There is no question that nearly all Americans think children
should have access to quality health care. But according
to a recent survey, only about one in five believe the federal
government is the payer most responsible for children's
health care. Most people believe the responsibility for
that care rests with the children's parents.
Yet many Americans are unaware that the Clinton Administration's
"Kids First" back-up plan is being implemented across the
country. Fewer than one-third of Americans report hearing
about a new federal program that takes a giant step toward
nationalizing health care for children and overriding this
Today a bevy of health care providers, private foundations,
government officials, and political activists are successfully
setting up universal health care for children. Their success
is found in nationwide school-based health centers, Medicaid
expansions, and the new $48 billion federal health care
program for children. The new federal program attempts to
bring middle-income children into Medicaid, the government
health care program that already covers one-quarter of American
While current efforts to expand government health care
programs for children may be well intentioned, these programs
have serious unintended consequences. Experience has shown
that expanding government health care programs encourages
families to drop their private health insurance, reduces
health care choices, infringes upon parental rights, and
threatens medical privacy.
The dangers of a nationalized health care system for children
-- which could serve as the precursor to a socialized health
care system for all Americans -- should be publicly debated
before all children are placed under a single government
health care roof.
Naomi Lopez is the director of health and welfare studies
at the Pacific Research Institute in San Francisco, CA.
Many Americans assume that efforts to create a government-financed
health care system in the United States were halted in 1994,
along with President Clinton's failure to establish universal
health care. Just the opposite is true. Efforts to establish
government health care programs are stronger than ever;
they are just not as obvious.
In fact, Clinton Health Care Task Force documents -- made
public through court order -- reveal that "if they [the
Clinton Administration] are unsuccessful in getting the
Clinton-style, universal health care, that they should take
a kids first approach which would be used as the first step
to phase in the full Clinton-style health care plan."(1)
The Association of American Physicians and Surgeons
| [Clinton Health Care] Task
Force documents showed, "Kids First" is really a precursor
to the new system. It could be implemented through
Medicaid or another plan.(2)
Since the defeat of universal health care legislation in
1994, President Clinton has publicly stated that, rather
than re-attempting to pass universal coverage in one stroke,
he will promote universal health care incrementally -- one
group at a time.(3)
That strategy is working. The goal of government-sponsored
children's health care has gained bipartisan support and
is being actively, but quietly, pursued at the federal and
state levels by a bevy of health care providers, private
foundations, government officials, and political activists.
Their success is found in the more than 900 school-based
health centers now operating in more than forty states across
the country that provide, among other services, psychological
and reproductive counseling to children.(4)
Their success is also seen in the State Children's
Health Insurance Program (SCHIP), a new federal program
that expands government health care for children.
Who Should Be Responsible for
Children's Health Care?
Source: Harvard University, The Robert Wood
Johnson Foundation, and the University of Maryland,
"Attitudes Toward Children's Health Care Issues,"
November 1997. The survey question was worded "Who,
if anyone, do you think should be most responsible
for paying to make sure that children get this right
[to health care and health insurance]?" The survey
margin of error is plus or minus 3 percentage points.
While most Americans think children should have access
to quality health care, only 20.6 percent believe the federal
government is most responsible for financing that care,
according to a recent survey. The majority (52.4 percent)
believe the responsibility for health care rests with the
children's parents (see Figure 1).(5)
Yet few people realize that more than one-quarter of American
children already receive government-sponsored health care.
And, fewer than one-third of Americans report hearing about
the new $48 billion federal program(6)
that takes a giant step toward further nationalizing
government-sponsored health care for children across the
country, removing this responsibility from parents. Undoubtedly,
the first major steps toward universal health care for all
children have already been taken.
Is There Really
Rather than addressing the question of "Who lacks health
insurance and why?" lawmakers recently posed the emotionally
charged question, "Are you for or against children's health?"
Because sentiment rather than logic too often guides this
debate, lawmakers established a new federal health care
program for children, even though there is ample evidence
that no "crisis" exists. In fact, the overall rate of insured
children has remained stable over the past decade (see Figure
Percent of Children With Health
| Source: U.S. Bureau of the Census, Housing
and Household Economic Statistics Division, unpublished
tables based on analyses from the March Current Population
Survey as cited in Federal Interagency Forum on Child
and Family Statistics, America's Children: Key National
Indicators of Well-Being, 1997, Table ECON5, p. 71
and U.S. Bureau of the Census, March 1997, Current
Although welfare advocates and the media portray a health
insurance crisis among poor and low-income working families,
most uninsured children qualify for (but do not enroll in)
existing government programs, or they live in households
with moderate to high incomes. It is estimated that between
eight and eleven million children lack health insurance.(7)
There are about 4.7 million children who are eligible
for, but do not participate in, the federal Medicaid program.(8)
While some families do not realize their child is eligible,
many families choose not to participate because they are
concerned about the stigma attached to welfare or they do
not have an immediate need for health care services.
