Efforts to Stall Health Care Reform Unreasonable

This week the Harris County Hospital District hosted Senator Kay Bailey Hutchison at a news conference asking Congress to delay reforming our broken health care system.

Some of the institutions represented at the press conference pointed out that many programs vital to our state's health care system are being short-changed. These are valid points with which I agree. As one of the people that President Obama has entrusted to achieve health care reform, I have scheduled meetings with the Harris County Hospital District, the Texas Medical Center, and others represented at the press conference to ensure they are heard.

Interestingly enough, the challenges discussed by the institutions were caused by policy decisions [HB 2292 by Arlene Wohlgemuth, aided by Talmadge Heflin and pushed by Governor Perry, David Dewhusrt and Tom Craddick] made at the state level in 2003.

Now, the Republican leadership is attempting to kill health care reform by using delay tactics that will prevent a vote on any bill. At a time when six million Texans, including 1.5 million children lack health insurance, failing to act on policy issues that will insure millions of Texans and Americans is not an option. Harris County alone has 1.1 million uninsured residents.

The dilemma began when the hospital district presented a double standard on policy which has harmed the people I represent. However, now we are moving forward to focus on the policy of the people rather than the politics of the moment.

Below I have included:

• A Houston Chronicle article describing an apparently partisan press conference hosted by the Harris County Hospital District at the request of Senator Hutchison.
• A Houston Chronicle article detailing Senator Hutchison's press conference and her wish to delay health care reform.
• A New York Times Sunday editorial that explains how federal health care reform legislation will affect you and your family.

I will continue to keep you updated on this policy matter. Please click here to visit our new health insurance reform policy page on our website. If you are interested in receiving emails related to health reform, please sign up on the link at the top right of the new page.

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Houston Chronicle

Democrat questions health care news event

By TODD ACKERMAN
July 30, 2009, 8:26PM

State Rep. Garnet Coleman is calling out the Harris County Hospital District for hosting U.S. Sen. Kay Bailey Hutchison's news conference on health care reform Monday, 1½ years after it rejected his request to hold a similar event on the grounds that it was political.

Coleman said the Hutchison event, where many of the Texas Medical Center's top leaders urged Congress not to rush efforts to fix America's health care system, betrayed a "double standard" and may have lent a partisan meaning many of those leaders didn't intend.

"The Republican Party is trying to kill health care reform, and anyone in politics knows delay delay delay is one good way to do it," said Coleman, D-Houston, who is on President Barack Obama's 32-member team of State Legislators for Health Reform. "It's unfortunate the medical center was used to help that cause."

Republicans spoke

Medical Center leaders at the news conference emphasized they're strongly in favor of health care reform. But one contacted Thursday reiterated Congress needs to be as careful about its details as doctors are about treating patients.

In a statement, the hospital district said it hasn't taken a position on any legislation or policy and will work to ensure that appropriate reform strategies are implemented as quickly as possible. It said it agrees with its medical center peers that "a prudent review" of the current proposals is appropriate.

The news conference at Ben Taub Hospital was arranged by Hutchison, R-Texas, following phone calls of concern from the hospital district and other urban hospitals around the state about House legislation that would reduce reimbursement of uncompensated care.

Hutchison and U.S. Rep. Kevin Brady, R-The Woodlands, led off the news conference with criticism of a bill that House Speaker Nancy Pelosi last week said she wanted to pass before the August recess but now will have to wait until September.

Hutchison and Brady were followed in their remarks by many of the medical center's most influential people, virtually all of whom emphasized that Congress should proceed slowly, so as to ensure that reform not only fixes the problems but preserves the things American health care does well.

Welcomes forum

Dr. Kenneth Mattox, chief of staff at Ben Taub, said he knew little about the news conference when he was asked to attend. But he played down questions about its appropriateness, saying he welcomes any forum to talk about health care reform.

"Everybody indicated we must have a change in the health care delivery and the status quo," he said. "You didn't hear anyone there say anything about killing health reform."

Coleman responded that it's common political strategy to "kill bills without saying so."

The news conference Coleman had wanted to hold at the hospital district in late 2007 involved his push for the federal government to renew the Children's Health Insurance Program. Implying the rejection was a mistake, the hospital district said Thursday that Coleman is welcome "to hold an event at any of our facilities at any time to share his views on current health care reform initiatives."

todd.ackerman@chron.com

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Houston Chronicle

Med Center leaders: Slow down on health reform

By TODD ACKERMAN
July 29, 2009, 7:17PM

In their first unified voice on the subject, Texas Medical Center leaders Monday sent a message to Congress as it tries to reform America's troubled health care system: slow down.

