Congress is moving fast to reauthorize the State Children's Health Insurance Program, which is set to expire at the end of March. Reauthorization bills have already passed both chambers of Congress.

Conservatives were quick to complain that the legislation fails to require coverage of the poorest kids before expanding up the income ladder. There also were questions raised about whether immediately covering legal immigrants who are not yet U.S. citizens would eventually lead to coverage of illegal aliens.

Sen. Charles Grassley of Iowa, the ranking Republican on the Finance Committee, objects that both bills ignore last year's agreement "to prevent the crowd out of private coverage, putting more pressure on the federal budget."

Both bills carry $32 billion price tags and would cover about 11 million kids. Both would allow states to lift a five-year coverage delay for legal immigrants and pregnant women. The House bill would place restrictions on physician-owned specialty hospitals.

What do you think are the major strengths or weaknesses of the SCHIP bills passed by the House and Senate?

-- Marilyn Werber Serafini, NationalJournal.com

America’s economic crisis extends into all walks of life and affects millions of people.  Children can be hit the hardest by the recession and hard-working families are struggling to care for themselves.  With rising unemployment, families should not worry about whether or not they can afford to take their children to the doctor.  By extending health coverage to millions of uninsured children, Congress is making the statement that health care is a top priority for the 111th Congress.

The new SCHIP legislation preserves coverage for the 7 million children currently covered under the program and extends coverage to 4 million uninsured children who are currently eligible for, but not enrolled in, Medicaid or SCHIP.

Twice in the 110th Congress, the House and Senate passed bi-partisan legislation to re-authorize and improve S-CHIP only to receive a veto from President Bush.  I shudder to think how many children were unable to afford proper care during that span of time and I hope their long-term health will not suffer as a result.

President Obama has promised to sign this legislation into law and will take a much needed step towards fixing an ailing health care system.  It is completely unacceptable that there are millions of children in America today who would not have health insurance if not for this legislation.   Children’s health should no longer be a political pawn.  Emergency room care providers should not have to provide basic health care that a primary doctor would normally give.  Access to health care must change, and S-CHIP expansion is a perfect place to start.

This version of S-CHIP is more state-friendly than drafted previously.  It gives the states the option to eliminate the restrictions which result in a five-year delay in coverage for low-income uninsured children and pregnant women who are legally in the United States.  It allows for improved outreach, dental coverage and other improvements over the length of the four-and-a-half years of the extension of the program.  The cost of the program will be paid for by an increase in the tobacco tax.  It is fitting that a tax on a primary cause of diseases in our country will pay for keeping our children healthy and the higher cost of cigarettes will hopefully discourage children from beginning a deadly habit.

State allotments will be responsive to state demographic and national spending trends.  States that face a funding shortfall and meet enrollment goals will receive an adjustment payment so an eligible child is not denied coverage.  There are also provisions in place to place caps on funding to ensure that expenditures do not exceed the authorized amounts.  In New York, over 650,000 children were enrolled in the state’s stand-alone Child Health Plus program and is the third largest S-CHIP program in the nation.   Thanks to S-CHIP, New York was able to reduce the number of uninsured children by 40 percent at the end of 2006 – one of only seven states to achieve a decline of that magnitude. 

S-CHIP has served New York and our nation well and I will continue to support this important program to care for our children’s health.

The State Children’s Health Insurance Program (SCHIP) has been instrumental in helping millions of America’s children get a healthy start in life, putting them on a more productive path.  With more than 7 million low-income children receiving health care coverage through SCHIP, it’s important that our nation acts now to protect this precious resource. 

Studies show that uninsured children do poorer in school than their insured classmates, and can suffer severe health consequences. Uninsured children are more than twice as likely to go without care for recurring ear infections, which, if untreated can lead to permanent hearing loss. They are 25% more likely to miss school than insured children.  They are four times more likely to end up in the emergency department with conditions that could have been avoided.   Children without insurance are between three and five times more likely to have unmet medical needs than insured children.  Being without health coverage limits a child’s ability to grow, thrive and engage in society in a productive way.    

We’re pleased that the House of Representatives recently passed H.R. 2, the Children’s Health Insurance Program Reauthorization Act of 2009.  This legislation will secure coverage for those 7 million children and add coverage to approximately 4 million more, most of whom are eligible for Medicaid or SCHIP but are not enrolled. 