Over three million of the uninsured children live in families
with incomes more than twice the federal poverty level.(9)
A substantial portion of the remaining uninsured children
(fewer than one million to less than four million, depending
on the estimate) remain so for short periods of time, such
as when a parent is temporarily unemployed.(10)
That is because, in this country, employers rather
than employees own health insurance. When a worker is laid
off or loses his job, he loses his health insurance. This
is the result of current federal tax law whereby employer-provided
health insurance is excluded from taxation, but individually
purchased health insurance is not. These differences in
tax treatment can effectively double the cost of health
insurance for those families who purchase it on their own.
For this reason, many people choose to forego purchasing
health insurance while between jobs or while temporarily
Health policy analyst Robert Goldberg of George Washington
University, citing the Department of Health and Human Services,
finds that only 13 percent of uninsured children under age
18 lack health insurance because of its reported high cost.(11)
In fact, children are the healthiest part of our population
and the lowest-cost group to insure.(12)
The average cost of a health insurance policy for a
child is $900 per year, according to Robert Goldberg.(13)
Even so, the 105th Congress chose to create
a new federal health care program for children, instead
of reducing families' overall tax burden to help them pay
for their children's health care. This was unfortunate because
the new federal program paves the road to socialized medicine,
and does so with little public awareness.
Seniors Were Lured
Into Socialized Medicine:
Are Children Next?
While current efforts to expand government health care
programs for children may seem like a noble goal, these
programs could rapidly evolve into a government-mandated
health care program for all children in the United States.
The government's Medicare Part A program -- which is a mandatory
hospital insurance program that covers the majority of the
nation's elderly -- forces seniors to drop their private
health insurance and prevents them from seeking medical
care privately. A look at the government's Medicare program
illustrates how such an evolution in government health insurance
for children might occur.
How Seniors Were Lured into Socialized Medicine
Initially, Medicare was created with the promise that it
would not interfere with seniors' right to use private health
But after Medicare was passed in 1965, the federal
government garnered enough power over the private market
to force private insurers to drop seniors. As a result,
private health insurance carriers no longer offer primary
hospital insurance to seniors.(15)
Today, seniors have no alternative but to join the
government-sponsored Medicare program.
Moreover, many Americans are unaware that Medicare was
created to serve as a stepping stone to socialized medicine
for all Americans. Twenty-five years ago, health policy
analyst Howard Berliner revealed that:
| ...Medicare was designed to eventually be expanded
into a comprehensive and compulsory national health
insurance system. ...[H]ealth insurance for the aged
was a strategy to get a 'foot in the door.' It was
hoped that the small Medicare program would eventually
be expanded to include everyone in the country.(16)
Today, legal barriers prevent seniors from voluntarily
opting out of the government's Medicare program. A recent
judicial decision has ruled that seniors who are eligible
for Medicare do not have a constitutional right to pay privately
for their own Medicare-covered health services.(17)
Seniors are legally forced to participate in the Medicare
program or face severe financial penalties, even if they
have recognized religious or philosophical objections to
Furthermore, the Medicare program is fraught with fraud
and abuse in excess of $54 million per day, and subjects
doctors and Medicare patients to over 45,000 pages of government
The real tragedy of the situation is that seniors cannot
opt out of the program and have lost their legal right to
purchase health care services with their own money. Meanwhile,
health care rationing and reduced health care choice may
be compromising the quality of health care that seniors
One has to wonder how Medicare was initially created and
evolved into such a restrictive government program without
greater public debate. Economist Charlotte Twight explains:
| For more than 50 years before the 1965 enactment
of Medicare, the American people repeatedly rejected
the idea of government-mandated health insurance.
Yet advocates of such federal power inside and outside
government did not take no for an answer. Year after
year they kept coming back -- pursuing incremental
strategies, misrepresenting their proposals, even
distributing propaganda paid for with government money
in apparent violation of existing law.(21)
Many of the same tactics that were used to force seniors
into socialized medicine are being employed today. But this
time the efforts are targeted at children.
How Children Are Being Lured into Socialized
Government-sponsored health care for children may already
be traveling down the similar, dangerous path as Medicare.
The government Medicaid program, which provides medical
assistance to low-income families, is rapidly evolving into
a middle-class entitlement program that could soon replace
private insurance for our nation's children.
