State Children's Health Insurance Program

State Children's Health Insurance Program

The State Children's Health Insurance Program (SCHIP) – later known more simply as the Children's Health Insurance Program (CHIP)[1] – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children.[2] The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

At its creation in 1997, SCHIP was the largest expansion of taxpayer-funded health insurance coverage for children in the U.S. since Medicaid began in the 1960s. The statutory authority for SCHIP is under title XXI of the Social Security Act. It was sponsored by Senator Edward Kennedy in a partnership with Senator Orrin Hatch[3] with support coming from First Lady Hillary Rodham Clinton during the Clinton administration.[4][5][6]

States are given flexibility in designing their SCHIP eligibility requirements and policies within broad federal guidelines. Some states have received authority through waivers of statutory provisions to use SCHIP funds to cover the parents of children receiving benefits from both SCHIP and Medicaid, pregnant women, and other adults. SCHIP covered 6.6 million children and 670,000 adults at some point during federal fiscal year 2006, and every state, except Arizona [1] has an approved plan.[7] Despite SCHIP, the number of uninsured children continued to rise, particularly among families that cannot qualify for SCHIP. An October 2007 study by the Vimo Research Group found that 68.7 percent of newly uninsured children were in families whose incomes were 200 percent of the federal poverty level or higher.[8] In FY 2008, the program faced funding shortfalls in several states.[9]

During the administration of George W. Bush, two attempts to expand funding for the program failed when President Bush vetoed them. Mr. Bush argued that such efforts were steps toward federalization of health care, and would "steer the program away from its core purpose of providing insurance for poor children and toward covering children from middle-class families."[10] On February 4, 2009, President Barack Obama signed the Children's Health Insurance Reauthorization Act of 2009, expanding the healthcare program to an additional 4 million children and pregnant women, including for the first time legal immigrants without a waiting period.



Health care in the United States
Public health care

Private health coverage

Health care reform law

State level reform
Municipal health coverage

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As a part of the fallout from the failed 1993 Clinton health care plan, both Democratic Senator Ted Kennedy and the Clinton administration were looking for smaller initiatives for publicly-funded health care that could gain bipartisan support.[4]

Kennedy was intrigued by a children's health insurance plan in Massachusetts that had passed in 1996, and met with a Boston Medical Center pediatrics director and a Massachusetts state legislator to discuss the feasibility of a national initiative.[11] Kennedy also saw using an increase in tobacco taxes as a way to pay for the expanded coverage.[11] Thus, in October 1996, Kennedy introduced a bill to provide health care coverage for children of the working poor, to be financed via a 75 cents a pack cigarette tax increase.[5]

Meanwhile, in December 1996 First Lady Hillary Rodham Clinton examined several possible such initiatives and decided expanding health care insurance to children who had none was the one to advance,[4] especially as its focus on children would be politically popular.[5] Indeed, a different variant of this approach, dubbed "Kids First", had been envisioned as a backup plan during the original 1993 Task Force on National Health Care Reform meetings.[6][12] Additionally, Hillary Clinton had discussed an SCHIP-ish program with a White House health policy coordinator during the time her full-blown health care plan had suffered political failure.[13]

The new initiative was proposed at Bill Clinton's January 1997 State of the Union address, with the stated goal of coverage up to five million children.[4][5] Kennedy continued to write much of the bill, using the increase in tobacco taxes to pay the $20 billion price tag.[3] In March 1997, Kennedy brought Republican Senator Orrin Hatch onto the legislation as co-sponsor; Kennedy and Hatch had worked together as an "odd couple" in the Senate before, and here Hatch said that "Children are being terribly hurt and perhaps scarred for the rest of their lives" and that "as a nation, as a society, we have a moral responsibility" to provide coverage.[3] Hatch's role would infuriate some Republican colleagues[14][15] and conservative commentators.[16] The First Lady did not hold news conferences or testify before Congress on behalf of the bill.[13]

An initial objection of Republicans in the Senate was that proposing to pay for the services by raising the federal tax on cigarettes, from 24 cents a pack to 67 cents a pack, ignored the likely consequence that sale of tobacco products would decrease and tax revenues would increasingly fall short of those needed to pay for the expansion of benefits.[17] Kennedy and Hatch scoffed at the objection, with the former saying, "If we can keep people healthy and stop them from dying, I think most Americans would say 'Amen; isn't that a great result?' If fewer people smoke, states will save far more in lower health costs than they will lose in revenues from the cigarette tax."[17] Republicans also criticized the bill as an open-ended entitlement program, although it was structured as a block grant rather than an entitlement;[17] Senate Majority Leader Trent Lott was an early opponent of the measure, calling it a "big-government program" that would not pass.[14]

