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The New York Times
December 3, 2005
By John M. Broder
LOS ANGELES--The number of American children
without health care coverage has been slowly but steadily
declining over the past several years even as health care
costs continue to rise and fewer employers provide insurance,
creating a breach that states have stepped in to fill with
new programs and fresh money.
The overall ranks of the uninsured continue
to swell, to nearly 46 million Americans at the beginning
of this year. But a landmark federal program begun in 1997
to provide health coverage to poor and working-class children
and additional measures taken by states have provided health
insurance to millions of children who might otherwise go without.
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.
"Let's get real about it," Ms.
Granholm said. "Let's design a public system that truly
reflects where we want to be, so states are not twisted into
pretzels to try to insure their most vulnerable citizens.
I don't think we want to be a nation where you go to Dunkin'
Donuts to put a quarter in a jar for Aunt Linda's mastectomy.
We need a national solution for competitiveness and moral
reasons. And Washington is utterly silent."
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