The federal Medicaid program is financed by combined federal
and state funds. According to the National Governors' Association,
over the past decade the vast majority of states have expanded
Medicaid eligibility for pregnant women and children beyond
the federally established mandate.(22)
Consequently, more children have become enrolled in
the Medicaid program. The Kaiser Commission on the Future
of Medicaid reports:
| Prior to 1986, Medicaid primarily served children
who received AFDC [Aid to Families with Dependent
Children] welfare assistance. Today, children qualify
for Medicaid based on their age and income. As a result,
Medicaid plays an essentially important role for young
children, covering 33% of infants and 29% of children
age one to five. . .. In 1995, 17.1 million children
-- one quarter of all children under age 18 -- had
Since then, states have further expanded their Medicaid
programs and most states do not require asset tests to determine
eligibility. Some states have offered Medicaid coverage
to children in families with incomes between 300 and 400
percent of the poverty level.(24)
Expanding Socialized Medicine Through Public Schools
The Clinton Health Care Task Force advocated delivering
health care through the public schools. The basic infrastructure
for expanding school-based health care is already well-entrenched
across the nation. School clinics have long delivered first-aid
and emergency care, as well as documented immunizations.
But that has been changing.
School-based health centers have expanded their missions,
adding a broad array of services such as psychological and
In 1985, there were only about 40 school-based health centers
operating in the United States.(25)
By 1993, 40 states used federal block grant funds or
state general funds to support school-based health clinics,
according to a Robert Wood Johnson Foundation survey.(26)
Today, there are over 900 hundred school-based health
centers operating in all but seven states, according to
a survey by Making the Grade, a Robert Wood Johnson Foundation
affiliate (see Table 1).(27)
1. School-Based Health Centers
by Rank and State:
||District of Columbia
||District of Columbia
| Source: Making the Grade, "National Survey
of State School-Based Initiatives: School Year 1995-96,"
George Washington University, Washington, D.C., 1997.
With the number of school-based health clinics rapidly
increasing, it is no surprise that the amount of money that
federal and state governments are contributing to school-based
health care is also increasing. During 1994, 25 states appropriated
more than $22 million in state revenues for school-based
health clinics -- an increase of 140 percent from the $9.2
million spent in 1992.(28)
The cornerstone of government funding for school-based
health care is Medicaid's Early and Periodic Screening,
Diagnosis and Treatment Program (EPSDT). Under EPSDT, Medicaid
pays for preventive health services and medical services
to improve health care functions.(29)
Additionally, EPSDT covers non-health services, such
as translation, outreach, and transportation.
Over half of all states have established Medicaid mechanisms
that permit them to deliver health care services in public
A report on Missouri's experience in creating school-based
programs provides an example of how Medicaid is being expanded
to pay for school-based health care:
"Over the past three years, the Independence School
District has generated more than $2 million from creative
use of Medicaid financing, primarily through the Medicaid's
Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)
and administrative case management (ACM) provisions. . .
Since 1967, the Title XIX of the Social Security Act, which
established the Medicaid program, had required states to
operate EPSDT programs to provide preventive health services
to all Medicaid-eligible children under the age 21. The
Omnibus Budget Reconciliation Act of 1989 sought to increase
the effectiveness of this program and improve the health
of poor children by requiring states to increase the percentage
of eligible children accessing the EPSDT program from 30
percent to 80 percent by FY 1995. To do this, states were
required to take a more active role in improving access
of children to preventive health services and in assuring
that once screened, children were provided with the full
range of health and mental health treatments needed to address
The Pennsylvania legislature has examined how Medicaid's
EPSDT program is affecting school-age children in Pennsylvania.
In their report "Findings of Fact and Report," the Pennsylvania
House of Representatives Committee on Education reports:
"[Pennsylvania] Executive Branch officials have manipulated
existing state programs and the Medicaid program in order
to use the public school system as a means of fully exploiting
the EPSDT program. These practices, which are not required
by federal law, have caused the cost of the EPSDT program
to skyrocket. In 1996, DPW [Pennsylvania Department of Welfare]
expanded the targeted enrollment of EPSDT to 900,000 children
by December 1997. This manipulation of the EPSDT program
has required taxpayers to bear the burden of paying for
a host of subjectively determined services which are more
in the behavioral and education realm than the traditional
medical arena. This, in turn, raises concerns that too many
students are being inappropriately labeled as emotionally
disturbed or mentally disturbed or disabled in order to
qualify them for the EPSDT program."(32)
In addition to Medicaid, schools also utilize funds provided
by the federally funded Centers for Disease Control, according
to the General Accounting Office.(33)
Other sources of federal support include the Preventive
Health Block Grant; Drug Free Schools and Communities Act;
and the Social Security Block Grant.(34)
States are also relying on private foundation grant
programs, federal grants from the Maternal and Child Health
Bureau, the Individuals with Disabilities Education Act,
and Goals 2000 for Education to fund school-based clinics.(35)
It is not difficult to envision how a children's health
care system, delivered through the public school system
and/or through the Medicaid program, could serve as precursor
to a nationalized health care system as outlined in the
Clinton Health Care Task Force back-up plan. The American
public should closely scrutinize any further government
intrusion into children's health care or children's health
care will face a fate similar to the Medicare program.