We also support provisions in the legislation which give states the flexibility to eliminate the five-year waiting period for legal immigrant children and pregnant mothers to be covered under SCHIP.  H.R. 2 continues to fund SCHIP through the federal tax on tobacco, and we support increasing this tax to make certain SCHIP has the resources to cover as many children as possible. 

The Senate is currently debating a very similar version of H.R. 2 and with the March 31 deadline looming, we urge the Senate to help make certain that low-income, uninsured children get the health care coverage they need and deserve and pass SCHIP reauthorization. 

We must continue to work together to make health coverage for children as universal as elementary and secondary education.

 Free The Kids

 House and Senate Democrats are pushing to expand SCHIP eligibility to the middle-class.  They seem undeterred by research from Obama’s own advisor, David Cutler, which determined that Medicaid expansion from the early 1990s resulted in a crowd-out rate of 49% to 74%.  More recent work by Cutler’s co-author, Jonathan Gruber, found an average crowd-out rate of about 60% for SCHIP. 

Expanding SCHIP also runs the risk of reducing access to care as families drop private insurance to enroll in lower-cost public coverage.  Public programs tend to reimburse providers at much lower rates than private coverage.  As a result, providers are loath to participate, making it a struggle to find a doctor. 

Another problem with expanding SCHIP is the high cost – nearly $2,000 per child.  This seems excessive by about double, given that children are generally healthy and cheap to insure in the private market.

The affordable funding mechanism to expand health coverage for children is already in place.  Read my ten-point plan to Free the Kids.

The Children’s Health Insurance Program (CHIP) provides health care coverage for children living in families not poor enough for Medicaid, but still unable to afford private health insurance.  Today, nearly seven million children rely on CHIP to get the doctor’s visits and medicines they need to stay well.  Renewing this vital program will give more than four million more low-income, uninsured kids access to care under CHIP.

The Children’s Health Insurance Program Reauthorization Act of 2009 is nearly identical to bills that Democrats and Republicans worked together to craft and pass in 2007, which were later vetoed by President George W. Bush.  Some in Congress have raised objections to the few changes that were made.  They oppose lifting the five year ban on legal immigrant children being eligible for CHIP, but those kids come from low-income families with parents that work hard and pay taxes just like citizens.  And, those kids need check-ups and prescriptions just like all  other CHIP kids.  Some in Congress say this bill does nothing to minimize the number of CHIP-eligible kids who move from private health insurance into CHIP.  But in reality, this bill creates a new option for states to subsidize private coverage for CHIP-eligible kids, makes it easier for states to offer premium assistance, and provides incentives for enrollment of the lowest-income kids who are least likely to have private insurance. 

A few modifications have been made, but the changes between this bill and the bills passed overwhelmingly Congress in 2007 pale in comparison to the similarities between them.  

In its first decade, the Children’s Health Insurance Program reduced the number of uninsured kids in this country by one third.  Keeping America’s next generation healthy was the focus of the Children’s Health Insurance Program when it was created in 1997 and when Congress passed legislation to reauthorize the program in 2007.  I urge my colleagues to keep healthy kids a priority in Congress, and join me in supporting  the Children’s Health Insurance Program Reauthorization Act of 2009. 

Expansion of the State Children's Health Insurance Program would make high-quality health insurance coverage available to four million more of America's previously uninsured, low-income children -- clearly an important goal that means more than just care.  It also means peace of mind.  That's why the Pharmaceutical Research and Manufacturers of America (PhRMA) supported passage of H.R. 2, the Children's Health Insurance Program Reauthorization Act of 2009.

The bill does more than just expand eligibility; it also expands outreach activities to get eligible children enrolled.  In addition, H.R. 2 takes the novel step of enhancing a state's option to use SCHIP to help subsidize qualified employer-sponsored coverage for low-income children and families.  This maximizes the effectiveness of both public and private sector coverage and will improve access to health care services.  

The bill encourages development of pediatric quality-of-care measures.  How productive it is for legislation that aims to provide patient access to health care for that same bill to work toward improving health outcomes for those patients!  

Expansion of SCHIP, along with other programs such as Medicare and Medicaid, could be an important step toward meaningful health care reform that helps millions of Americans who are uninsured get the health care they need.  Let's just make sure that the SCHIP expansion itself is meaningful. 

The American Medical Association supports adequate funding of SCHIP so that all children who are eligible for the program can be enrolled and to ensure pregnant women get the care they need. More funding for outreach and education, as well as efforts to reduce enrollment barriers, should improve access to SCHIP coverage for eligible children. A premium assistance program will also give states more flexibility to coordinate and partner with existing employer-provided health insurers while easing budgetary pressures on SCHIP in the process.

