WASHINGTON (By Robert Pear, NYTimes) August 21, 2007
— The Bush administration, continuing its fight to stop
states from expanding the popular Children’s Health Insurance
Program, has adopted new standards that would make it much more
difficult for New York, California and others to extend coverage to
children in middle-income families.
Administration officials outlined the new standards in a letter sent
to state health officials on Friday evening, in the middle of a
monthlong Congressional recess. In interviews, they said the changes
were intended to return the Children’s Health Insurance Program to
its original focus on low-income children and to make sure the
program did not become a substitute for private health coverage.
After learning of the new policy, some state
officials said yesterday that it could cripple their efforts to
cover more children and would impose standards that could not be
met.
“We are horrified at the new federal policy,” said
Ann Clemency Kohler, deputy commissioner of human services in New
Jersey. “It will cause havoc with our program and could jeopardize
coverage for thousands of children.”
Stan Rosenstein, the Medicaid director in
California, said the new policy was “highly restrictive, much more
restrictive than what we want to do.”
The poverty level for a family of four is set by
the federal government at $20,650 in annual income. Many states have
received federal permission to cover children with family incomes
exceeding twice the poverty level — $41,300 for a family of four. In
New York, which covers children up to 250 percent of the poverty
level, the Legislature has passed a bill that would raise the limit
to 400 percent— $82,600 for a family of four — but the change is
subject to federal approval.
California wants to increase its income limit to
300 percent of the poverty level, from 250 percent. Pennsylvania
recently raised its limit to 300 percent, from 200 percent. New
Jersey has had a limit of 350 percent for more than five years.
As with issues like immigration, the White House
is taking action on its own to advance policies that have not been
embraced by Congress.
In his budget in February, President Bush proposed
strict limits on family income for the child health program. Both
houses of Congress voted this month to renew the program for five
years, but neither chamber accepted that proposal. Legal authority
for the program expires on Sept. 30.
The administration’s new policy is explained in a
letter that was sent about 7:30 p.m. on Friday to state health
officials from Dennis G. Smith, the director of the federal Center
for Medicaid and State Operations. The policy would continue
indefinitely, though Democrats in Congress could try to override it.
The Children’s Health Insurance Program has strong
support from governors of both parties, including Republicans like
Arnold Schwarzenegger of California, Tim Pawlenty of Minnesota and
Sonny Perdue of Georgia. When the Senate passed a bill to expand the
program this month, 18 Republican senators voted for it, in defiance
of a veto threat from Mr. Bush. The House passed a more expansive
bill and will try to work out differences with the Senate when
Congress reconvenes next month.
In his letter, Mr. Smith set a high standard for
states that want to raise eligibility for the child health program
above 250 percent of the poverty level.
Before making such a change, Mr. Smith wrote,
states must demonstrate that they have “enrolled at least 95 percent
of children in the state below 200 percent of the federal poverty
level” who are eligible for either Medicaid or the child health
program.
Deborah S. Bachrach, a deputy commissioner in the
New York State Health Department, said, “No state in the nation has
a participation rate of 95 percent.”
And Cindy Mann, a research professor at the Health
Policy Institute of Georgetown University, said, “No state would
ever achieve that level of participation under the president’s
budget proposals.”
The Congressional Budget Office has said that the
president’s budget, which seeks $30 billion for the program from
2008 to 2012, is not enough to pay for current levels of enrollment,
much less to cover children who are eligible but not enrolled.
When Congress created the Children’s Health
Insurance Program in 1997, it said the purpose was to cover
“uninsured low-income children.” Under the law, states are supposed
to make sure public coverage “does not substitute for coverage under
group health plans.”
In an interview yesterday, Mr. Smith said, “The
program was always meant for children in lower-income families.” As
a state increases its income limits, he said, “it’s more likely to
substitute for private coverage.”
To minimize the risk of such substitution, Mr.
Smith said in his letter, states should charge co-payments or
premiums that approximate the cost of private coverage and should
impose “waiting periods” to make sure middle-income children do not
go directly from a private health plan to a public program.
If a state wants to set its income limit above 250
percent of the poverty level — $51,625 for a family of four — Mr.
Smith said, “the state must establish a minimum of a one-year period
of uninsurance for individuals” before they can receive public
coverage.
That is considerably stricter than past
requirements. In February, for example, the Bush administration
allowed Pennsylvania to increase its income limit to 300 percent of
the poverty level after the state agreed to a six-month waiting
period for children who were 2 and older with family incomes
exceeding 200 percent of the poverty level.
As another precaution, Mr. Smith said, states that
want to cover children above 250 percent of the poverty level must
show that “the number of children in the target population insured
through private employers has not decreased by more than two
percentage points over the prior five-year period.”
In New Jersey, which has a three-month waiting
period, Ms. Kohler said, “we have no evidence of a decline in
employer-sponsored coverage resulting from the Children’s Health
Insurance Program.”
In the Senate debate this month, several
Republicans offered a proposal similar to the new Bush
administration policy. They wanted to require states to cover 95
percent of low-income children before allowing states to expand
eligibility.
Senator Max Baucus, the Montana Democrat who is
chairman of the Finance Committee, argued against the proposal,
saying: “No state can meet 95 percent. No state currently meets 95
percent.”
In his letter, Mr. Smith said the new standards
would apply to states that previously received federal approval to
cover children with family incomes over 250 percent of the poverty
level. Such states should amend their state plans to meet federal
expectations within 12 months, or the Bush administration “may
pursue corrective action,” Mr. Smith said.
Two Republican senators, Charles E. Grassley of
Iowa and Pat Roberts of Kansas, urged the Bush administration last
week to deny New York’s request to cover children with family
incomes up to four times the poverty level. The proposal, they said,
violates the original intent of Congress.
But Gov. Eliot Spitzer of New York said that,
“contrary to the senators’ objections,” federal law allows states to
set higher income limits. “Granting this expansion,” Mr. Spitzer
said, “is essential to the health and well-being of New York’s
children.”