In what seems like an overt effort to enrage Congress, President Bush has undermined the implementation of a bill expanding the Children's Health Insurance Program by issuing a set of guidelines virtually impossible for most states to meet.
With Congress in a month-long recess, Dennis G. Smith, director of the federal Center for Medicaid and State Operations, sent a letter to state health officials this past Friday outlining Bush's new standards for the program, which impose what many believe are unattainable restrictions. States need to conform to the new rules within twelve months, warned the letter, or the administration "may pursue corrective action."
That's as good as a threat to many state officials, who say that the new standards could devastate their efforts to insure more children currently going without health coverage.
"We are horrified at the new federal policy," said Ann Clemency Kohler, deputy commissioner of human services in New Jersey.
"[This will] cause havoc with our program and jeopardize coverage for thousands of children."Texas will be one of the states hardest hit. Twenty-five percent of its population is already going uninsured, and that doesn't include the 2.2 million children covered by Medicaid or CHIP, as of 2006. The Texas Legislature just passed House Bill 109, which is designed to loosen restrictions on CHIP enrollment, and is set to take effect September 1st. Under new state guidelines, the program's enrollment period would extend to twelve months -- versus the previous six -- would eliminate the ninety-day waiting period for most children, and would ease certain asset restrictions. Bush's standards would override many of these changes. The healthcare communities in Dallas, Houston, and Austin, especially, are already in danger of collapse due to the large number of uninsured, or underinsured patients. Any more could devastate their facilities.
The Children's Health Insurance Program is designed to insure children in families whose incomes exceed Medicaid requirements, but who are still unable to afford private coverage. The program allows for families below the federal poverty line, ,650 for a family of four, to obtain subsidized health insurance. However, this figure is far too low in many states to be realistic; many families surpassing this income still can not afford private health plans. Several states, therefore, applied for (and received) permission to extend coverage to families making up to four times the federal poverty income standards.
While that figure may seem outrageous to some, the basic cost of living in states like New Jersey, New York, and California is far higher than in the Midwest or Southwest, and federal poverty standards only reflect averages from the entire nation. New York grants coverage under CHIP to families making up to 250% of the federal poverty income standard, and is hoping to increase that to 400%. Pennsylvania extended its program to families earning up to 300% of federal poverty standards, and New Jersey expanded coverage for those families making up to 350%.
Under Bush's guidelines, states must enroll ninety-five percent of eligible children below 200% of the federal poverty level, in either Medicaid or CHIP, before expanding coverage to include higher-income families. The problem with this is not so much states' willingness to insure those children, but families' willingness, or capability, to enroll.
"No state in this nation has a participation rate of ninety-five percent," said Deborah S. Bachrach, deputy commissioner in New York's State Health Department.
Cindy Mann, research professor at the Health Policy Institute of Georgetown University, agrees. "No state would ever achieve that level of participation under the president's budget proposals." In other words, Bush has created a virtually unsurpassable barrier to achieving the Congressional goal of insuring more children under CHIP.
President Bush has been vocal from the start about his opposition to Congressional proposals to expand the program, believing such efforts are one step closer to providing universal health coverage. The President's proposal was to budget billion over the next five years for the program, a fraction of the Democratic budget proposals and, many argue, a figure that wouldn't even cover current levels of enrollment, let alone allow for any increase.
Under the new guidelines, Bush would also impose co-payments or premiums equivalent to the cost of private insurance and enforce long "waiting periods" for middle-income families. For those families whose incomes exceed 250% of federal poverty standards, "the state must establish a minimum of a one-year period of uninsurance for individuals." Additionally, "the number of children in the target population insured through private employers [must] not [decrease] by more than two percentage points over the prior five-year period."
Basically, that means children must go uninsured for one year before becoming eligible for CHIP, states must prove that families are not switching their children from private, employer-sponsored insurance to CHIP, in addition to proving that the state has not had such a trend for five years. By the time many states prove this, however, the five-year plan will be up.
"We have no evidence of a decline in employer-sponsored coverage resulting from CHIP," said Kohler, who referenced the current three-month waiting period for families. For states like Texas, who want to eliminate the three-month waiting period for all but those who had private insurance within ninety days of their applications, these changes would prove devastating to efforts to expand CHIP coverage.
New York Governor Eliot Spitzer was bolder in his response. "Contrary to…objections, federal law allows states to set higher income limits…Granting this expansion is essential to the health and well-being of…children."
Another solution is to urge private insurance companies to offer more affordable plans. The problem with the millions of Americans going without insurance is not so much lack of insurance itself, but what that lack of coverage means. Many often forgo needed treatments and tests, and facilities often go unreimbursed for services provided. Offering plans that would enable even one more in a family to actually afford coverage would ease many of these problems. For states like Texas, that could make all the difference.
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