Then the bill had to comply with the existing balanced budget agreement between Congress and the White House, something that Lott said it did not.[4] Pressure was on to reduce the amount of grants involved, with $16 billion a possible compromise; Hillary Clinton instead argued for $24 billion.[4][6] The Clinton administration had a deal with the Republican leadership in Congress that forbade the administration from backing any amendments to the budget resolution.[11] Thus, Bill Clinton phoned members of Congress and asked that they kill the children's health insurance provision when it came to the floor.[4] On May 22, it was so done, with the necessary cigarette tax amendment defeated by a 55–45 margin.[18] Hillary Clinton defended her husband's action at the time, saying "He had to safeguard the overall budget proposal,"[4] but Kennedy was surprised and angered by it,[11] considering it a betrayal,[5] and saying that his calls to Bill Clinton and Vice President Al Gore had not been returned.[18] Hatch was also upset, saying that Lott may have been bluffing and that, "I think the President and the people in the White House caved here."[18]

Kennedy did not give up on the measure, saying: "We shall offer it again and again until we prevail. It's more important to protect children than to protect the tobacco industry."[18] Both Bill and Hillary Clinton argued for including the children's health insurance in subsequent legislation.[11] The bill was indeed revived by Kennedy and Hatch a month after its initial defeat.[5] Organizations from the Children's Defense Fund to the Girl Scouts of the USA lobbied for its passage, putting public pressure on Congress;[5] Hillary Clinton was pushing for it as well,[4] with Kennedy urging her to use her influence within the White House.[5] SCHIP was then passed and signed into law by Bill Clinton on August 5, 1997[4] as part of the Balanced Budget Act of 1997, to take effect the following month.[19] At a press conference following the signing, Kennedy thanked Hatch, Senate Minority Leader Tom Daschle, Children's Defense Fund head Marian Wright Edelman, Bill Clinton, and Hillary Clinton.[6] About the latter, Kennedy said, "Mrs. Clinton ... was of invaluable help, both in the fashioning and the shaping of the program and also as a clear advocate."[5]

SCHIP is located at Title IV, subtitle J of H.R. 2015 [105th] Balanced Budget Act of 1997. H.R. 2015 was introduced and sponsored by Rep John Kasich [R-OH] with no cosponsors.[20] On 25 June 1997, H.R. 2015 passed House Vote Roll #241 mainly among partisan lines, 270 ayes and 162 nays, with most Democrats in the House of Representatives in opposition. On the same day, the bill passed in the Senate, with a substitute amendment, by unanimous consent. After a conference between the House and Senate, passage in both House (Roll #345: 346-85) and Senate (Roll #209: 85-15) on the conference substitute became more bipartisan.

State administration

Like Medicaid, SCHIP is a partnership between federal and state governments. The programs are run by the individual states according to requirements set by the federal Centers for Medicare and Medicaid Services. States may design their SCHIP programs as an independent program separate from Medicaid (separate child health programs), use SCHIP funds to expand their Medicaid program (SCHIP Medicaid expansion programs), or combine these approaches (SCHIP combination programs). States receive enhanced federal funds for their SCHIP programs at a rate above the regular Medicaid match.

By February 1999, 47 states had set up SCHIP programs, but it took effort to get children enrolled.[6] That month, the Clinton administration launched the "Insure Kids Now" campaign, designed to get more children enrolled;[21] the campaign would fall under the aegis of the Health Resources and Services Administration. By April 1999, some 1 million children had been enrolled, and the Clinton administration set a goal of raising the figure to 2.5 million by 2000.[22]

States with separate child health programs follow the regulations described in Section 42 of the Code of Federal Regulations, Section 457. Separate child health programs have much more flexibility than Medicaid programs. Separate programs can impose cost sharing, tailor their benefit packages, and employ a great deal of flexibility in eligibility and enrollment matters. The limits to this flexibility are described in the regulations, and states must describe their program characteristics in their SCHIP state plans. Out of 50 state governors, 43 support SCHIP renewal.[23] Some states have incorporated the use of private companies to administer portions of their SCHIP benefits. These programs, typically referred to as Medicaid managed care, allow private insurance companies or health maintenance organizations to contract directly with a state Medicaid department at a fixed price per enrollee. The health plans then enroll eligible individuals into their programs and become responsible for assuring SCHIP benefits are delivered to eligible beneficiaries.