Forty-Eight Billion Dollars for Socializing Children's
In response to the question, "Are you for or against children's
health?" lawmakers passed a ten-year, $48 billion State
Children's Health Insurance Program (SCHIP). This new program,
passed as part of the Balanced Budget Act of 1997, allocates
federal funds to states. Under the SCHIP program, states
have several options for spending the new federal health
care dollars. Contingent upon federal approval, states may
expand their current Medicaid programs, create a new state
child health insurance program, create a combination of
both, provide health care services directly such as through
the public schools with increased funding from Medicaid,
or decline to participate entirely.(36)
The program will cover children under the age of 19
whose family income may exceed 200 percent of the federal
poverty level, which is the equivalent of $32,900 for a
family of four.
Leading free-market policy experts have voiced strong concern
that most states appear to be leaning toward expanding their
Medicaid programs (see Figure 3).(37)
Medicaid Expansion Under the New
Federal SCHIP Program
||AL*, AR, DC, ID, IL*,
IA, IN, MD, MN, MO*, NE, NM, OH*, OK*, RI*, SC*, SD,
TN, TX, VT, WI*
expansion & new state program (7)
||CA*, CT*, FL*, MA*, ME,
state health care program (10)
||CO*, GA, MI*, MT, NC,
NV, NY*, OR, PA*, UT
includes Medicaid expansion (11)
(plan yet to be submitted)
|AK, AZ, DE, HI, KS, KY,
LA, MS, ND, VA, WV
||Not participating in SCHIP
at this time (2)
* State plan approved by the U.S. Department of Health
and Human Services (HHS) as of June 9, 1998. Note: Congress
extended the deadline for obtaining HHS approval from Sept.
30, 1998 to Sept. 30, 1999. Source: American Legislative
Exchange Council, "1998 Health and Human Services Task Force
Legislative Update," May 5, 1998; Brian K. Bruen and Frank
Ullman, "Children's Health Insurance Programs: Where States
Are, Where They are Headed," Urban Institute New Federalism
Issues and Options for States, Series A, no. A-20, May 1998,
Figure 1, pp. 3-4; Health Care Finance Administration, "Child
Health Insurance Program State Plans," June 9, 1998; and
Bureau of National Affairs, "Children's Health Supplemental
Spending Law Gives States Extra Year to Submit [S]CHIP Plans
to HHS," Health Care Policy Report, vol. 6, no. 18, May
The Consensus Group, a group of leading health policy analysts
from major public policy organizations, warns:
| Although Medicaid expansion appears to be an
expedient option, it locks a state into a far more
expensive set of benefits than may be appropriate
for [S]CHIP children, exacerbating existing cost pressures
in the Medicaid program. Choice also is constrained,
even when states contract with private or public health
plans to provide coverage for Medicaid beneficiaries.(38)
Senate Minority leader Tom Daschle (D-SD) praised SCHIP
as "the single biggest health achievement since we passed
Medicaid in 1965."(39)
Unfortunately, this "achievement" may be paving the
way for socialized medicine for our nation's children and
could ultimately compromise health care quality and freedom
in many ways.
The Hidden Dangers
While efforts to expand health care access and affordability
may be well-intentioned, this current trend could have serious
unintended consequences. By creating or expanding school-based
health clinics and providing government-sponsored health
insurance for children, government health care programs
could encourage families to drop their private health insurance,
reduce health care choices, infringe upon parental rights,
and threaten medical privacy.
Eroding Private Health Insurance
One of the greatest dangers of expanding government-funded
health programs for children is that such programs could
reduce the number of privately insured children. Many parents
who currently purchase private insurance coverage for their
children will switch over to subsidized government care.
Health policy expert Robert Goldberg of George Washington
University Medical School, explains:
[T]he Congressional Budget Office estimates that half of
all new enrollees [in SCHIP] will be from families who drop
private coverage in favor of a federally subsidized entitlement.