We also view increasing the federal tobacco tax to fund SCHIP as a win-win proposal that will help children get the health care they need while also acting as a deterrent to young smokers and potential smokers. Studies show that for every 10 percent increase in the price of cigarettes, youth smoking is reduced by seven percent, and overall tobacco consumption is reduced by four percent. Higher tobacco taxes result in lower smoking rates in the long run, which will generate long-term health care savings - as fewer smokers means fewer people with strokes, heart attacks, cancer and other smoking-related conditions.  

Expanding coverage to the millions of uninsured Americans is a top priority of the American Medical Association, and we support and applaud the House passage of SCHIP reauthorization.  We look to the Senate to take action, as well.  However, we believe the important work of reauthorizing SCHIP should focus on providing care to children in need and not on limiting access or choice for Medicare beneficiaries through provisions that would place restrictions on physician ownership of hospitals.  We oppose provisions in the House bill that restrict physician-owned hospitals, which have been demonstrated to provide high quality care and patient satisfaction.

"Expanded access to quality health care for children and provisions that address childhood obesity are among the strengths of the SCHIP legislation. We’re pleased that the House and Senate bills would expand access to affordable health care for an additional four million children.  This is extremely important for children from low-income families who are born with heart-defects – the No. 1 birth defect in the United States.  The legislation helps strengthen the medical safety net to help these children lead healthy and productive lives.  The American Heart Association also supports provisions to expand coverage to low-income pregnant women - which can help reduce all forms of birth defects.  And with more families confronting health risks associated with obesity, including an increased risk of heart disease and stroke, funding for a demonstration project to develop a comprehensive and systematic model for reducing the incidence of childhood obesity is both timely and necessary.   And finally, the decision to support the costs of these provisions with an increase in federal excise taxes on cigarettes and other tobacco products will save countless lives and reduce health care costs.  Evidence has demonstrated that a ten percent increase in the cost of a pack of cigarettes reduces smoking in youth by seven percent and overall by four percent."

 Although NAHU would like to see additional steps taken by Congress concerning cost-sharing limitations, crowd-out requirements and uniform national requirements for employers, these bills do go a long way toward ensuring that states will have an additional option to cover the children of low-income working parents in an affordable and family-friendly manner. Many parents of SCHIP-eligible children have access to employer-sponsored health insurance coverage but cannot afford their portion of the dependent premiums. This bill sought to make the process for states to voluntarily use SCHIP dollars to subsidize employer-sponsored coverage much simpler, so that more families can be covered together under the same private market plan.     

 Allowing states to pursue innovative and cost-efficient partnerships with the employer-sponsored plans of the parents of children who are eligible for SCHIP is an important foundation for ensuring that SCHIP works to combine the best that the public and private sectors have to offer. NAHU believes that the inclusion of premium assistance improvements will go a long way toward leveraging premium dollars that employers are willing to contribute toward family coverage while helping to ease budgetary pressures on SCHIP. 

It’s sad that this SCHIP bill is a return to partisan policy. Last year’s bipartisan bill was replaced with a one that drops provisions that had won Some Republican support. That does not auger well for the prospects of bipartisan support for broader health reform.

President Obama also said in the campaign that he would make sure Americans could keep the coverage they have if they are happy with it. But the SCHIP bill would result in some Americans losing their private health insurance. Recent analysis by Heritage analysts found that as eligibility for public coverage is extended to children in families with incomes between 200 and 300 percent of FPL, as many as half of those children who had been transitioned into public coverage would have otherwise had private insurance. Yet the House bill removes any anti-crowd out provisions, ignoring these problems.

All children deserve to grow up healthy – and ear infections, chicken pox, and childhood accidents affect them all equally. Our kids are our future, and if there’s one message that young voters and immigrant voters sent last November, it’s that they are so over the tired appeals to categories and ideologies that divide us. Senate Majority Leader Harry Reid said it best: “Some people want to use this as a debate over immigration,” he said. “This isn’t a debate over immigration. It’s a debate about taking care of our children – children who are here legally.”

The current SCHIP bill includes a provision that would give states the option to enroll lawfully residing immigrant children in the program without a five-year waiting period. Hundreds of local, state, and national organizations have voiced support for the measure – including the National Governors’ Association and the National Conference of State Legislatures. They all recognize the cost-effectiveness of providing access to primary and preventative care, and waiting five years to care for a child could lead to long-term ailments or developmental delays. Health does not wait five years. This arbitrary bar placed on hard-working, tax-paying legal immigrants should be lifted.