In Ohio, SCHIP funds are used to expand eligibility for the state's Medicaid program. Thus all Medicaid rules and regulations (including cost sharing and benefits) apply. Children from birth through age 18 who live in families with incomes above the Medicaid thresholds in 1996 and up to 200% of the federal poverty level are eligible for the SCHIP Medicaid expansion program. In 2008, the maximum annual income needed for a family of four to fall within 100% of the federal poverty guidelines was $21,200, while 200% of the poverty guidelines was $42,400.[24]

Other states have similar SCHIP guidelines, with some states being more generous or restrictive in the number of children they allow into the program.[25] SCHIP Medicaid expansion programs typically use the same names for the expansion and Medicaid programs. Separate child health programs typically have different names for their programs. A few states also call the SCHIP program by the term "Children's Health Insurance Program" (CHIP).

States are allowed to use Medicaid and SCHIP funds for premium assistance programs that help eligible individuals purchase private health insurance. As of 2008 relatively few states had premium assistance programs, and enrollment was relatively low. Interest in this approach remained high, however.[26]

In August 2007, the Bush Administration announced a rule requiring states (as of August 2008) to sign up 95% of families with children, earning 200% of the federal poverty level, before using the funds to serve families earning more than 250% of the federal poverty level. The federal government said that 9 out the 17 states that offer benefits to higher-earning families were already compliant. Opponents of this rule argued that signing up higher-income families makes lower-income families more likely to sign up, and that the rule was incompassionate toward children who would otherwise go without medical insurance.[27]

Debate over impacts

SCHIP has cost the federal government $40 billion over its first 10 years, and the debate over its fiscal impacts reflects the larger debate in the U.S. over the government's role in health care.

In 2007, researchers from Brigham Young University and Arizona State found that children who drop out of SCHIP cost states more money because they shift away from routine care to more frequent emergency care situations.[28] The conclusion of the study is that an attempt to cut the costs of a state healthcare program could create a false savings because other government organizations pick up the tab for the children who lose insurance coverage and later need care.

Detractors of the program focus on the impact to the private health insurance industry. In a 2007 analysis by the Congressional Budget Office, researchers determined that "for every 100 children who gain coverage as a result of SCHIP, there is a corresponding reduction in private coverage of between 25 and 50 children." The CBO speculates this is because the state programs offer better benefits at lower cost to enrollees than the private alternatives.[7] A briefing paper by libertarian think-tank Cato Institute estimated the "crowding out" of private insurers by the public program could be as much as 60%.[29]


SCHIP was created in 1997 as a ten-year program; to continue past federal fiscal year 2007, passage of a reauthorization bill was required. The first two reauthorization bills to pass through Congress would also expand the program's scope; President George W. Bush vetoed them as improper expansions. A two-year reauthorization bill was signed into law by the President in December 2007 that would merely extend current SCHIP services without expanding any portion of the program. With the 2008 Presidential and Congressional elections bringing Democrats to a majority in both houses of Congress and to the Oval Office, SCHIP was reauthorized and expanded in the same bill through fiscal year 2013.

2007 reauthorization

HR 976

In 2007, both houses of Congress passed a bipartisan measure to expand the SCHIP program, H.R. 976. The measure would have expanded coverage to over 4 million more participants by 2012, while phasing out most state expansions in the program that include any adults other than pregnant women. The bill called for a budget increase for five years totaling $35 billion, increasing total SCHIP spending to $60 billion for the five-year period. Opposition to HR 976 focused on the $35 billion increase in government health insurance as well as $6.5 billion in Medicaid benefits to illegal immigrants. Originally intended to provide health care coverage to low-income children, HR 976 was criticized as a giveaway that would have benefited adults as well as non-U.S. citizens.[30][31][32][33][34] The program expansion was to have been funded by sharply increasing federal excise taxes on tobacco products.[35] On the other hand, opponents said this proposed expansion was for families with annual incomes up to $82,600 (400 percent of the federal poverty level)[36]

On October 3, 2007, President Bush vetoed the bill,[37] stating that he believed it would "federalize health care", expanding the scope of SCHIP much farther than its original intent.[38][39] The veto was the fourth of his administration.[38] After his veto, Bush said he was open to a compromise that would entail more than the $5 billion originally budgeted, but would not agree to any proposal drastically expanding the number of children eligible for coverage.[40]

On October 18, 2007, the House of Representatives fell 13 votes short (273-156) of the two-thirds majority required to override the president's veto, although 44 Republicans joined 229 Democrats in supporting the measure.[41]

HR 3963

Within a week of the failed veto override vote, the House passed a second bill attempting a similar expansion of SCHIP. According to Democrats, the second bill, H.R. 3963, created firmer caps on income eligibility, prevented adults from joining, and banned children of illegal immigrants from receiving benefits. According to its opponents, however, this second proposed expansion was for families with annual incomes up to $62,000 (300 percent of the federal poverty level).[36] The Senate passed the measure on November 1, 2007, but on December 12, 2007, Bush vetoed this bill as well, saying it was "essentially identical" to the earlier legislation,[42] and a House vote in January 2008 failed to override the veto.