That's what happened when Medicaid opened in 1987 to pregnant
women and their children with incomes 250% of the poverty
level. Between 1988 and 1995, the percentage of children
covered by private insurance fell to 64% from 72%. At the
same time, the percentage of children covered by Medicaid
climbed to 23.1% from 15.5%. Studies show that at least
three-fourths of the shift was the result of parents dropping
private coverage for themselves and their children.(40)
Indeed, there is empirical evidence proving that when government
health care grows, private health insurance shrinks. Health
economists from Harvard University and Massachusetts Institute
of Technology examined how Medicaid expansions have affected
private coverage between 1987 and 1992. Researchers concluded:
| Our net result is that the Medicaid expansions
led to an effective total of 3.5 million more persons
with public coverage and 1.7 million fewer persons
with private coverage. . . The decline in private
insurance was roughly 50 percent (1.7 million of 3.5
million) of the increase in Medicaid coverage induced
by the expansions. . . Our results find evidence of
substitution of Medicaid for private insurance.(41)
In an effort to attract larger numbers of families to participate
in the new SCHIP program, states are (unsuccessfully) employing
aggressive marketing techniques that target lower-income
families. Strategies include using coupons, payments, and
gifts in exchange for enrollment.(42)
For example, 14 states use coupons to encourage families
to enroll their children. The coupon books offer discounts
on a variety of children's goods, such as diapers, baby
food, and formula. Some states require that a medical provider
validate the coupon book before the coupons can be redeemed.(43)
In other words, some states are using tax dollars to lure
families into government-sponsored health care in an effort
to promote an agenda of universal health care for children,
with little or no public debate.
Similar to the government Medicare program -- which forces
seniors to drop their private health insurance -- these
new children's health care programs could ultimately force
all American children to participate in government programs
by destroying the private market for health insurance or
by making it illegal to seek health care services privately.
It has happened to seniors' health care and could easily
happen to children's now that the framework for government-sponsored
medical care for children is becoming entrenched at the
federal and state levels.
Infringing on Parental Rights and Medical Privacy
While school-based health clinics are being established
with the good intention of providing health care to the
uninsured, they will ultimately lead to negative consequences
that infringe on parental rights. In fact, a report on how
a Missouri school district implemented school-based health
care warned that schools should not consider such programs
if their philosophy is that "it is the sole responsibility
of parents to attend to the health care needs of children."(44)
School-based health centers give public schools broad
responsibility and considerable latitude regarding medical
treatment and psychological and reproductive counseling
of children. A recent Forbes feature article revealed
one of the most shocking instances that occurred at a school-based
| In the summer of 1993 Betsy Grice of Owensboro,
Ky. [Kentucky] took her 11-year-old daughter to the
local elementary school for the checkup she needed
before starting sixth grade. Grice was shocked to
learn that the doctor intended to give the child a
genital examination. Turns out it's required by the
Department of Education.(45)
Unfortunately, this is not an isolated example of the usurpation
of parental rights by schools funded by taxpayers and private
foundations. For example, the Pennsylvania Legislature learned
that 11-year-old girls were being subjected to genital exams
as part of "routine" physicals in public school, without
specific parental consent and over the objection of the
In fact, some schools have designed permission slips
to treat students in a way that automatically grants permission
if there is no parental response after a specific period
Another concern with school-based health care is the lack
of health privacy. In many cases, children are subjected
to intrusive psychological testing without parental consent.
Psychological testing information and records can then be
shared between state government agencies, again without
parental consent. For example, State Representative Samuel
Rohrer investigated Pennsylvania school-based health centers
and found that confidential information becomes the property
of private foundations responsible for funding school-based
Not only does sensitive information become the property
of private foundations, but the foundations also retain
the right to license others to use data.(48)
Additionally, the results of psychological tests, however
subjective, become part of a student's permanent school
record, which could then affect future career opportunities.
What Can Be Done
This Dangerous Trend?
While expanding the Medicaid program may be the simplest
approach for states to pursue in providing children's health
coverage, it may not be the most efficient choice. The Consensus
Group developed recommendations for the states to provide
free-market alternatives under SCHIP. In particular, the
group advocates the use of tax credits, vouchers, and pilot
programs that provide direct payments to individuals. Such
approaches "give families greater control and choice in
health insurance coverage and provide a foundation for a
more stable and efficient market for medical care and health
insurance in the United States."(49)
Rather than relying on the one-size-fits-all government
approach, these alternatives provide the maximum parental
control and allow for the greatest flexibility in helping
parents to best meet their children's health care needs.
