December 4, 2005
By JOHN M. BRODER
In the past year, 20 states have taken steps to increase access to health coverage for children and their parents and nine states have reversed actions they took during the 2001-3 economic downturn to limit benefits, according to the Kaiser Commission on Medicaid and the Uninsured, part of the Kaiser Family Foundation, which tracks health care trends. Among them are Illinois, which just signed a child health bill, and Vermont, with its "Dr. Dynasaur" health program, both of which broadened coverage for children.
As a result of these and other steps, there are 350,000 fewer uninsured children in the United States than there were in 2000, the foundation reported. Over the same period, the overall number of uninsured rose by six million.
While elected officials cannot agree on how to provide or pay for health coverage for uninsured adults, there seems to be a consensus in many states that covering children is medically wise and politically smart.
However, even the situation for children is not uniformly favorable. Eleven states facing political and financial pressure, including Maryland, Pennsylvania and Tennessee, made it more difficult for eligible children to retain coverage.
The movement to expand coverage for children dates to the mid-1990's, after the Clinton administration devised a complex plan to provide all Americans with health care coverage. That plan failed, and advocates of wider coverage began pursuing more incremental changes at the federal level and lobbying legislatures to expand coverage.
Alan R. Weil, executive director of the National Academy for State Health Policy, a nonpartisan research group, said children's health was one area of state spending that had consistently risen. Mr. Weil said it was much easier for officials to approve spending "for the kids" than to expand welfare programs for adults, even in times of hardship.
"It goes back to the Elizabethan poor laws that drew a conceptual distinction between the deserving and the undeserving poor," he said. "It's very hard to call kids undeserving, even if you don't like the parents' behavior."
Illinois took the most far-reaching step this fall, enacting a law intended to provide coverage to all children in the state, extending low-cost or free coverage to the 250,000 Illinois youngsters who are now uninsured.
But even states unwilling to go as far as Illinois are moving to provide insurance for children.
New Jersey, which imposed sharp restrictions on publicly financed health care for families during the economic slowdown, restored eligibility this year to some 75,000 low-income families.
In Washington State, where 39,000 children were dropped from state-financed health care programs in 2003 and 2004, officials reversed course this year. The state eased health care eligibility requirements for families with children and delayed a plan to charge premiums.
And Texas, which has one of the nation's highest rates of uninsured children, took steps this year to stop a decline in the number of children with health coverage. The state eliminated premiums for the poorest families enrolled in state health care programs and stopped cutting off families with higher incomes that failed to keep up with premiums.
As of the beginning of this year, 16 percent of all Americans lacked health insurance, but only 12 percent of children under 18 went uncovered, although that still amounts to nine million children, according to the Kaiser commission. That gap has been widening over the years as fewer employers offer health care coverage, federal spending fails to keep pace with rising costs, and states limit eligibility to balance budgets.
The picture is brighter for children than for adults in large part because of the enactment of the State Children's Health Insurance Program, or Schip, in 1997. The program provides federal money for child health care to states, which determine eligibility, income limits and covered benefits within federal guidelines. The number of children covered under the federal-state program grew rapidly, from 897,000 children nationwide in 1998 to 3.95 million in the middle of 2003, before leveling off.
The percentage of uninsured children ranges from less than 5 percent in Vermont to almost 20 percent in Texas. The differences reflect state policies, the poverty rate, the number of immigrants, and the percentage of children covered by employers and other programs.
The chief factor determining how many children are covered is the income eligibility level set by the states under Schip. The federal government requires coverage for families at or below the federal poverty level, about $20,000 for a family of four. Only a few states set the limit that low. In some states, including Minnesota, Rhode Island and Vermont, families with incomes at 250 percent or even 300 percent of the federal poverty line qualify.
California is witnessing a battle that is also playing out in Washington and other states. State officials here and private groups are trying to bring health coverage to more than a million California children who now go without it. A bill that passed the Legislature this year would have eased eligibility requirements for the poorest families, bringing coverage to hundreds of thousands of children. Gov. Arnold Schwarzenegger, a Republican, vetoed the bill, saying that he agreed with its aims but that the sponsors had not come up with a way to pay for it.
Partly in reaction, a coalition of health groups including the American Cancer Society and the American Heart Association are proposing a ballot initiative to raise the state cigarette tax to finance universal health care for children. Sponsors say that the estimated $1.4 billion raised by the new tax would pay for health coverage for more than 800,000 California children.
Vermont leads the nation in the percentage of its children who are insured through state and federal programs and private insurance, with almost 95 percent coverage.
In 1989, Madeleine M. Kunin, then the governor, created a state-financed program for pregnant women and for children up to age 6 who did not have private insurance and did not qualify for Medicaid. The program, which came to be known as Dr. Dynasaur, was expanded in 1992 under Gov. Howard Dean to cover children through age 17. Families with incomes up to 300 percent of the federal poverty level, or nearly $60,000 a year, qualify, and the program covers doctor visits, dental care, immunizations, vision care, medicines and mental health.
Financing comes from the federal government, tobacco taxes and general state revenues.
Despite the fading fortunes of the auto industry, 93 percent of Michigan children are covered, several percentage points higher than the national average. But that still leaves 200,000 Michigan youngsters uninsured.
Even though Ms. Granholm intends to ask for significant cuts in some state programs in her budget next month, she said she would propose increasing spending to address the problem of uninsured children.