Published Online: September 4, 2007
Published in Print: September 5, 2007, as Children’s Health Coverage Seen at Risk
Includes correction(s): December 13, 2011

Children’s Health Coverage Seen at Risk

Plans to increase eligibility for state-federal program collide with tight guidelines from Bush administration.

At a time when several states and both houses in Congress are pushing to expand a children’s health-insurance program partially financed by the federal government, the Bush administration’s new guidelines restricting enrollment have drawn criticism from school officials and health advocates, who warn that children will lose access to insured medical care.

The $25 billion-a-year State Children's Health Insurance Program, or SCHIP, is intended for children in families that earn too much to be eligible for Medicaid but may find it hard to afford private health insurance.

The U.S. Department of Health and Human Services, in an Aug. 17 letter, told states that they cannot enroll children from higher-income families—those with income above 250 percent of the federal poverty line—unless the states can prove that 95 percent of their poorest children are already covered through Medicaid or SCHIP.

Though the letter is described as clarifying existing regulations, some state officials see it as new policy and an attempt to circumvent the efforts by states and Congress to expand the program. The 95 percent enrollment target for the state’s poorest children is impossible to meet, they contend.

As a result, many children will remain uninsured, school health officials argue—and that could affect schools by weakening student preparedness for learning and increasing the need for services.

“The more kids that are covered, the more kids are likely to come to school without chronic health-care problems and ready to learn,” said Bruce Hunter, the associate executive director for public policy for the Arlington, Va.-based American Association of School Administrators, whose organization supports the congressional proposals to expand SCHIP coverage.

Without insurance of their own, many families also come to rely on schools for services, said Donna Mazyck, the president of the National Association of School Nurses, based in Silver Spring, Md. “School nurses are sometimes the only health-care provider a student regularly sees,” she said. “We definitely see the importance of students’ having a regular primary- care provider.”

Policy Debate

About 6.6 million children and 670,000 adults are insured through SCHIP, which varies in structure and income eligibility from state to state. Most states provide insurance to children in families earning 200 percent of the federal poverty level. That percentage currently comes to $41,300 for a family of four.

The move to tighten the qualification rules comes as Congress debates renewing the program, which expires at the end of this month. President Bush’s budget proposal for fiscal 2008, which begins Oct. 1, would add $5 billion a year over the next five years to the program, while aiming to “refocus SCHIP on low-income, uninsured children.”

SCHIP Facts

The 10-year-old State Children’s Health Insurance Program is a partnership between federal and state government intended for families who earn too much to qualify for Medicaid but who cannot afford private insurance. In several states, the program covers children with family incomes up to or exceeding three times the $20,650 federal poverty level for a family of four.

Some states would like to expand the program to cover more children.

California: Gov. Arnold Schwarzeneggar has proposed expanding SCHIP for children in families up to 300 percent of the federal poverty line, or $61,950 for a family of four.

New York: Gov. Eliot Spitzer and the state legislature recently created a plan to expand eligibility to children in families that earn up to four times the federal poverty level, or $82,600 for a family of four. That limit would be the highest eligibility ceiling in the country.

Washington: A bill passed in March expands eligibility to children in families up to 250 percent of the federal poverty line, or up to $43,040 for a family of four, regardless of citizenship.

In contrast, the Senate and the House of Representatives have forged their own proposals that would add as much as $50 billion to the $25 billion already budgeted over the next five years. President Bush has said he would veto such expansions because they open an avenue for people to switch to government-funded programs from private insurance.

Meanwhile, with federal approval, several states have expanded SCHIP to serve some adults and pregnant women. Seven states insure children in families that earn up to three times the federal poverty level. New Jersey has the highest eligibility ceiling; its program covers children in families that earn up to 350 percent of the poverty level, or $72,275 for a family of four.

The National Governors Association has written several letters to federal lawmakers in support of expanding the program and allowing state flexibility in administering it.

But financial pressures on the program have intensified. States have also been outspending their federal allocations. Fourteen states are projected to have shortfalls in fiscal 2007, according to the Government Accountability Office, the congressional watchdog agency.

And there is plenty of potential demand—according to U.S. Census Bureau data, about 8.6 million children were uninsured in 2006. The Congressional Budget Office, which provides nonpartisan economic analysis, has reported that the program needs $9 billion more than the president’s proposal to maintain services for the children and adults currently enrolled.

State Concerns

The Bush administration’s recent letter lists other restrictions, such as requiring families to be uninsured for a year before enrolling in the child-health program. State officials say that, taken together, the restrictions appear to throw their plans for program expansion into doubt.

For example, New York wants to expand its SCHIP eligibility ceiling to four times the federal poverty level for a family of four, or $82,600, from 2½ times. Such a ceiling is needed for a high costof- living state like New York, said Judith Arnold, the deputy health commissioner overseeing the child-health program.

New York’s participants would be expected to pay up to 2 percent of their income for coverage for their children, plus co-payments, Ms. Arnold added.

“There’s a real misconception being put forth that somehow people are getting this free from the government,” she said.

Washington state plans to increase its eligibility ceiling to 300 percent of the federal poverty level by January 2009, from 200 percent. State officials plan to actively work for SCHIP expansion, said Jim Stevenson, the spokesman for the state’s Medicaid office.

“The governor has a plan to insure all children by 2010,” Mr. Stevenson said. Officials, he said, “don’t plan to sit and wait.”

States can use their own money to provide insurance, but tight budgets may make that difficult. And though the Bush administration’s letter says there should be no effect on current enrollees, states that have a high eligibility ceiling will be expected to amend their plans.

Advocates also note that neither version of the SCHIP reauthorization bill in Congress would provide reimbursement for the more than 1,700 primary-health-care centers that are based on school campuses. Such a move is supported by the National Assembly on School- Based Health Care, in Washington.

Relying on the private market “hasn’t served low-income children very well,” said John Schlitt, the group’s executive director.

Vol. 27, Issue 2, Pages 17-18

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Correction: 
An earlier version of this story should have said that a bill passed in Washington state expands eligibility for SCHIP to children in families with incomes up to 300 percent of the federal poverty line, or $61,950 for a family of four.

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