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PROLOGUEInsurance Design For Children’s CoverageAn extreme contrast between upside and downside potential marks the run-up to this year’s decisions about reauthorization of the State Children’s Health Insurance Program (SCHIP). With coverage initiatives bubbling up at the state level from Maine to California, many see the political appeal of program expansions for children as a door-opener for universal coverage. At worst, incremental SCHIP and Medicaid expansions can be portrayed by state advocates and the new Democratic majority in Congress as responsible, viable steps toward reducing the ranks of the uninsured—a safe and shrewd way of keeping the issue of universal coverage alive and warm for the 2008 presidential election. At the same time, the recent history of SCHIP and its parent program, Medicaid, reveals the perennial vulnerability of both. Both programs helped offset a loss of private coverage during the economic downturn of the early decade but encountered withering budget pressures along the way. More recently, despite improving state revenues, both face major constraints from the Deficit Reduction Act (DRA) of 2005 and the Democrats’ adoption of pay-as-you-go budget rules. As Genevieve Kenney and Justin Yee point out in the first of the following five papers on children’s coverage, SCHIP reauthorization will have to increase baseline funding just to maintain the program’s current level of effort; new DRA proof-of-citizenship regulations threaten to undercut Medicaid’s outreach and retention, according to the second of these papers, by Lisa Dubay, of the Johns Hopkins Bloomberg School, and colleagues. After tracing SCHIP’s growth over the program’s first ten years, Kenney and Yee, of the Urban Institute, outline additional challenges faced in this year’s reauthorization process. Dubay and colleagues appropriately set children’s coverage in the context of the larger, older, and complementary Medicaid program. The two papers detail the countercyclical budget dynamics that both programs have to contend with, when demand for public coverage rises at the same time that state revenues fall. The tension between Medicaid’s traditional foundation as a federal entitlement program and DRA provisions allowing the states greater flexibility in program design is highlighted in a penetrating historical analysis of Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit, by Sara Rosenbaum and Paul Wise of George Washington and Stanford Universities, respectively. Next is a thoughtful exploration of the potential interaction between strategies for children’s and universal coverage initiatives by Stephen Berman of the University of Colorado. Len Nichols of the New America Foundation concludes the section with an urgent plea to consider the ultimate reasons for coverage policy.
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