Bush has sought to limit coverage to children in families with incomes less than 200% of the federal poverty level, or $41,300 for a family of four.
Results from the 170 respondents show a majority consider the safety net childrens insurer a success and its expansion a way to reduce the nations ranks of uninsured, says Commonwealth Fund President Karen Davis. Those surveyed agree we ought to build on its success and we ought to expand it to those for whom it makes sense, she says.
Eighty-eight percent of those surveyed supported expanding enrollment to children in families with incomes up to three times the federal poverty level. Without a far-reaching plan for universal coverage, 80% said low-income parents should be eligible for the childrens insurance plan, and 73% said adults without children who live in poverty should be covered as well.
The Commonwealth Fund survey found less agreement over how to pay for expansion: More than one-third called for increased taxes or fees; roughly one-fourth supported using funds already spent elsewhere; and another quarter of respondents said Congress should exempt the childrens insurance plan from a mandate to offset new spending with budget cuts or taxes.
The Bush administration opposes such expansion and would cut federal matching funds to states for adults or children in families with incomes above 200% of the federal poverty level. Eleven states offered limited coverage to parents with children as of January, according to the Henry J. Kaiser Family Foundation, a health policy not-for-profit. In 2006, 15 states had eligibility criteria that exceed Bushs income threshold, according to an analysis by George Washington University health policy analysis associate professor Jeanne Lambrew.
Katherine Baicker, a health policy expert on the presidents Council of Economic Advisors, says the presidents plan, which would boost SCHIPs five-year budget to roughly $30 billion from $25 billion, targets spending toward low-income children for whom the plan was created. Baicker argued that private market initiatives in the presidents health coverage planincluding changes to the tax code that would overhaul healthcare deductionswould go further than expanded public programs to control healthcare costs and expand coverage for adults and middle-income families.
Governors and congressional Democrats have criticized Bushs funding as inadequate to maintain current enrollment. One estimate, by the Center on Budget and Policy Priorities, indicates as much as $13.4 billion would be needed over the next five years just to offset inflation and population growth. The U.S. House and Senate have approved budget bills that boost spending for SCHIP by $50 billion over five years; lawmakers have proposed tobacco taxes and Medicare cuts to finance the increased spending.
The American Hospital Association joined a diverse coalition that in January called for a $45 billion increase in funding over the five years, though the group endorsed an income limit for children of twice the federal poverty level. Richard Pollack, the Chicago-based trade groups executive vice president of advocacy and public policy, says the eligibility cap combined with a proposed tax credit for higher-income families was the sweet spot that secured backing from an ideologically diverse group after lengthy negotiations. It may not expand eligibility, but it sure expands coverage, he says. The AHA opposes Medicare cuts to pay for SCHIP expansion.
One respondent, Georganne Chapin, president and chief executive officer of Hudson Health Plan, a not-for-profit managed-care plan based in Tarrytown, N.Y., agrees. I believe that all people, adults and children, should have access to healthcare, and that cutting children off at an arbitrary income threshold is both irrational and expensive, she says in an e-mail.
Despite the widespread support for the program, Chapin and other respondents say SCHIP could do more to track and disclose quality and performance standards. Eighty-one percent called for federal performance and outcome standards for the program, and nearly as many, 78%, backed a requirement for states to reward managed-care plans or providers for meeting performance criteria, such as child development screenings and preventive care. Chapin says such a strategy is one way for states to require quality standards of providers and plans.
In Virginia, the childrens health insurance plan largely follows criteria proposed under the Bush administrations budget, but the state risks operating in the red by 2009 without increased funding, says Linda Nablo, director of the states maternal and child health programs. Were going to lose ground, she says. In the current fiscal year, 14 states face losses on the program. Both houses of Congress have passed stopgap funding, but the measure, included in a war spending bill, faces a presidential veto.
The public plan covers 82,000 children, and Nablo credits the expansion for helping enroll another 90,000 children in Medicaid since 2002. Medicaid, also jointly funded by states and the federal government, typically requires that states shoulder a greater share of costs than the childrens health insurance plan.
Virginias 2007 SCHIP budget totaled $148 million, including $94 million in federal funds, state funds and surplus from prior years. Nablo says another 90,000 children in Virginia are eligible but are not yet enrolled for Medicaid or SCHIP and more than 20,000 could gain coverage if eligibility rose to 300% of the federal poverty level. Under the Bush plan, Virginia could neither recruit children already eligible nor expand coverage, she says. Like Virginia, states face curbing enrollment without additional funding.
If were going to make gains and enroll those eligible and attempt at some point in this country to say most, if not all children, can be covered with an affordable, comprehensive health insurance program, then there needs to be significantly more money for SCHIP, she says.