, SSI coverage in the over- whelming majority of states conveys au- tomatic eligibility for Medicaid, assur- ing the disabled child's access to ur- gently needed health care. See 42 U.S.C. § 1396a(a)(10)(A)(i) (II) (1982); see also United Sta es Department of Health and Human Services, | 3 F State Assis — 2. grams _for SS] Recipients, (1989), p. 110. For low-income families of children who require frequent and cost- ly medical treatment, the importance of such ceverage cannot be overstated. Even the rare low-income family that has access to private health insurance, through employment or otherwise, may de- pend heavily on SSI-based Medicaid cov- erage to ensure a disabled child's ac- cess to medical care; insurance may leave a significant portion of charges uncovered, may exclude necessary spe- Cialized services, or may even exclude the child entirely because of his or her condition. Despite Congress's expressed inten- tion to guarantee SSI benefits for dis- abled children, and thereby to relieve the states of the costs of their care, SSA has adopted a rigid, restrictive ap- proach to e:igibility determinations for children that effectively excludes many whose conditions do in fact disable them severely. Although the statute by its terms requires comparable treatment of adults and children in disability deter- minations, 42 9. C. 5 1382c(a)(3)(A) (1982), SSA subjects children to a more restrictive standard than adults, te- quiring only children to demonstrate medical findings that meet or equal those included in its listings of pre- sumptively disabling conditions, and providing no mechanism for evaluating the combined effect of multiple impair- ing conditions on children. 2. As s result, large numbers of chil- dren whose impairments are comparable to ones that would disable adults from sub- stantial gainful employment are denied SSI benefits, in contravention of the Statute. Many of these low-income, dis- abled children and their families turn to state programs for assistance with the financial burdens arising from their impairments. Thus, through its cdminis- trative policy, SSA has circumvented Congress's intention to assume these burdens at the federal level, and has shifted them to the states. A. Welfare Programs. Re Aid to Families With Dependent Children Erroneous denials of SSI benefits to disabled children impose a wide variety 216 of direct and indirect burdens on state budgets. The most direct costs appear in welfare programs partially or wholly funded by the states. Many children who are financially eligible for SSI are members of families who also qualify for Aid to Families with Dependent Children ("AFDC"). See, @.g., “Survey of Disabled Children Under SSI Program", Social Security Bulletin, January, 1980, Vol. 43, Wo. tl, op. 10.4/ Approximately half of the fund- ing for AFDC benefits comes from the state. 42 U.S.C. § 603 (1982). 2/ The proportion of SSI eligible fami- lies who also qualify for AFDC varies from state to state, because AFDC finan- ciel eligibility criteria vary among the states, while SSI financial eligibility is uniform nationwide. 42 U.S.C. §§ 602 (a)(7), 1382 (1982). =, = The amount paid to a family on AFDC depends on the number of persons in the AFDC assistance unit. Since a child re- ceiving SSI is autometically excluded from the assistance unit, that child's SSI eligibility reduces the size of the unit for AFDC purposes, and consequently reduces the financial burden on the state. 42 U.S.C. § 602(a)(24) (1982) .27 Conversely, if the child is erroneously excluded from 881, and 3/ For example, an AFDC-eligible family with two children would be treated for AFDC purposes as a family with one child if the second child were on SSI. The family would receive the child's SSI benefit, plus an AFDC grant for the other family members. If the second child were denied SSI benefits, however, the family would be treated as having two children and would receive a higher AFDC grant. The increased AFDC grant would not be enough to offset the lost SS. benefit, so both the family and the state would suffer an economic loss. -18- therefore remains in the AFDC unit, the state's AFDC burden is higher than it would be otherwise be. For the family, however, the denial of SSI coverage out- weighs the additional AFDC benefit, Since SSI payments are uniformly higher than the incremental AFDC payment for an additional family member . 4/ 4/ In states that supplement 881 payments and that include children among those eligible for such supplements, the cost of AFDC benefits for these children may be at least partially offset by reduced SSI supplements. The fiscal impact on states of such offsets varies widely because of the greatly varying size of, and eligibility requirements for, supplements paid by the states. See United States Dept. of Health and Human Services, Characteristics of State Assistance Programs for SSI Recipients (1989). -19- . General Assistance. Many states also operate general as- Sistance programs that provide both cash benefits and medical assistance to low- income families not eligible for AFDC. Ea. Md. Ann. Code Art. 88A, §§ 65A, 65B; Mass. Gen. Laws ch. 117, §§ 1-25 (1986); Mass. Admin. Code Tit. 106, § 312 (1988).2 These programs are operated and funded completely by the states and local governments, wit.: no 37 As of 1983, at least forty-two states had general assistance programs and at least thirty-four states had med- ical assistance programs for which chil- Gren wrongfully denied SSI could qual- ify. Urban Systems Research and Engi- neering, Inc., Characteristics of Gen- eral Assistance Programs 1982 ( U.S. Department of Commerce, National Techni- cal Information Service, 1983). -20- federal contribution to either the cash benefit or the medical assistance. In states that do not participate in the AFDC-Unemployed Parent ("AFDC-UP") program, see 42 U.S.C. § 60/ (1982), general assistance may be the only wel- fare program available to children in 87 Even in states two-parent families. that do have the AFDC-UP program, some families who do not meet the particular requirements of that program may be eli- gible for general assistance, medical 6/ As of 1988, twenty-eight states and other jurisdictions operated AFDC-UP programs; twenty-six did not. United States Department of Health and Human Services, Characteristics of State Plans for AFDC (1988). A modified form of the AFDC-UP program will become mandatory for all jurisdictions as of October 1, 1990. 