Appearing at a news conference sponsored by U.S. Sen. Kay Bailey Hutchison, R-Texas, many of the medical center's biggest names said the issue is too important to rush through legislation that could have unforeseen harmful consequences.

"This is a monumental piece of legislation that is going to impact people for many years, both the 253 million people who have insurance and the 47 million who don't," said Dan Wolterman, CEO of the Memorial Hermann Health Care System. "The priority should be, let's get it right, not let's get it done fast."

Afterward, some of the leaders acknowledged the time needed might extend past 2009 but said it's more important to pass a good bill than to meet an arbitrary timetable. Two said the process ought to take years, perhaps involving a series of bills.

Others said they were optimistic it can be done by the end of the year.

President Barack Obama originally had called for passage of a bill by the end of August but last week said the end of the year is fine, following the Senate Finance Committee's decision to hold off on the matter until after the August recess. The committee has not yet released the bill it has been negotiating, though details began leaking Monday.

But House Speaker Nancy Pelosi, D-Calif., is still vowing to pass health care reform before the break in the House. Pelosi said Monday that lawmakers were "moving closer" to agreement on the 1,000-page, $1 trillion measure that last week stalled in committees.

The bill has faced criticism from all sides about its cost, scope and funding, and Republicans have blasted it as a gateway to a government takeover of health care.

All back idea of reform

At the news conference at Ben Taub Hospital on Monday, Hutchison said "everything about the bill is counter intuitive," then turned over the podium to a who's who of medical center leaders that included Harris County Hospital District President and Chief Executive David Lopez, University of Texas Health Science Center at Houston President Dr. Larry Kaiser, Texas Heart Institute President Dr. James Willerson and Ben Taub Chief of Staff Ken Mattox. Every major medical center institution was represented.

Though each brought its own concerns, they were united that reform is necessary but that Congress needs to tread carefully to preserve the best of American health care while it tries to fix what's broken. They complained that Congress has done little to solicit input from the medical community.

"I applaud Congress' efforts, but now isn't the time to rush," Kaiser said. "I liken it to taking out a tumor. There's a time when there's an urge to get it done quickly, but that's when mistakes can be made. That's the time to take it slowly and carefully."

But Kaiser said he thinks Congress needs to act by the end of the year, or else it risks losing momentum on the issue. He said he thinks the American people want something and won't be content with no health care reform being accomplished this year.

Mattox said he'd like to see a Texas Medical Center document recommending the key principles of reform.

Medical center leaders' criticism of reform efforts include: no mechanism to pay for the expanded coverage by cutting waste, fraud and errors; no attention paid to the role of illegal immigrants on health care costs; and no emphasis on prevention and graduate medical education.

The unity extended to those not at the press conference, such as Texas Medical Center President Richard Wainerdi, who said the House bill "may have unintended consequences that could be catastrophic to providers and patients" and UT M.D. Anderson Cancer Center President Dr. John Mendelsohn, who said "Congress needs to focus on the whole package, not just access."

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The New York Times

Health Care Reform and You

July 26, 2009
EDITORIAL

The health care reform bills moving through Congress look as though they would do a good job of providing coverage for millions of uninsured Americans. But what would they do for the far greater number of people who already have insurance? As President Obama noted in his news conference last week, many of them are wondering: "What's in this for me? How does my family stand to benefit from health insurance reform?"

Many crucial decisions on coverage and financing have yet to be made, but the general direction of the legislation is clear enough to make some educated guesses about the likely winners and losers.

WHAT ARE THE ELEMENTS OF REFORM? The House bill and a similar bill in the Senate would require virtually all Americans to carry health insurance with specified minimum benefits or pay a penalty. They would require all but the smallest businesses to provide and subsidize insurance that meets minimum standards for their workers or pay a fee for failing to do so.

The reforms would help the poorest of the uninsured by expanding Medicaid. Some middle-class Americans — earning up to three or four times the poverty level, or $66,000 to $88,000 for a family of four — would get subsidies to help them buy coverage through new health insurance exchanges, national or state, which would offer a menu of policies from different companies.

IS THERE HELP FOR THE INSURED? Many insured people need help almost as much as the uninsured. Premiums and out-of-pocket spending for health care have been rising far faster than wages. Millions of people are "underinsured" — their policies don't come close to covering their medical bills. Many postpone medical care or don't fill prescriptions because they can't afford to pay their share of the costs. And many declare personal bankruptcy because they are unable to pay big medical debts.

