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21/11/07
A Word about SCHIP
by Andrew D. Coates

The recent proposal, vetoed by President Bush, to expand the State Children's Health Insurance Program (SCHIP) represents an important effort to defend working families with uninsured children from the grim cruelty of paying out of pocket for the care of sick children, which can too easily lead to financial ruin for the entire families and create impediments, at least, to medical care for the children.

American health care is in crisis, and yet we are still putting coins and dollars into humble jars and coffee cans at diner counters, supermarket bake sales, and church fundraisers to try to raise money for the treatments of uninsured children afflicted with malignancies.  (Charity exists in America, but only for children who never did anything to anyone and who, even from the most conservative, fundamentalist, neo-liberal, or Malthusian viewpoint, could never be said to deserve their illnesses.)  Haven't we all wondered at one time or another: what if we find ourselves among those parents who can't find the money or time off work when their child needs to see a doctor or a dentist?  And what if the doctor said that more tests are needed, or a specialist, or a hospital?  What kind of society do we live in that produces, so readily, such personal desperation when a child becomes sick?

The SCHIP program not only promises to address this appalling situation by reducing the number of uninsured children but should cost society relatively little since children in America are by and large healthy and require, compared to older people, fewer expensive treatments, hospitalizations, and interventions.  So (like the 84% in the New York Times poll earlier this year) we can all agree that SCHIP should be expanded to include ALL of the roughly 9 million children in America who have no health insurance.

But what can we, who are serious about health care reform, expect from SCHIP?  Some characterize SCHIP as a step toward universal health insurance.  Would that it were so.

Launched in 1998, SCHIP gives a block grant to states to fund programs to either augment Medicaid benefits to children, or establish a separate subsidized health insurance for children, or do some combination of these two.  The program did help to reduce the number of uninsured children until 2004.  However, the number of children losing private employer-based coverage has progressively outstripped enrollment in SCHIP.  Since 2004, the number of uninsured children has risen dramatically, by more than 1 million children, through 2006.  Yet the SCHIP expansion proposal, introduced by Congressman Rangel (HR 976), did not aim to cover all children.  It hoped to provide funds to cover 3.2 to 4.2 million children by 2012 -- fewer than half of children who lack health insurance now.

Thus, this SCHIP expansion, even if enacted, would still fall short of meeting all the unmet needs as private health insurance fails ever more children than before.  So one step forward, one step back.

Worse, SCHIP is a capped grant given out state by state, so not only does its delivery vary widely from state to state, but funding for the children now covered by SCHIP has lagged behind the skyrocketing costs of health care, creating a crisis in many states.  More realistically, then, one step forward, two steps back.

Therefore, it's misleading to call the SCHIP expansion proposal a step toward universal health insurance.  The proposal should be vigorously supported, but, at the same time, we should explain that SCHIP, a laudable social reform that has protected many families from ruin, does nothing -- absolutely nothing -- about the cause of the burgeoning number of uninsured children: the fact that our system is dominated by private employer-based health insurance.

Reforms that rely on private health insurance, including those that set up publicly-financed insurance alongside the existing system (as SCHIP does), will simply not work.  They will be brought down by the harsh realities of health care bought and sold as a corporate commodity, which does not provide health security and is becoming less and less affordable each day: soaring costs at every level, widening disparities in access and outcomes, lack of choice of provider or clinic or hospital, and deteriorating quality of care.  Proposals for health reform that avoid this fundamental issue may mitigate the inhumanities of our health care system, but they will not get us out of the crisis.

So what should we do?

Even as we support the expansion of SCHIP, we must make clear what created the urgent need for a program like that to begin with: the failure of private health insurance.  In other words, in struggle for SCHIP, activists must lay the groundwork for reform that offers a true step forward -- a proposal for a publicly-financed single-payer national health program, like House Bill HR 676.

The past record of private health insurance corporations has disqualified them from continuing as the central force managing American health care.  If mainstream politicians lack the courage to say so, they are out of step with the American people, who now recognize that private insurance has got to go -- in a democracy, the public should decide health policies.


Andrew D. Coates, MD, secretary of the Capital District (NY) chapter of Physicians for a National Health Program (at www.pnhp.org/), practices medicine in Albany, NY. 
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