Public Law 110-173

Congress ultimately passed Pub.L. 110-173, which extended SCHIP funding through March 31, 2009, and the President signed it into law on December 21, 2007.

2009 reauthorization

In the wake of President Barack Obama's inauguration and the Democrats' increased majorities in both houses of Congress, legislative leaders moved quickly to break the political stalemate over SCHIP expansion. On January 14, 2009, the House passed H.R. 2 on a vote of 290-138. The bill authorized spending an added $32.8 billion to expand the health coverage program to include about 4 million more children, including coverage of legal immigrants[43] with no waiting period for the first time. A cigarette tax increase of 62 cents—bringing the total tax on a pack of cigarettes to $1.01—an increase of tax on chewing tobacco from $0.195/lb. to $0.50/lb.—as well as tax increases on other tobacco products[44] will fund the program's expansion. On January 29, the Senate passed the house bill by a 66-32 margin, with two amendments.[45] The House accepted the amended version on a vote of 290 to 135,[43] and President Obama signed the bill into law as Pub.L. 111-3 on February 4, 2009.[46]

Arizona rescission

In early 2010, Arizona Governor Jan Brewer, along with the House and Senate of the state passed a budget that eliminated S-CHIP, known as KidsCare in Arizona. As of 22 April 2010, the state assembly, after learning they will lose federal matching and stimulus funds, is looking at restoring some of the program, but not allowing new enrollment.[47]