The Cato Institute recently released a study showing how
a universal tax credit policy would enable families to buy
insurance on their own, and still receive a tax break. In
their publication "Restoring Freedom to Health Care: The
Case for a Universal Tax Credit for Health Insurance," the
author explains how this policy gives families greater control
of their health insurance coverage.(50)
For example, the tax credit could be used to purchase
health insurance, health care services, or to create a family
medical savings account (MSA).
To date, one state has adopted a tax-credit policy for
covering uninsured children. In April, North Carolina set
a national precedent by approving a tax credit for middle-income
families, as part of its new health-insurance program for
children. While North Carolina will still use federal funds
to cover 71,000 low-income children, it will use only state
funds to provide a tax-credit for health insurance to some
400,000 middle-income families.(51)
Free-market advocates are heralding this plan, because
it empowers families and limits the growth of federal health
Although efforts to pass a large-scale version of socialized
medicine failed in 1994, the "Kids First" back-up plan is
successfully being implemented at the federal and state
levels. Yet, only about one-third of Americans are aware
of the new $48 billion State Children's Health Insurance
Program (SCHIP) and even fewer people believe that health
care for children should be provided by the federal government.
This new program has enormous potential to force all American
children into government health care and is the first incremental
step toward implementing the same Clinton health care plan
that Americans resoundingly rejected in 1994. The American
public should know about and debate government's role in
providing health care to children before all children are
forced under a single government health care roof.
(Click on the footnote number to return to its reference)
Ernest J. Istook, Jr. (R-OK) as quoted in 20 September 1994,
Congressional Record, 103rd Congress,
2nd session, p. H9291.
2. Association of
American Physicians and Surgeons, "Clinton Care Through
the Kitchen Door," AAPS 52, no. 1 (January 1996):
3. Bureau of National
Affairs, "Clinton Floats Trial Balloons on Expansion of
Health Coverage," Health Care Policy Report 5, no.
37 (September 22, 1997): p. 1441.
4. Bureau of National
Affairs, "School-Based Centers Gaining Attention for Providing
Access to Uninsured Kids," Health Care Policy Report
5, no. 32 (August 11, 1997): p. 1273; and Making
the Grade, "National Survey of State SBHC Initiatives: School
Year 1995-96," (Washington: George Washington University,
5. Harvard University,
The Robert Wood Johnson Foundation, and the University of
Maryland, "Attitudes Toward Children's Health Care Issues,"
November 1997. The survey was funded by the Robert Wood
Johnson Foundation. It was designed by the Harvard University
School of Public Health, with assistance from the Survey
Research Center at the University of Maryland at College
Park. Survey analysis was performed at Harvard. The survey
of 1501 adults within the continental United States was
conducted by telephone by the Survey Research Center, and
the survey's margin of error is plus or minus 3 percentage
7. Alliance for Health
Reform, "Outreach to Uninsured Kids," Health Coverage
1998, (May 1998): p. 2.
8. Thomas M. Selden,
Jessica S. Banthin, and Joel W. Cohen, "Medicaid's Problem
Children: Eligible But Not Enrolled," Health Affairs
17, no. 3, (May/June 1998): pp. 192-200.
9. Employee Benefit
Research Institute, 1997 as cited in Alliance for Health
Reform, p. 3.
10. Data from the
U.S. Census Bureau, Survey of Income and Program Participation
indicates that only 4.1 percent of children lacked health
insurance for an entire 28-month period during
1992 to 1994. In other words, few children are chronically
11. The 13 percent
figure is based on 1.3 million [of the 10 million uninsured
children under 18] who lack health insurance because of
its costs. Robert M. Goldberg, "The Birth of Clintoncare
Jr. . . . ," Wall Street Journal, August 5, 1997,
12. A survey conducted
by the Council for Affordable Health Insurance found the
cost of child-only policies for a single child ranges between
$58 and $66 per month, depending on geographic region. Council
for Affordable Health Insurance, "Is There Really An Uninsured
Epidemic?," CAHI Policy Brief 1, no. 1 (April 1,
1997): p. 5.
13. Golberg, p.
14. 42 USC Sec.
1395 states "Nothing in this title shall be construed to
authorized any Federal officer or employee to exercise any
supervision or control over the practice of medicine or
the manner in which Medical services are provided, or over
the selection, tenure, or compensation of any officer or
employee of any institution, agency, or person providing
health services; or to exercise any supervision or control
over the administration or operation of any such institution,
agency, or person." Sec. 1395(a) states "Any individual
entitled to insurance benefits under this title may obtain
health services from any institution, agency, or person
qualified to participate under this title if such institution,
agency or person undertakes to provide him such services."