The reform effort should help ease the burdens of many of them, some more quickly than others. The legislation seems almost certain to include a new marketplace, the so-called health insurance exchange. Since there will be tens of millions of new subscribers, virtually all major insurers are expected to offer policies through an exchange. To participate, these companies would have to agree to provide a specified level of benefits, and they would set premiums at rates more comparable to group rates for big employers than to the exorbitant rates typically charged for individual coverage.

Under the House bill, the exchanges would start operating in 2013. They would be open initially to people who lack any insurance; to the 13 million people who have bought individual policies from insurance companies, which often charge them high rates for relatively skimpy coverage; and to employees of small businesses, who often pay high rates for their group policies, especially if a few of their co-workers have run up high medical bills. By the third year, larger businesses might be allowed to shift their workers to an exchange. All told, the Congressional Budget Office estimates that 36 million people would be covered by policies purchased on an exchange by 2019.

IS THERE MORE SECURITY FOR ALL? As part of health reform, all insurance companies would be more tightly regulated. For Americans who are never quite certain that their policies will come through for them when needed, that is very good news.

The House bill, for example, would require that all new policies sold on or off the exchanges must offer yet-to-be-determined "essential benefits." It would prohibit those policies from excluding or charging higher rates to people with pre-existing conditions and would bar the companies from rescinding policies after people come down with a serious illness. It would also prohibit insurers from setting annual or lifetime limits on what a policy would pay. All this would kick in immediately for all new policies. These rules would start in 2013 for policies purchased on the exchange, and, after a grace period, would apply to employer-provided plans as well.

WHO PAYS? Current estimates suggest that it would cost in the neighborhood of $1 trillion over 10 years to extend coverage to tens of millions of uninsured Americans. Under current plans, half or more of that would be covered by reducing payments to providers within the giant Medicare program, but the rest would require new taxes or revenue sources.

If President Obama and House Democratic leaders have their way, the entire tax burden would be dropped on families earning more than $250,000 or $350,000 or $1 million a year, depending on who's talking. There is strong opposition in the Senate, and it seems likely that at least some burden would fall on the less wealthy.

Many Americans reflexively reject the idea of any new taxes — especially to pay for others' health insurance. They should remember that if this reform effort fails, there is little hope of reining in the relentless rise of health care costs. That means their own premiums and out-of-pocket medical expenses will continue to soar faster than their wages. And they will end up paying higher taxes anyway, to cover a swelling federal deficit driven by escalating Medicare and Medicaid costs.

WHO WON'T BE HAPPY? Healthy young people who might prefer not to buy insurance at all will probably be forced to by a federal mandate. That is all to the good. When such people get into a bad accident or contract a serious illness, they often can't pay the cost of their care, and the rest of us bear their burden. Moreover, conscripting healthy people into the insured pool would help reduce the premiums for sicker people.

Less clear is what financial burden middle-income Americans would bear when forced to buy coverage. There are concerns that the subsidies ultimately approved by Congress might not be generous enough.

WHAT IF I HAVE GOOD GROUP COVERAGE? The main gain for these people is greater security. If they got laid off or chose to leave their jobs, they would no longer be faced with the exorbitant costs of individually bought insurance but could buy new policies through the insurance exchanges at affordable rates.

President Obama has also pledged that if you like your current insurance you can keep it.

Right now employers are free to change or even drop your coverage at any time. Under likely reforms, they would remain free to do so, provided they paid a penalty to help offset the cost for their workers who would then buy coverage through an exchange. Under the House reform bill, all employers would eventually be allowed to enroll their workers in insurance exchanges that would offer an array of policies to choose from, including a public plan whose premiums would almost certainly be lower than those of competing private plans.

Some employers might well conclude that it is a better deal — for them or for you — to subsidize your coverage on the exchange rather than in your current plan. If so, you might end up with better or cheaper coverage. You would probably also have a wider choice of plans, since most employers offer only one or two options.

WILL I PAY LESS? Two factors could help drive down the premiums for those who are insured.

In the short-term, if reform manages to cover most of the uninsured, that should greatly reduce the amount of charity care delivered by hospitals and eliminate the need for the hospitals to shift such costs to patients who have private insurance. One oft-cited study estimates that cost-shifting to cover care for the uninsured adds about $1,000 to a family's annual insurance premiums; other experts think it may be a few hundred dollars. In theory, eliminating most charity care should help hold down or even reduce the premiums charged for private insurance. When, if ever, that might happen is unclear.

In the long run, if reform efforts slow the growth of health care costs, then the increase in insurance costs should ease as well. And if the new health insurance exchanges — and possibly a new public plan — inject more competition into markets that are often dominated by one or two big private insurance companies, that, too, could help bring down premiums.

