Now that the Bush administration has failed to prevent Congress from passing an expansion of the Child Health Insurance Program (CHIP), Bush has decided to pursue his agenda through executive order instead. The new plan is to forbid states, which have been at the forefront of expanding the program beyond the ranks of the absolute poor, to cover families above 200% of the poverty line, unless they have covered 95% of families below that level. As of today, no state has achieved this kind of coverage through CHIP.
This new Bush strategy brings up a number of important issues. In the first place, and as I have written before, we do face a tragedy across the country of eligible families failing to enroll their children. Since the average enrollment across states for eligible children is somewhere between 70 and 80%, a non-negligible number of poor kids continue to go without insurance, even though we have decided as a society to provide it to them. There is no question that something should be done about this, and that “something” could include incentives to get states to be more creative about enrollment.
The second point is that it is reasonable to ask whether a government program to provide health insurance to children should be a universal entitlement or not. Should we only provide health care to poor kids, or do we as a society believe that all kids have a right to health insurance, guaranteed by the government (though not for free; non-poor enrollees do pay premiums)? Certainly, the latter view motivates the expansion of CHIP in a place like New York to families at 400% of the poverty line. In this sense, the Bush administration is correct to pose expansions of CHIP in ideological terms: it really is about what we believe the government’s role should be in ensuring health care for American children.
It is ironic, however, that the Bush administration is effectively threatening to undermine the capacity of states to decide for themselves who deserves health insurance coverage. After all, conservatives are usually the ones pushing “states’ rights” and arguing for “subsidiarity,” the idea that people at the local level know what’s best. But it turns out that when the states’ view of what’s best is different from the president’s, he would prefer to centralize.
This is a tendency that liberals should support. The biggest problem with the American healthcare system is its severe degree of decentralization. Ultimately, the decision to set the true poverty line at 100, 200, 300, or even 400% of the federal line, is an arbitrary one, and we can agree to disagree about the exact cut off. We should not allow, however, the basic right to health care to be arbitrarily granted to citizens in some states, but not in others.
That, however, is exactly what we currently do. Contrary to popular belief, there is no national program which guarantees health care to the poor. Medicaid does not do this, because eligibility rules vary by state. In many states, just being poor is not enough to qualify for Medicaid. You must be both poor, and meet other restrictive criteria. Nor do we have a single HIV policy for the poor in America. Depending on your state of residence, you may have to wait years for ARV treatment. And CHIP only covers some kids, some of the time, in some places, leaving others, depending on the state, without any coverage at all.
In the case of CHIP, the fact is that the states have failed to enroll all of their eligible children, even though the federal government is footing a large part of the bill. What will it take to get the missing kids into CHIP? I doubt anyone can answer this question definitively. One reasonable hypothesis, however, is that the solution is a national program, backed by strong federal will, and a single, visible manager. The president’s plan, by contrast, relies on the current (broken) system to reform itself. It would simply prohibit states from doing anything new until they fix their current problems. But, in the decentralized health system we have, this will just create another theater for political gamesmanship. The feds can blame the states for not enrolling poor kids, and the states can blame the feds for prohibiting them from enrolling the near-poor. Meanwhile, nobody gets health care. An all-out effort to find and enroll children, coordinated at the national level under a single leader, would be more likely to create accountability and yield results.
The president’s strategy presents supporters of a universal guarantee of health care for children with a choice. They can use this as an issue to attack the president and hope that he eventually backs down, leaving us with an expanded version of the inefficient, patchwork system we have today. Or, they can call his bluff, push for greater centralization and create a national program to guarantee, finally, health insurance to every American child. Both strategies are political winners. The only question is: which strategy will lead to more kids getting health care?