In the most recent edition of the New England Journal of Medicine, there is a perspective piece by Sara Rosenbaum that bluntly describes how the Bush Administration’s opposition to S-CHIP (the State Children’s Health Insurance Program) is based on ideology and not economic cost (italics mine):
Why would the President veto bipartisan legislation that does precisely what he insisted on — namely, aggressively enroll the poorest children? One might blame the poisonous atmosphere that pervades Washington these days, but other important social policy reforms have managed to get through.
One answer lies in a far larger dimension of SCHIP that is basic to any health insurance legislation–namely, the legislative architecture of the reform plan, its structural and operational approach. Viewed from this vantage point, the SCHIP battle turns out not to have been about family-income assistance levels or the mechanism for financing coverage subsidies (although both the Medicare managed-care industry and the tobacco companies weighed in noisily on the latter question). Instead, the issue became the role of government in organizing and overseeing the health care marketplace…. SCHIP uses the power of government to form insured groups, select qualified plans, oversee plan operations, and measure results. It is this architecture to which the President was referring when he said that the legislation would move the health care system in the wrong direction.
…The use of government as purchaser and market overseer itself represents a crucial policy and political compromise between advocates of pure public insurance models and proponents of full market deregulation. Certain recent high-profile legislative reforms — Medicare Advantage, Medicare Part D, and the Massachusetts Connector Authority, for example — are evidence of the potential for architectural compromise. Given the need for a compromise providing a robust approach to managing an enterprise as vast as the purchasing of personal health care services, these hybrid systems appear to offer a means of breaking the policy logjam.
But it was such a solution that the administration sought to halt in the case of SCHIP, precisely because of its implications for broader future reforms.
Maybe the Republicans were right: perhaps expanding S-CHIP would lead to inefficient ‘crowdout’ of corporate health insurance. That is, corporate insurance companies would face unfair competition from federal insurance programs*. Erm, not so much:
The President’s own tax plan–which is not income-related–underscores the reality that the issue with regard to SCHIP was never the level of family income that would qualify children for a subsidy. Bush’s tax proposal also suggests that the real concern is not health insurance crowd-out: estimates show that his tax-credit plan would have a far greater crowd-out effect than any proposed expansion of SCHIP and would result in a net gain of only 3 million insured people. The administration’s policy recommendations related to non-means-tested tax subsidies and its support for association health plans lead to the conclusion that the real issue is the role of government in a reformed health care system. The war is over ideology, not money.
Of course, what would any Bush policy be without Mayberry Machivellianism:
The effort to stop SCHIP was aided by the toxic atmosphere in Washington and the administration’s labeling of SCHIP as a middle-class boondoggle. This allegation was made believable, according to one prominent Republican polling expert, because some families receiving assistance in certain states, such as New Jersey, had incomes that, though modest by regional standards, far exceeded the national median. The veto “played well in the South” for the administration, according to this expert; the maximum annual income of eligible New Jersey families seemed absurdly high to focus groups in poorer (and Republican) parts of the country, whose own SCHIP programs were far less generous. Reactions in these strongholds were powerful enough to reassure Republican House members that their support for the President’s veto would not damage their chances in the 2008 elections.
As always, politics, not the health and welfare of all Americans would come first with the Bush Administration. Republicans don’t seem particularly fond of the notion of good governance for all Americans (surprising, I know). And, yes, what Little Lord Pontchartrain could not achieve legislatively, he attempted to achieve via executive dictat:
The administration’s war over efforts to move the health care system in the “wrong direction” has not been limited to vetoes.
…This [HHS] letter announced that the Centers for Medicare and Medicaid Services (CMS), which administers SCHIP, would deny federal funding to states that exceeded the 250% mark unless they could make certain assurances: that they were enrolling at least 95% of children with family incomes below 200% of the federal poverty level (an achievement that experts in voluntary health insurance systems consider impossible); that the proportion of children covered by private employers had not dropped by more than 2 percentage points over the previous 5 years (although the federal Employee Retirement Income Security Act [ERISA] prohibits states from regulating private, employer-sponsored group health benefit plans); and that they were in compliance with certain anti-crowd-out practices, the most astounding of which, from a public health point of view, is the imposition of a 12-month waiting period before permitting uninsured children of any family-income level to enroll in SCHIP.
….By the end of 2007, several states had announced that they would be scrapping planned expansions of SCHIP to 300% of the poverty level — changes that affect thousands of children and families.
In sum, what the administration could not achieve through legislation it has sought to achieve by fiat, including administrative directives that appear to run afoul of other federal laws, such as ERISA. So determined does the administration appear to be to halt the growth of a health insurance architecture it opposes — at least in the case of working families and children not covered through the Federal Employees Health Benefits Plan — that it will flout the law and punish thousands of children in order to achieve its goals.
Yes, another successful Republican policy: ideology trumps economics, they screw over people who aren’t their political base, hurt thousands of children, violate federal law, and act by fiat.
*Why there is a moral obligation or economic incentive to guarantee that more expensive and inefficient–and thus more inaccessible to some–corporate health insurance should be protected escapes me. The goal is to pay for healthcare for sick people, not provide protection for political powerful corporations…