See also

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  1. ^ "Children's Health Insurance Program". United States Department of Health and Human Services. Retrieved July 29, 2009. 
  2. ^ Sultz, H., & Young, K. Health Care USA Understanding its Organization and Delivery pg. 257
  3. ^ a b c Pear, Robert (1997-03-14). "Hatch Joins Kennedy to Back a Health Program". The New York Times (The New York Times Company). Retrieved 2008-01-06. 
  4. ^ a b c d e f g h i j Beth Fouhy (2007-10-05). "Hillary Claims Credit for Child Program". Associated Press for NewsMax. Archived from the original on 2008-01-23. Retrieved 2007-10-07. 
  5. ^ a b c d e f g h i Karen Tumulty, Michael Duffy, Massimo Calabresi (2008-03-13). "Assessing Clinton's "Experience": Children's Health Care". Time.,8599,1721966,00.html. Retrieved 2008-03-17. 
  6. ^ a b c d e Brooks Jackson (2008-03-18). "Giving Hillary Credit for SCHIP". Retrieved 2008-03-19. 
  7. ^ a b "The State Children's Health Insurance Program" (PDF). Congressional Budget Office. 2007-05-10. Retrieved 2007-10-16. 
  8. ^ Espe, Erik (2007-10). "The Uninsured In America" (PDF). Vimo Research Group. Retrieved 2008-01-06. 
  9. ^ "President's FY 2008 Budget and the State Children's Health Insurance Program (SCHIP)" (PDF). Henry J. Kaiser Family Foundation. Retrieved 2007-07-03. 
  10. ^ "Bush Vetoes Children's Health Bill". 2007-10-03. Retrieved 2009-01-08. 
  11. ^ a b c d e Susan Milligan (2008-03-14). "Clinton role in health program disputed". The Boston Globe. Retrieved 2008-03-15. 
  12. ^ "Clinton Care Through the Kitchen Door". Association of American Physicians and Surgeons. January 1996. Retrieved 2008-01-22. 
  13. ^ a b Shailagh Murray, Jonathan Weisman (2008-03-24). "Both Obama And Clinton Embellish Their Roles". The Washington Post. Retrieved 2008-03-24. 
  14. ^ a b James Carney (1997-04-21). "Hatching Mischief". Time.,9171,986210,00.html. Retrieved 2008-01-22. 
  15. ^ Michael Crowley (2004-02-20). "Sen. Orrin Hatch". Slate. Retrieved 2008-01-22. 
  16. ^ Phyllis Schlafly (1997-03-25). "Orrin Hatch Turns Out To Be A Latter Day Liberal". Eagle Forum. Retrieved 2008-01-22. 
  17. ^ a b c Adam Clymer (1997-05-21). "Child Insurance Bill Opposed As Threat to Cigarette Revenue". The New York Times. Retrieved 2008-01-22. 
  18. ^ a b c d Adam Clymer (1997-05-22). "Clinton Helps Kill Proposal to Raise Tax on Cigarettes". The New York Times. Retrieved 2008-03-17. 
  19. ^ Peter T. Kilborn (1997-09-21). "States to Give More Children Health Coverage". The New York Times. Retrieved 2008-01-21. 
  20. ^ H.R. 2015 [105th]: Balanced Budget Act of 1997 (
  21. ^ "President Clinton and First Lady Hillary Rodham Clinton Launch the [Insure Kids Now Campaign Promoting Children's Health Insurance Outreach"] (Press release). 1999-02-23. Retrieved 2008-03-19. 
  22. ^ "First Lady Hillary Rodham Clinton Announces That Almost One Million Children Are Enrolled in the Children's Health Insurance Program" (Press release). 1999-04-20. Retrieved 2008-03-19. 
  23. ^ Overriding the SCHIP Veto by the Numbers Center for American Progress.
  24. ^ Federal Register, Vol. 73, No. 15, January 23, 2008, pp. 3971-3972. Also see "US Department of Health and Human Services Poverty Guidelines"
  25. ^ "Medicaid and SCHIP Program Eligibility Rules by State"
  26. ^ Joan Alker, "Choosing Premium Assistance: What Does State Experience Tell Us?", The Kaiser Family Foundation, May 2008
  27. ^ Proposal Favoring SCHIP's Poorest Kids Criticized
  28. ^ Rimsza ME, Butler RJ, Johnson WG (2007). "Impact of Medicaid disenrollment on health care use and cost". Pediatrics 119 (5): e1026–32. doi:10.1542/peds.2006-2747. PMID 17473075. Retrieved 2008-01-05. 
  29. ^ Michael F. Cannon. "Sinking SCHIP: A first step toward stopping the growth of government health programs". Retrieved 2007-10-04. 
  30. ^ Congressman Robert B. Aderholt : News Releases : Aderholt Opposes $35 Billion Expansion of Government Health Insurance: SCHIP Bill Includes $6.5 Billion Giveaway For Illegal Immigrants
  31. ^ Political posturing obscures the issue Insuring health care for poor children should be highest priority as Congress votes By Rep
  32. ^ Galloway, J; Kemper B (2007-09-21). "More SCHIP: Revived but already dead". The Atlanta Journal-Constitution (Cox Enterprises). Retrieved 2008-01-06. 
  33. ^ "Health Care" (webpage). Retrieved 2007-10-04. 
  34. ^ "Bush's False Claims About Children's Health Insurance" (webpage). Retrieved 2007-10-10. 
  35. ^ "GovTrack: H.R. 976: Text of Legislation" (webpage). GovTrack. Retrieved 2007-12-24. 
  36. ^ a b John Paulton (February 2009). "Game Plan". Citizen 23 (2): pp. 36–37. ISSN 1084-6832. 
  37. ^ "Bush vetoes child health insurance plan" (webpage). MSNBC. Retrieved 2007-10-03. 
  38. ^ a b Abramowitz, Michael (2007-10-03). "Bush Vetoes Children's Health Insurance Plan". The Washington Post. 
  39. ^ White House web site
  40. ^ Stolberg, Sheryl Gay; Carl Hulse (2007-10-04). "Bush Vetoes Child Health Bill Privately". The New York Times. Retrieved 2007-12-08. 
  41. ^ "Final Vote Results for Roll Call 982" (webpage). U.S. House of Representatives. Retrieved 2007-10-18. 
  42. ^ "President Bush vetoes child health bill again". CNN. 2007-12-13. Retrieved 2007-12-14. 
  43. ^ a b Pear, Robert (February 4, 2009). "Obama Signs Children's Health Insurance Bill". Retrieved February 6, 2009. 
  44. ^ "Health Groups Hail Increase in Federal Tobacco Taxes". NCI Cancer Bulletin. National Cancer Institute. February 10, 2009. Retrieved 2009-02-10. 
  45. ^ Connolly, Ceci (January 30, 2009). "Senate Passes Health Insurance Bill for Children". Washington Post. Retrieved January 31, 2009. 
  46. ^ "Obama signs kids' health insurance bill". The Associated Press (MSNBC). February 4, 2009. Retrieved 2009-02-04. 
  47. ^

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