At a time when the economy is in crisis and working families are struggling with surging health care costs, Congress should act quickly to reauthorize and strengthen SCHIP. From there, we should move quickly to tackle the other challenges we face in health care – making coverage more affordable, getting a handle on costs while promoting quality, and offering more options for small businesses, early retirees, and others who are poorly served in today’s insurance market. Reauthorizing SCHIP is just the beginning. Let’s start now.

Early action on SCHIP could provide needed momentum for further changes and represent an important “down payment” on health reform. In a recent Commonwealth Fund essay, Sherry Glied, Ph.D, of Columbia University discussed how reauthorization could encourage states to ensure universal coverage for children, a goal that will not only reduce hospital admissions and improves outcomes in the short-term but also represent an essential investment in the health and well-bring of future generations. Several states, including Maine, Minnesota, New York, Oregon, Pennsylvania, Vermont, and Washington, have already begun the process of moving towards coverage for all children.

One of the major arguments against SCHIP expansion is that it would replace private coverage among higher-income children. Yet, predicted crowd-out has not been seen in Massachusetts following the enactment of its universal coverage law. According to a Fund study of working-age adults, employers neither dropped coverage nor restricted eligibility for coverage in the state's first year of health reform.

SCHIP reauthorization and expansion will go a long way toward solving the uninsured problem among children, but improving health care quality and efficiency are also important steps along the path to a high-performance health system. Congress needs to address payment reform, the reorganization of our health care system, and support of the infrastructure and information systems required to ensure that the U.S. health system becomes the best it can be.

One can answer this question from a longer-run, strategic perspective or a short-run, tactical perspective.

LONG-RUN, STRATEGIC VISION

            The answer from a longer-run strategic perspective would depend on which of two alternative views one has of the role of children in society.

            On the first perspective is that children are viewed as national treasures. In my view, that perspective ought to come easy in a country whose ratio of workers to elderly will fall steadily and substantially during the next several decades and whose adults endlessly fret about that prospect. On this view parents who give children life and rear them ought to be thanked for that arduous task by the rest of society – especially mothers, who usually do most of the heavy lifting.

            On the second perspective one views children as the human analogue of pets. I do not mean this to be crude or clever. Americans do adore their pets, and we have many laws protecting them. But the overarching mantra in connection with pets is this: You have them, therefore feeding and caring for them is your responsibility.

            Coming from countries (Germany and Canada) in which the first view predominates and guides health policy, I would propose the following as a long-run strategic approach:

            Any child born on territory regarded as American is ipso facto a U.S. citizen, even if the mother is an illegal alien. By the same token, any child born on American soil should be issued a health-insurance card with a benefit package as generous as the typical package enjoyed by the children of Members of Congress. That insurance coverage ought to extend to age 22 or at least until the child is a fully enfranchised adult.

As a going-in proposition, the child should be enrolled automatically in a Medicare-like national, tax-financed program whose fees would be no lower than those paid by Medicare, or be equal to Medicare plus some markup. The idea would be that the program values the professional work of health-care providers when applied to children the same as Members of Congress value that work through their own insurance programs.

Parents who would prefer to see their child privately insured would have the right to a risk adjusted voucher usable only for the purchase of private insurance. Coverage would be mandatory, and failure to purchase insurance coverage for one’s child with the voucher would carry a stiff penalty.

Such a system would make it feasibly to use schools as a locus for the delivery of much routine preventive care, as schools often are in other countries.

SHORT-RUN, TACTICAL APPROACH

I do not really know which view of children predominates in the U.S.: the national treasure” or the “human pet” view. It is probably an unstable mixture of the two, which is why, on the one hand, we do consider feeding and caring in the first instance the financial responsibility of the parents (the human pet theory), but also have put in place a somewhat rag-tag safety net for children.

I say “rag-tag,” because SCHIP/Medicaid is known to be extremely cumbersome to access, which probably is why millions of American children who are actually entitled to SCHIP/Medicaid are not in the programs. Furthermore, a child’s entitlement to SCHIP/ Medicaid comes and goes as a function of the parents’ economic situation, which makes coverage of the child haphazard and health-care delivery to the child suboptimal. Finally, in many states legislators value the work of health-care professionals applied to poor children much, much less than they value the work of the same professionals when applied to the legislators’ own children. In New Jersey, for example, pediatricians are paid around $30 per office visit by Medicaid while the going commercial rate is in excess of $100. There is no question that New Jersey legislators apply differential values to the work of pediatricians. The question Americans should ask themselves is whether this is really a proper relative valuation of the work of health professionals, especially when applied to American children.