42 U.S.C. § 607(b), as amended by Act of Oct. 13, 1988, Pub. L. 100-485, Title IV, and Act of Nov. 10, 1988, Pub. L. 100-647, Title VIII. afte assistance, or both. See generally (1977). SSI coverage for a disabled child reduces general assistance payments to the child's family by decreasing the amount of general assistance for which the family is eligible. Conversely, im- proper denials of SSI coverage increase the burdens on general assistance programs, to the states’ fiscal detri- 17 In states not adopting the ment. Medicaid-Under 21 program, 42 U.S.C. § 1396a(a)(10)(A)(ii) (1982), any med- ical benefits to these children 7/ For example, the Massachusetts De- partment of Public Welfare noted dra- matic increases in the number of inca- pacitated adults receiving General Re- lief during the years 1981-1983, when the Social Security Administration im- plemented a nationwide ,rogram of re viewing earlier SSI disability determi- nations. 222. also are funded solely by the states; those states thus suffer an even greater fiscal drain from improper denials of 881.87 B. Specialized State-Funded Health Care Programs. In addition to AFDC and general as- Sistance programs, a wide variety of state-funded health and human service programs bear increased burdens when children are erroneously excluded from 8/ Improper denials of SSI eligibility to children increase the states’ AFDC and general assistance burdens through an additional, less direct mechanism. Without funds for the purchase of ser- vices, a disabled child's need for con- stant, specialized care may prevent a parent from working, thus rendering the entire family dependent on state-funded benefits. For many such families, SSI benefits could make employment -- and economic independence -- possible by funding alternative care for the dis- abled child. 289. 881. In Massachusetts, for example, three programs sponsored by the Department of Public Health ("DPH"), funded solely by the Commonwealth, pro- vide limitod quantities of goods or ser- vices to children with special medical needs. The “Home Health Care” program pro- vides intermittent at-home assistance in the care of multiply handicapped chil- dren, particularly after surgery or at times of emergency, thus promoting the ability of families to care for their children at home. The “Early Interven- tion“ program provides a variety of spe- cialized rehabilitative therapies, to promote maximum long-term development of children with developmental delay. Under the “Special Medical Needs” pro- gram, DPH has provided chronically ill -24- or physically impaired children with one-time grants of up to five thousand dollars for medical procedures or 1€habilitative equipment. Funds for these and similar programs are limited, however, and services are provided only subject to availability of funds. To the extent that families can use SSI benefits to purchase these ser- vices, or that Medicaid reimbursement is available as a result of SSI eligibil- ity, limited state resources can be used for services to other equally needy per- sons. Conversely, for disabled children who are erroneously denied SSI benefits, such limited state-funded programs may be the only alternative.“ 9/ Similarly, state-funded mental health and mental retardation services, respite care, case management, and (footnote continued) . S. Qther Health Care Costs. Even when disabled children who are erroneously rejected from SSI and corresponding Medicaid coverage do not participate in state-funded programs, dhe costs of whatever health care they receive ultimately falls, at least in part, upon state and local governments. Children who lack adequate health insur- ance or Medicaid coverage often rely on public hospitals, which are supported by states and local governments. Even pri- vate hospital charges, when left unpaid by a child's family, may ultimately te- (footnote continued) related programs bear undue burdens in serving children who are erroneously excluded from SSI and related Medicaid eligibility. 260 vert to state-subsidized uncompensated care pools. Ses, e.g., Mass. Gen. Laws ch. 118F, §§ 15, 17 (Supp. 1988). Through such mechanisms, state funds 01 timately fill some of the gap that is created when SSA policy causes chroni- cally ill and disabled children to be excluded from the program that Congress intended to fund their care. +2/ 107 State-subsidized insurance or guasi-insurance programs may also assist in paying the costs of health care for these children. For example, the Massa- chusetts “CommonHealth" program, Mass. Gen. Laws ch. LI8E, § 6B (Supp. 1988), provides health benefits to disabled children who are not eligible for SSI. This program is designed for families who are financially ineligible for SSI; the Massachusetts statute incorporates the SSI disability standards. Disabil- ity determinations for the program, how- ever, are made separately from SSI de- terminations. Thus, it is possible that some disabled children who are improper- ly rejected from SSI may participate in this state-funded program. 99. These state-funded programs, numer- ous and costly as they are, do not en- sure a disabled child's access to neces- sary services. Without SSI benefits and associated Medicaid coverage, some chil- dren will not receive preventive and re- habilitative services that would promote their development II“ ultimately, for some of these children, such deprivation will result in greater life-long depend- ency on publicly-funded services, in- cluding institutional care, than would otherwise have been necessary. For the III