On Thursday, 15 January 2009, the House of Representatives passed a reauthorization of the Children’s Health Insurance Program, CHIPRA, by a vote of 289 to 139. On the same day the Senate Finance Committee approved a similar version of the bill by a vote of 12 to 7 and placed it on the Senate’s calendar. If the failure of SCHIP reauthorization in 2007 presaged the politics of 2008, it is fair to ask if the passage of the House bill, and imminent passage of a bill in the Senate, provide hints of what is to come under an Obama administration.
There are some tantalizing clues in both the 150-vote margin of passage in the House and the text of the 185-page bill. Forty Republicans voted for the bill–over 22% of the Republicans in the House. All the opposing votes save one came from Republicans as well, but the geographic divide among Republicans is quite striking. Much of the opposition came from the Deep South. The bill had substantial support from Republicans in Ohio, Minnesota, Michigan, Pennsylvania, Virginia, and Florida; it also received support from Republican representatives from Idaho, Montana, and Alaska, three of the four states where SCHIP is currently funded at less than 200% of poverty.
Newly elected Republican members who voted for the bill included representatives from New York, New Jersey, Pennsylvania, and Ohio and the first Vietnamese member of the House, Anh Cao of New Orleans. Republicans perhaps found the 2009 version of CHIPRA more appealing because this version dropped the five-year waiting period for legal immigrants –children and pregnant mothers — before they could obtain benefits. It’s hard to understand how that provision made much sense from a medical perspective, but what is even more cheering is that this may signal the end of the demonization of immigrants in health care reform debates, at least in the House.
Provisions On Immigrants, Specialty Hospitals Prove Less Popular Among Senate Republicans Than Their House Counterparts
Interestingly enough, the same provisions in the 2009 version of CHIPRA engendered a reversal of fortune in the Senate Finance Committee. SCHIP reauthorizations in 2007 passed the committee by a vote of 17 to 4 with substantial Republican support, including Senators Charles Grassley (IA) and Orrin Hatch (UT). This time, only Republican Olympia Snowe of Maine joined her Democratic colleagues in supporting the bill and an amendment that also did away with the five-year waiting period for legal immigrants. Both passed the committee by a vote of 12 to 7. Two major sticking points for Republicans were the waiving of the five-year waiting period for legal immigrants and the provision in the House bill (Title VI, Section 623) restricting the ability of physician-owned specialty hospitals to get Medicare reimbursements.
Two competing political themes emerge from the voting patterns. The House vote reveals that the Republican Party has to be somewhat cautious in relying too much on a purely Southern strategy. The Senate vote reveals that Democrats need to keep bipartisan paths open, particularly in health care, with senators like Grassley and Hatch, if they and the president hope to pass major health care reform legislation.
House And Senate Bills Would Relax Documentation Requirements
One of the issues addressed in the new bill in both the House and Senate versions is documentation for eligibility. Since the passage of the Deficit Reduction Act in 2005, documentation requirements have become increasingly controversial. The Bush administration interpreted the DRA requirements strictly and narrowly as requiring Medicaid applicants to bring original documentation to apply for Medicaid although not for SCHIP. The effects, however, could be felt in both programs, particularly in states that had simplified or unified enrollment procedures for both programs. Qualified applicants struggled with the documentation requirements, state enrollments declined, and the GAO reported in 2007 that 22 states out of 44 reported declines in enrollment largely due to the burdensome documentation requirements. Virginia reported a decline of over 13,000 children in Medicaid in the first six months after the DRA rules took effect. The new bill allows citizenship and income verification through Social Security and other federal programs.
Perhaps more damning and more compelling to legislators was the GAO finding that — in the states that had data, six states with 3,655,500 enrollees — officials found a grand total of eight undocumented immigrants. The cost to the state and federal governments to do this checking was estimated at $16.6 million, half of it borne by the federal government and half by the state governments. The federal government’s savings amounted to $11,048. It would seem that even the most fiscally conservative representative opposed to large government programs could see that spending $8 million or $16 million to save $11,000 is not the wisest of options.
There are broad hints in the new CHIPRA bills of priorities for the new Obama administration. The bills provide authorization for up to ten demonstration projects “to evaluate promising ideas for improving the quality of children’s health care including the promotion of health information technology and demonstrating the impact of electronic health records for improving pediatric health.” Both bills also contain extensive provisions for funding, developing, and evaluating quality measures, as well as provisions to extend mental health parity and dental coverage under SCHIP.
The children’s advocacy camp is encouraged by the provisions for the development of quality measures and the pilot projects for health IT, which in pediatrics have generally lagged behind adult medicine. The emphasis on more comprehensive coverage, including dental and mental health, is also enouraging to advocates. These provisions will probably float under the political radar compared to the immigration and specialty hospital issues; they also signal what we might expect in future legislative proposals emanating from the White House.
As the House first took up voting on CHIPRA, the local Washington press reported that in two of the nation’s wealthiest counties, Fairfax in Virginia and Montgomery in Maryland, requests by families for state health insurance for their children had risen by 16% in the last year, as rising unemployment put private insurance out of reach. On the eve of the Senate vote, a New York Times poll revealed the growing strain on states attempting to provide Medicaid as enrollment surges among low-income children in the wake of parental job loss and loss of insurance. The Times reported that in an Atlanta suburb, a room was so packed with applicants for Medicaid that a fire marshal insisted on opening another room to accommodate the overflow crowd.
It seems that a bill that extends medical insurance coverage for an additional four million children and sustains the coverage for the seven million currently enrolled, and keeps these children enrolled for the next four and a half years, cannot pass too soon for beleaguered parents and state governments.