I am no fan of taxes, but when it comes to taxation I stand in the middle of the American road – I would rather not pay them, but if I do, let the money be well spent. This is why it pains me to see one of the more successful government programs in recent history tied up in a partisan battle in Washington.
The State Children’s Health Insurance Program, or SCHIP, was created under the Clinton administration to provide health insurance to the gap kids whose parents are too poor to afford private insurance and too rich to qualify for Medicaid. Almost seven million children were enrolled in SCHIP in 2006, and from my standpoint as a practicing pediatrician, children have benefited greatly from its services. SCHIP has virtually eliminated the problem I routinely encounter with my adult patients – the lower-middle-class patient with a significant medical problem and no health insurance. One of the sad peculiarites of the American healthcare system is that it overlooks not the poorest of the poor, who qualify for Medicaid, but the people just above them who are trying to stay out of poverty.
The President, as well as the corps of sycophantic Republicans who parrot him for the sake of basking in His reflected light, argues that the SCHIP bill that recently passed Congress is too expensive. The program so far has been quite frugal, spending about $40 billion over the last decade – a drop in the bucket compared to the massive Medicaid and Medicare programs. The Congressional bill calls for an increase of $35 billion over the next 5 years. The President wants $5 billion. Since health care costs increased at a rate of 6% last year, and often rise at double digit rates, $5 billion increase will not cover costs at their current level, and will likely force most states to cut back coverage. The $35 billion, on the other hand, was a compromise amount that would allow states to slowly expand SCHIP coverage and keep pace with inflation.
There is, curled within the president's gloved hand, the fist of an idea. The President is not simply trying to contain SCHIP, he is hoping to starve it to death. Conservatives in this country favor private insurance and oppose government involvement in the health care industry. They feel that expanding SCHIP would expand government role in health care, and would bring us one step closer to Big Government Universal Health (BGUH). They further worry that parents, given the choice between SCHIP and employer-provided health plans, will choose to enroll their children in the free SCHIP. This process, sometimes called "the crowding out" of private insurance, could amount to a transfer of millions of children from the private to the public sector.
As someone who thinks BGUH an improvement over the abortion that passes for health coverage in this country, the "Omigod, look out, here comes Federal control" argument falls flat. The Feds are all over medicine anyway. They already run Medicare, Medicaid, and health plans for armed services personnel. The oversee many aspects of medical licensing and drug approval. They send me letters telling me what medications I should prescribe, and pass laws determining my legal liability in many patient interactions. They tell me how much I must charge to treat their patients, and threaten me with jail should I dare ask for a penny more. They even regulate how I dispose of my garbage. Anyone who thinks we are not halfway to BGUH already needs to get some health insurance and pay a visit to the ophthalmologist.
There is some evidence that expanding SCHIP would produce a transfer of children from private to public insurance. The number is in debate, but there is a Congressional Budget Office study that suggests anywhere from 25% to 50% of kids that qualify for SCHIP could get insurance somewhere else. Just because they can, though, doesn't mean they will, and it also doesn't mean getting private insurance won't cause significant hardship. Free health insurance for the kids also frees up the parents to get better insurance for themselves, or to spend it in other useful ways. According to recent figures, it costs $12,100 to insure a family of four for a year. SCHIP could reduce that number by as much as half, and for someone making $30,000 a year, that is very significant.
The big picture, however, suggests this should not be our main worry. According to the U.S. Census Bureau, the total number of Americans insured through their employers has dropped from 60.5% in 2004 to 59.7% in 2006. Over the same period, the percentage of children covered through their parents employers has also fallen from 61.4% to 59.7%, and total number of uninsured kids has risen from 10.5 to 11.7%. In other words, private insurance plans are slowly insuring fewer children, and these kids seem to be falling directly into the ranks of the uninsured. Yes, the percentage changes are small, but in a nation of 300 million, one percent is 3 million people. It is not safe to ignore this.
The crowding out argument might hold water if private carriers were trying to pick up the lost kids, but they are not. Instead, they are slowly shedding customers, and seem pretty content to do so. I am not aware of a public outreach by private insurers to enroll children. Children are generally healthier than adults, and cheaper to insure, and yet how many major carriers actively market children-only options? College-aged teenagers are buried with credit card offers, but rarely are they offered low-cost health insurance plans. Insurance companies are locked into their large corporate accounts, and ignore the uninsured youth. If private insurers are making no effort to fill the gap, it makes perfect sense to expand SCHIP.
In the U.S., we insure children through their parent's employers. While it is debatable that adult insurance should be dependent on employment, it makes even less sense that a child's health should be funded this way. Children have no control over their parents' employment decisions. Why should they suffer the consequences if their parents work a job that has no insurance, or choose not to work at all? And what is the point of a public policy that has the effect of placing responsibility for pediatric health care in the hands of employers? If BGUH would be such a bad judge of the needs of our nation's children, there is no reason to think that Exxon or GM would be any better.
Employers have no special incentive to insure the children of their employees. Employer-based health insurance is a form of compensation companies use to retain workers. But a single adult, a father of two, and a mother of six present three entirely different situations to an employer. Why would an employer want to hire and keep a mother of six, when a single man puts so much less pressure on the company health plan? As health insurance costs climb, employers will be under increasing pressure to eliminate children from their benefits packages. They can do this by increasing the the differential between single and family premiums taken out of employees' paychecks.
Children are, as a population, very healthy and relatively inexpensive to insure. The government already offers universal health care to adults over 65 in the form of Medicare. Through Medicaid, it offers universal health care to all people with incomes at or under the poverty level. Neither of these populations are as economically important as children are. Healthy children become healthy adults, and are more likely to enter the productive work force. Well kids stay in school, and nothing correlates better with long-term health, longevity, and economic productivity than education. America stands to benefit greatly from universal health care for children, far more than it could ever hope to benefit from insuring the elderly or the poorest of the poor.
Conservatives oppose universal health care for children for the simple reason that they realize it will probably work, and will probably be popular. The more SCHIP succeeds, the more adults will wonder why the program cannot be expanded to include them. Conservatives fear that if they concede anything now, they will eventually be forced to concede everything.
This may or may not be true. Nonetheless, it is not fair to hold the SCHIP program hostage to a principle. Medicine is not a theoretical science; it is applied science. We use what works in medicine, not what we think should work in theory. As a practicing doctor I look at the end product of the health insurance system. Either I am able to take care of a patient properly, or I am not. If SCHIP works, we should use it. If it does not, we should dump it. The plan has been in effect for 10 years and seems to be working well. It is stupid to throw out a treatment that is working simply because the textbooks say there should be a better way.
The SCHIPS bill the president vetoed enjoyed extraordinary support among medical professionals. My own state medical society, the Mississippi Medical Society supported it. The American Academy of Pediatricians and the American College of Physicians endorsed it. The American Academy of Family Physicians supported it, and roundly denounced President Bush for vetoing it. Even the American Medical Association, well known for its obstructionist approach to health care reform, has recommended the plan. That a group of career politicians would defy the nearly unanimous opinion of the medical community on such a matter is incomprehensible.
The free market has to be a big part of health care in the U.S. But the free market, as it is, has been slowly crumbling under the feet of our kids. We shouldn't waste our time debating which tax credit or tax shelter is going to bring kids back under the private umbrella while a perfectly good insurance program starves to death on the sidelines. We can put SCHIP into action today, and then work on free market solutions in the meantime. The current bill only funds the program for 5 more years. That's five years conservatives have to come up with a better plan.