Children's Health Care on Agenda

The success of the decade-old Children's Health Insurance Program is exposing Washington's familiar ideological divisions over health care as Congress begins to work on renewing the state-federal program.

Members of both parties want to continue the popular $5 billion-a-year effort, which at any given time provides health insurance to more than 4 million children from lower-income families that do not qualify for Medicaid but cannot afford insurance on their own. But Republicans and Democrats cannot agree on how much money the program should get, and whom it should cover.

The conflicts track long-standing divisions over the proper role of government in health care, with Democrats generally favoring more activist attempts to ensure that everyone has access and Republicans supporting a more limited role that focuses on helping the neediest.

The nonpartisan Congressional Budget Office and other analysts estimate that the program, known as SCHIP, will require $13 billion to $15 billion above current funding levels just to keep covering the same number of children for the next five years. The Bush administration has proposed $4.8 billion, saying that is enough to maintain enrollment for "priority low-income children."

Many Democrats on Capitol Hill and advocates for children call the White House proposal inadequate, but the dispute is about more than numbers. Some Democrats, in control of Congress for the first time since 1994, would like to increase funding levels by as much as $50 billion over five years to extend coverage to many of the nation's 8.3 million uninsured children -- and to some uninsured parents and childless adults as well.

One possible source of money is the nearly $65 billion that the CBO says could be saved by erasing the gap between what the government pays private insurers that operate Medicare HMOs and what it pays doctors and hospitals for traditional fee-for-service care. A Medicare advisory panel reported Thursday that federal payments to the HMOs are an average of 12 percent higher.

"A lot of states, including my own, have more kids that are eligible for the program but are not enrolled that we'd like to reach out to," Rep. Frank Pallone Jr. (D-N.J.), chairman of the House Energy and Commerce subcommittee on health, said Thursday in an interview during a break in a hearing on the program. "I don't understand what the president is doing. . . . If he's going to hold to his commitment that he wants to cover the uninsured, this is the best way to do it. I would ask that he not look at this from an ideological perspective, and maybe not like it because it's a government program. Look at it practically -- it's working."

But President Bush and many congressional Republicans, wary of creeping growth in a federal social program, say the program is losing its way. They note that 14 states have taken advantage of the program's flexibility to cover not just children but also 639,000 adults, according to the Government Accountability Office. States such as Arizona, Michigan, Minnesota and Wisconsin covered more adults than children in 2005, the GAO found.

Moreover, seven states cover children from families that earn as much as 300 percent of the federal poverty level or more, or $61,950 for a family of four. Bush and some GOP lawmakers argue that the program should focus on children from families at or below 200 percent of the poverty level, or $41,300 for a family of four.

"I fear that using these limited federal dollars for adults has undermined coverage for low-income children," said Charles E. Grassley (Iowa), the ranking Republican on the Senate Finance Committee. "The issue is not whether or not coverage for adults is desirable: It is. The issue is not whether or not coverage for adults is beneficial for the family: It is. . . . The issue is whether SCHIP funds used to cover adults have drained resources targeted by Congress for kids."

Health and Human Services Secretary Mike Leavitt said last week that the program, which must be reauthorized by the end of September, should not be "the engine that pulls the train of a national health insurance program."

The partisan divisions do not carry over to state leaders. When a federal program is funded jointly with the states, governors generally prefer to see more money from Washington -- regardless of political affiliation. More than a dozen governors of both parties last week urged the White House and Congress to approve more funding for the program, including an immediate $745 million infusion to head off projected shortfalls this year in Maryland and 13 other states.

Continued funding is vital for people such as Craig and Kim Lee Bedford of Baltimore, who at a Senate committee hearing last month said that they struggled to pay high monthly private insurance premiums for their five children until they learned they were eligible for the federal program in 2004.

"We no longer have to decide whether a child is really sick enough to warrant a doctor's visit," said Kim Bedford, whose husband is an insurance agent. "We no longer have to decide whether a child really needs a certain medication prescribed by his pediatrician. . . . The times when we would have to make medical decisions for our children based on financial criteria were extremely stressful as parents, full of those impossible choices. Those are not the kinds of choices that parents in a society as advanced and as resourced as ours should be forced to make."