Washington Watch: SCHIP expansion entangled in politics

By Rachel Benson Gold and Heather Boonstra
Public Policy Division
The Alan Guttmacher Institute
Washington, DC

Over the course of the last year, attempts to expand the State Children’s Health Insurance Program (SCHIP) to include coverage of pregnant women have become entangled in the murky politics of the abortion issue, a development that could sidetrack an important policy initiative and leave large numbers of low-income pregnant women without insurance at a critical time.

Enacted in 1997, SCHIP covers low-income, uninsured individuals through age 18. By 2001, 4.6 million children were enrolled, which makes the program a critical source of care for low-income families.

Because SCHIP was enacted following the demise of broad-based health care reform in the 1990s, its supporters have always seen the program as a first step in a broader strategy to reduce disparities in health insurance coverage. Proponents viewed covering low-income children, an issue with obvious political appeal, as a first — but by no means final — step in that direction. Armed with the knowledge that 38.7 million Americans remain uninsured, advocates and policy-makers have offered a variety of proposals to expand SCHIP.

One group high on just about everyone’s list to bring into SCHIP is pregnant women, based in no small measure on data showing that more than 400,000 pregnant women reported having no health insurance coverage in 1999. This initiative would build directly on the Medicaid expansions of the 1980s to cover pregnant women with incomes well above the traditional state-determined income ceilings.

Under Medicaid, pregnant women are covered throughout pregnancy — with important health benefits for both women and their newborns — and through 60 days postpartum, including coverage for family planning services and supplies. Over the last few years, a handful of states received federal approval to experiment with expanding their SCHIP efforts to pregnant women not eligible for Medicaid, and several proposals to expand the program along these lines are pending in Congress.

Enter abortion politics

As enthusiasm for an SCHIP expansion mounted, the Bush administration threw a wrench into the works in the summer of 2001 by announcing that it intended to take a controversial approach using the regulatory, rather than legislative, process. This, argued the administration, would be a more expeditious route than the often-tortuous process of enacting legislation. With the underlying SCHIP statute clearly limited to "children," the administration announced that it would propose defining "child" to include "children from conception to birth through age 19" for purposes of the program. This move would have the effect of considering fetuses, rather than pregnant women, to be beneficiaries. Regulations along these lines were formally proposed in March 2002.

Supporters of reproductive health and rights reacted quickly. While agreeing that expanding access to prenatal care is of paramount importance, many expressed grave concerns about unnecessarily involving abortion politics by appearing to establish a precedent for granting legal personhood to fetuses.

Grave consequences to occur?

Reproductive health advocates also fear the route chosen by the administration could have serious consequences for the health and well-being of pregnant women. Since the proposed rule would confer eligibility only upon the fetus, and not directly upon the pregnant woman, the rule would not ensure that pregnant women would be entitled to the full range of medical care needed by woman during pregnancy. In addition, supporters of reproductive health are concerned that while the proposed rule would guarantee the newborn access to necessary health care, it would not provide any coverage of postpartum care for women, an integral component of perinatal care, according to the Washington, DC-based American College of Obstetricians and Gynecologists.

As a result, many supporters of reproductive health care argue that any expansion for pregnant women should draw on the longstanding tradition of other federal programs. They argue that it should include the comprehensive package of pregnancy-related services needed by women during and immediately after pregnancy, including family planning services and supplies, covered under the Medicaid program.

The Centers for Medicare & Medicaid Services accepted public comments on the proposed rule through early May and, at press time, is developing a final regulation. In the meantime, several members of Congress are seeking to move legislation forward that not only would avoid the entanglement of abortion politics, but also provide the full package of benefits needed by pregnant and postpartum women. The extent to which achieving this widespread goal is possible in the current political and economic climate remains to be seen.