Sec. 1395(b) continues "Nothing contained in this title
shall be construed to preclude any State from providing,
or any individual from purchasing or otherwise securing,
protection against the cost of any health services."
15. U.S. District
Federal Judge Thomas F. Hogan recently noted "Medicare is,
in effect, the only primary health insurance available to
people over 65. No private health insurance companies offer
'first dollar' insurance to this group; they offer only
supplemental insurance (See Pls.' Mot. For Prelim. Inj.
at 18.)" United Seniors Association, Inc., v. Donna Shalala,
Civ. No. 97-3109, April 14, 1998.
16. Howard S. Berliner,
"The Origins of Health Insurance for the Aged," International
Journal of Health Services 3, no. 3 (1973): pp. 465-473.
17. U.S. District
Federal Judge Thomas F. Hogan recently opined "The Court
does not pass judgment on Congress' wisdom in passing Section
4507; the Court's role here is solely to determine whether
the United States Constitution confers a fundamental right
on individuals to contract privately with their physicians.
The Court finds that it does not. The Supreme Court has
declined to extend the right to autonomous decision-making
beyond certain limited contexts involving child rearing
and education, family relationships, procreation, marriage,
contraception and abortion. See Bowers v. Hardwick,
478 U.S. 186, 190 (1986). This Court is not inclined to
create new areas of constitutional protection. See Dronenberg
v. Zech, 741 F.2d 1388, 1937 (D.C. Cir. 1984) ("If it
is an any degree doubtful that the Supreme Court should
freely create new constitutional rights, we think it certain
that lower courts should not do so.") Therefore, the Court
finds that, on this record, Plaintiffs have not demonstrated
that they have a constitutional right to contract privately
with their physicians." United Seniors Association, Inc.,
v. Donna Shalala, Civ. No. 97-3109, April 14, 1998.
18. Social Security
Administration. The Social Security Operations Manual states
that "Some individuals entitled to monthly benefits have
asked to waive their HI [Medicare Part A Hospital Insurance]
entitlement because of religious or philosophical reasons
or because they prefer other health insurance. Policy: Individuals
entitled to monthly benefits which confer eligibility for
HI may not waive HI entitlement. The only way to avoid HI
entitlement is through withdrawal of the monthly benefit
application. Withdrawal requires repayment of all RSDI [retirement,
survivors, and disability insurance] and HI benefit payments
made." Social Security Operations Manual Policy no. HI 00801.002.
19. Medicare fraud
amount derived from Helen Dewar and Barbara Vobejda, "Medicare
Waste: 11 Cents per Dollar," Washington Post, April
24, 1998, p. A5. Senator Don Nickles (R-OK) recently remarked
that "Medicare's regulatory regime takes up about 45,000
pages." as cited in Association of American Physicians and
Surgeons, "The Medicare Paperwork Burden,"AAPS News
54, no. 5 (May 1998): p. S2.
20. Peter J. Ferrara,
"The Next Steps for Medicare Reform," Cato Institute Policy
Analysis no. 30, April 29, 1998, pp. 9-10.
21. Charlotte Twight,
"Medicare's Origin: The Economics and Politics of Dependency,"
Cato Journal 16, no. 3 (Winter 1997): pp. 309-338.
22. National Governors'
Association, "New Efforts to Provide Health Care Coverage
for Uninsured Children - Spring 1997," StateLine,
(April 22, 1997): p. 1.
23. The Kaiser
Commission on the Future of Medicaid, "Medicaid's Role for
Children," Medicaid Facts, May 1997, p. 1.
24. Brian K. Bruen
and Frank Ullman, "Children's Health Insurance Programs:
Where States Are, Where They Are Headed," Urban Institute
New Federalism Issues and Options for States, Series
A, no. A-20 (May 1998): Figure 1, pp. 3-4.
25. Bureau of National
Affairs, "School-Based Centers Gaining Attention for Providing
Access to Uninsured Kids," p. 1273.
26. Maternal and
Child Health Bureau, "School Health Fact Sheet," October
27. Bureau of National
Affairs, "School-Based Centers Gaining Attention for Providing
Access to Uninsured Kids," p. 1273.
28. Ibid, p. 1274.
29. The Center
for the Study of Social Policy, "A Strike for Independence:
How a Missouri School District Generated Two Million Dollars
to Improve the Lives of Children," (Washington: Center for
the Study of Social Policy, 1994), p 3.
