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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 October 13; 335(7623): 749.
PMCID: PMC2018821
Atlantic Crossing

The US muddle over a child's right to health care

Uwe E Reinhardt, James Madison professor of political economy

Up to eight million children of poor American families are without health insurance—so why is there a dispute over children's right to health care?

After the demise of President Bill Clinton's health reform plan in 1994, I posed for readers of JAMA (1997;278:1446-7) this question: “As a matter of national policy, and to the extent that a nation's health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given disease as does the child of a rich American family?”

That question has long been answered in the affirmative in most other industrialised nations. In the United States it evokes irritation. Of the several letters triggered by my question, all but one were from physicians. None of them answered the question but instead attacked me as a socialist “with the ancient propagandistic use of children.” Only one letter, penned by Richard A Epstein, a law professor at the University of Chicago, addressed my question head on, with a resounding “no.” He argued: “His [Reinhardt's] proposal for equal treatment perversely requires more care to children of poor parents than to children of rich ones, precisely because the rich families can more easily avoid injury and illness and can better pick up any slack in health care delivery.” Not one letter answered my question in the affirmative.

Unlike citizens of other nations, Americans have never been able to decide whether children are a national treasure for whose welfare the state should take primary legal and financial responsibility or are more in the nature of human pets who are owned, so to speak, by their parents and for whose welfare the parents should take primary legal and financial responsibility—albeit within a legal framework that strictly prohibits the maltreatment or egregious neglect of either children or animals. Unable to settle that question, Americans naturally have trouble also settling the question I raised in JAMA.

These issues come to mind on the day President George W Bush has vetoed a bill that would extend health insurance coverage under the State Children's Health Insurance Program (SCHIP) (News in Brief doi: 10.1136/bmj.39363.548715.DB). That programme is administered and partially funded by the states, although the federal government funds 70% of a state's spending on SCHIP, up to an annual cap that varies by state. The programme had originally been enacted in 1997 to extend insurance coverage to near poor children—those in families with incomes above 133% of the federal poverty line, the threshold for coverage by the Medicaid federal health insurance programme for poor people. Since that time SCHIP has had an important role in reducing the number of uninsured children in families below 200% of the poverty line, although anywhere between five and eight million children remain uninsured, depending on whether that status is defined as “uninsured for the entire past year” (about five million) or uninsured at the time of a survey (the higher figure).

SCHIP formally expired on 30 September. There has been general agreement that it would be extended for another five years. The political battle has been mainly over the level of federal funding that would be authorised for the next half decade.

Congress, controlled by the Democrats, had sent the president a bill authorising an additional $35bn (£17bn; €25bn) of federal funds for the next five years, on top of the $25bn baseline budget for a mere five year extension of the existing programme. This would allow the states to expand the programme to include children in families above the 200% threshold. To put this increase in perspective, the president's total budget request for the 2008 fiscal year is $2.9 trillion; the budget request for the Iraq and Afghanistan wars for the same year is $190bn.

President Bush had proposed a budget increase of only $1bn a year ($5bn over the next five years). The Congressional Budget Office has estimated that at traditional rates of inflation of healthcare costs, this increase would not even have maintained current enrolment levels. Arguing that “poor kids should come first,” the president would require states to enrol at least 95% of children in families living below 200% of the federal poverty line before permitting the use of federal funds for any expansion of SCHIP above the 200% threshold—a target that most states would probably not be able to meet. Finally, in vetoing the bill the president remarked, “I believe in private medicine, not the federal government running the healthcare system.”

The battle over SCHIP is a classic US health policy debate in which seemingly technical jargon such as “crowding out” private insurance, arguments over the relative “efficiency” of private versus government medicine, and endless body counts on the number of children actually without health insurance camouflages much deeper and chronic ideological divisions.

When I wrote my commentary for JAMA a decade ago I was not at all seeking to use children as a tool of socialist propaganda. Rather, I sincerely—and naively, it turns out—believed that Americans could at least settle on the distributive ethic that should govern health care for the US children who are effectively disenfranchised. Alas, Americans cannot agree on the role of children in their society, from conception through to adulthood, let alone on their children's right to health care. Thus the kids must muddle through as usual—through the ideological muddle of the nation's adults.

Americans have never been able to decide whether children are a national treasure for whose welfare the state should take primary legal and financial responsibility

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