Be that as it may, I believe the most we can achieve for children in the U.S. is to expand SCHIP along several dimensions: (a) reduce whatever bureaucratic barriers now hinder the enrollment of children already entitled to SCHIP, (b) increase the income threshold beneath which children are entitled to enrollment in SCHIP, (c) make sure that SCHIP receives enough funds from the federal and state governments that these programs can pay competitive fees in the market for health care for children and children covered by SCHIP are not disadvantaged vis a vis commercially insured children just by virtue of low fees.

Thought should also be given to ways to make SCHIP a more stable program for children whose coverage is not automatically lost when the parents’ income exceeds the relevant income threshold.

As to the children of legal immigrants, I find it hard to rationalize why one would treat them differently from children who are American citizens. The probability that the children of legal immigrants will become American citizens is very high—probably close to 100%. Why then would a sane nation withhold the benefits of health insurance from these ones.  

Furthermore, if one ever looked at combat platoons of our armed forces, one would find there many children whose parents at one point were legal immigrants. I should think that America’s moneyed elite (who would pay higher taxes to support child health care) have a vested interest in having a large corps of healthy youngsters to stand tall for the nation in uniform, lest the offspring of these moneyed elites would themselves have to stand tall for their nation (as now they typically do not, with a few notable exception). This furnishes one more rationale for providing all low-income American kids with easy access to first-rate health care.

SCHIP reauthorization should not be held hostage by the important discussions already underway about the future of health care in this country. While progress is being made to develop proposals and seek agreement on the many facets of health care reform, the issues are complex and deserve adequate consideration, debate and time. For many reasons, defaulting to a series of temporary extensions of the SCHIP program while these broader discussions occur is untenable for states and the millions of families who rely upon this health care program. Furthermore, a successful SCHIP reauthorization early next year does not preclude policymakers from realigning SCHIP with broader health care reforms in the future. For these reasons, a five year SCHIP reauthorization should be enacted as soon as possible.

The success of SCHIP rests on the fundamental design and structure of the current program and these should serve as the foundation for any program improvements. Regardless of differences of opinion on the specific reauthorization proposal, it is clear that without significant additional funding, states will be unable to reach the millions of currently eligible, unenrolled children. Federal funding levels should be increased to account for increased medical costs, population growth and to ensure that all eligible populations, determined by each state are able to have access to affordable health care under SCHIP. In addition to adequate, predictable funding, reauthorization also presents an important opportunity to enhance flexibilities for states that will allow improvements in health care and coverage for children.

The bill would extend the program's authorization for 4.5 years and is designed to add coverage for approximately 4.1 million uninsured children -- almost half of our nation's uninsured children. Altogether, the number of children who would be covered by either CHIP or Medicaid under the bill would approximate 11 million. The program would be fully paid for, mainly through a 61-cent increase in the tobacco tax, a public health as well as financing measure that would undoubtedly reduce smoking among children and adults across the country.

The most significant change from the two past versions of the CHIP reauthorization is that the House and Senate Finance Committee bills would eliminate the harmful exclusion of legal immigrant children and pregnant mothers from health coverage. Today, legal immigrant children and pregnant mothers are denied public health coverage, no matter how poor they may be, if they haven't lived in the country for at least five years. The new bills give states the option to cover these children and pregnant mothers without the five-year waiting period.

The pending legislation creates significant fiscal incentives for states to reach America's lowest-income children. Indeed, the Congressional Budget Office estimates that 83 percent of the newly covered children under the bills are already eligible for either Medicaid or CHIP. The bill is also designed to promote meaningful outreach and consumer-friendly enrollment systems so that low-income eligible children are more likely to participate.

The House adopted the bill by a more than 2-to-1 margin, with 40 Republicans joining virtually every Democrat in support of the bill. Although there was more partisan wrangling during the Senate Finance Committee's mark-up, a careful examination of the bill shows that few changes were made from the bill that received 68 votes in the Senate over a year ago.

This legislation is not only important for our nation's children, it is also a good down payment on meaningful health care reform. As such, it deserves strong support.