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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 July 14; 335(7610): 62–63.
PMCID: PMC1914500

US debates health insurance for millions of children

A successful US programme to insure children in poor families is coming up for its five year renewal in Congress at the end of September, amid controversy between Democrats and Republicans.

The situation is examined in a commentary in the New England Journal of Medicine by John Iglehart, the journal's national correspondent (2007;357:70-6 doi: 10.1056/NEJMhpr071840), and in a review by the not for profit Commonwealth Fund.

The Democrats want to expand the programme to cover more families, but the Republican president, George Bush, wants to reduce it, giving families tax incentives to buy private insurance. The programme may, therefore, be renewed for only a year or two.

An estimated seven or eight million US children don't have health insurance. The number has dropped from about 11 million in the 10 years since the federal government set up the state children's health insurance programme. The programme is about 70% funded by the federal government and 30% by the states. Some eligible children haven't been signed up by their parents.

The programme expanded on the Medicaid programme, which provides health care for children and others in families below the poverty line. For 2007 this is an income of about $21 000 (£10 400; €15 400) for a family of four.

The programme enrolled children in families that earned up to double the amount assessed as the poverty line (about $41 000 in 2007). Many were working poor people, with jobs but no health insurance or health insurance that they couldn't afford. The programme's payments to healthcare providers are more generous than Medicaid. Some states with high living costs allowed families earning up to 350% of the poverty level to enrol. Other states allowed parents of children in the programme to enrol.

When the programme expires on 30 September, Democrats have proposed expanding the programme by $50bn over five years to include children in middle class families who don't have health insurance. California, an expensive state, wants to cover families of four with incomes lower than $60 000. The Democrat senator Hillary Clinton (New York), who represents another expensive state, suggested covering families of four with incomes up to $82 000.

Republicans called for an increase of about $5bn over five years. President Bush said that attempts to expand the programme would be “incremental steps down the path to government run health care,” which he said was “wrong . . . for our nation.” He said a single payer healthcare system would end choice and competition; increase federal spending and taxes; and lead to rationing, inefficiency, and long waiting times for treatment.

Instead Mr Bush suggested changes to the tax code that would make it easier for Americans to buy private health insurance or to deduct the cost from their taxes.

The states of Utah and Louisiana recently expanded their coverage. The western state of Utah, which had frozen new enrolments since September 2006 because it ran out of funds, reopened enrolment when the state legislature gave it funds to cover about 12 000 children. About 45 000 Utah residents are eligible, but only 26 000 are enrolled in the programme. The southern state of Louisiana recently voted to expand the programme to cover families with incomes up to 300% of the poverty level—up from the current 200%.


The Commonwealth Fund's review, The State Children's Health Insurance Program: Past, Present, and Future, is at

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