30. Ibid, p. 10.
31. Ibid, pp. 2-3.
of Pennsylvania House of Representatives, Committee on Education,
Select Subcommittee on Education, Select Subcommittee on
House Resolution No. 37, Findings of Fact and Report,
November 1996, pp. 18-19.
33. U.S. General
Accounting Office, Health Care: School-Based Health Centers
Can Expand Access for Children, (Washington: GAO, December
34. Making the
Grade, p. 1.
35. Genevieve Young,
"FOCUS: The Medicalization of Public Schools," Eagle
Forum Education Reporter, no. 132, (January 1997): p.1.
36. Bureau of National
Affairs, "Conference Report, Joint Explanatory Statement
on Medicare, Medicaid, and Children's Health Provisions
of HR 2015 (H. Rept. 105-217)," Health Care Policy Report
Special Supplement 5, no. 31, (August 4, 1997). States
that participate in SCHIP are required to provide a package
of minimum benefits as follows: (1) A plan that is an equivalent
to one of the following benchmark plans, (2) FEHBP Blue
Cross/Blue Shield PPO option, (3) state employee health
plan that is generally available in the state, or (4) the
HMO with the highest commercial enrollment in the state.
Also, New York, Florida, and Pennsylvania are permitted
to use their current state-only programs' benefit plans
as a benchmark plan. A plan with the same actuarial value
as a benchmark plan. Under this option, states must cover
four basic services: (1) inpatient and outpatient hospital
services, (2) physicians' surgical and medical, (3) laboratory
and x-ray, and (4) well-baby/well-child care, including
immunizations. The new plan must have an aggregate actuarial
value at least equivalent to the benchmark plan and it must
assure that the plan's mental health, vision, hearing, and
prescription drug benefits have at least 75% of the actuarial
value of prescription drug, mental health, vision and/or
hearing services in the benchmark plan. In order to participate
in the new State Children's Health Insurance Program, states
are required to allocate some of their own funds to the
program. States must contribute 70% of a state's current
matching rate. For example, if a state currently contributes
50% to its total federal/state Medicaid program, the state
would be required to contribute 35% to the SCHIP (70% of
the current 50% Medicaid matching rate).
37. American Legislative
Exchange Council, "1998 Health and Human Services Task Force
Legislative Update," Washington, D.C., May 5, 1998.
38. The Consensus
Group, "Giving States and Citizens a Choice," Policy Statement
to State Governors, November 25, 1997, p. 2. The Health
Policy Consensus Group is a broad-based group of leading
health policy analysts from the major market-oriented think
tanks. The statement was developed by Grace-Marie Arnett
of the Galen Institute; Brad Belt of the Center for Strategic
and International Studies; Stephen Entin of the Institute
for Research on the Economics of Taxation; Robert Helms,
Ph.D. of the American Enterprise Institute; John Hoff, Esq.
a health policy attorney; John Goodman, Ph.D. and Merrill
Matthews, Ph.D. of the National Center for Policy Analysis;
David Kendall of the Progressive Policy Institute; Naomi
Lopez of the Institute for SocioEconomic Studies; Marty
McGeein of The McGeein Group; Robert Moffitt, Ph.D. and
Carrie Gavora of the Heritage Foundation; Mark Pauly, Ph.D.
of The Wharton School, University of Pennsylvania; and Michael
Tanner and Darcy Olsen of the Cato Institute. These views
reflect those of these individuals and not necessarily their
39. Bureau of National
Affairs, "Health Care for Uninsured Children Becomes Reality
in Compromised Plan," Health Care Policy Report 5,
no. 31, (August 4, 1997): p. 1204.
40. Goldberg, p.
41. David M. Cutler
and Jonathon Gruber, "Medicaid and Private Insurance: Evidence
and Implications," Health Affairs 16, no. 1 (1997)
42. National Governors'
Association Center for Best Practices, "How States Can Increase
Enrollment in the State Children's Health Insurance Program,"
NGA Center for Best Practices Issue Brief , (May
7, 1998), p. 9.
44. The Center
for the Study of Social Policy, p. 30.
45. Brigid McMenamin,
"Trojan Horse Money," Forbes, December 16, 1996,
46. Ibid, p. 126.
of Pennsylvania House of Representatives, pp. 33-34.
48. Ibid, p. 34.
49. The Consensus
50. Sue A. Blevins,
"Restoring Freedom to Health Care: The Case for a Universal
Tax Credit for Health Insurance," Cato Institute Policy
Analysis no. 290, December 12, 1997.
51. Bureau of National
Affairs, "Children's Health Proposal to Include Tax Credits
as Part of Overall Package," Health Care Policy Report
6, no. 18 (May 4, 1998): pp. 752-753.