But these are big question marks, and the effects seem distant.

WILL MY CARE SUFFER? Critics have raised the specter that health care will be "rationed" to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. That will not change any time soon.

It is true that the long-term goal of health reform is to get rid of the fee-for-service system in which patients often get very expensive care but not necessarily the best care. Virtually all experts blame the system for runaway health care costs because it pays doctors and hospitals for each service they perform, thus providing a financial incentive to order excessive tests or treatments, some of which harm the patients.

An earlier wave of managed care plans concentrated on reining in costs and aroused a backlash among angry beneficiaries who were denied the care they wanted. The most expensive treatment is not always the best treatment. The reform bills call for research and pilot programs to find ways to both control costs and improve patients' care.

The bills would alter payment incentives in Medicare to reduce needless readmissions to hospitals. They would promote comparative effectiveness research to determine which treatments are best but would not force doctors to use them. And they call for pilot programs in Medicare to test the best ways for doctors to manage and coordinate a patient's total care.

Any changes in the organization of care would take time to percolate from Medicare throughout the health care system. They are unlikely to affect most people in the immediate future.

WHAT DOES IT MEAN FOR OLDER AMERICANS? People over 65 are already covered by Medicare and would seem to have little to gain. But many of the chronically ill elderly who use lots of drugs could save significant money. The drug industry has already agreed to provide 50 percent discounts on brand-name drugs to Medicare beneficiaries who have reached the so-called "doughnut hole" where they must pay the full cost of their medicines. The House reform bill would gradually phase out the doughnut hole entirely, thus making it less likely that beneficiaries will stop taking their drugs once they have to pay the whole cost.

Not everyone in Medicare will be happy. The prospective losers are likely to include many people enrolled in the private plans that participate in Medicare, known as Medicare Advantage plans. They are heavily subsidized, and to pay for reform, Congress is likely to reduce or do away with those subsidies. If so, many of these plans are apt to charge their clients more for their current policies or offer them fewer benefits. The subsidies are hard to justify when the care could be delivered more cheaply in traditional Medicare, and the subsidies force up the premiums for the beneficiaries in traditional Medicare to cover their cost.

Reformers are planning to finance universal coverage in large part by saving money in the traditional Medicare program, raising the question of whether all beneficiaries will face a reduction in benefits. President Obama insisted that benefits won't be reduced, they'll simply be delivered in more efficient ways, like better coordination of care, elimination of duplicate tests and reliance on treatments known to work best.

The AARP, the main lobby for older Americans, has praised the emerging bills and thrown its weight behind the cause. All of this suggests to us that the great majority of Americans — those with insurance and those without — would benefit from health care reform.

Update on Federal Health Care Agreement

Yesterday Democratic leaders came to an agreement for a health reform bill in the Energy and Commerce Committee in the US House. For your information, I have included an article from the Houston Chronicle regarding the agreement.



House Dems push ahead on compromise health bill

By RICARDO ALONSO-ZALDIVAR and ERICA WERNER Associated Press Writers © 2009 The Associated Press

July 30, 2009, 3:36PM

WASHINGTON — House Democrats pushed ahead with a compromise health overhaul Thursday over liberals' complaints, intent on achieving tangible — if modest — success on President Barack Obama's top domestic priority ahead of a monthlong summer recess.

"We've got to pass the bill. Not only do we have to, but we're going to," said Rep. Henry Waxman, D-Calif., chairman of the Energy and Commerce Committee, the last of three House committees to act on the sweeping legislation.

In the Senate, which breaks for recess a week later than the House, talks on a bipartisan compromise were supposed to resume, but mixed signals emerged from negotiators.

Both chambers already jettisoned plans for floor votes before the summer break, and Democrats are now aiming just to get bills out of the final House and Senate committees that have yet to act.

Even that much has turned into a protracted struggle but Democratic leaders said it had to happen. Returning to their home districts with Obama's top issue in disarray on Capitol Hill was not an option.

Waxman's committee resumed work Thursday, with the goal of finishing Friday, after a week-and-a-half delay caused by objections from fiscally conservative Democrats. That rebellion was quelled with an agreement Wednesday that would protect more small businesses from a requirement to provide insurance to their employees, and restructure a new public insurance plan so it could pay higher rates to doctors and other providers, among other changes.

But the concessions Waxman made to the so-called Blue Dog Democrats infuriated House liberals. They denounced the proposed new structure of the public plan, which was originally designed to be based on Medicare rates. The new structure says rates would be negotiated with providers as occurs now with private companies, which could result in more expensive care.

"This agreement is not a step forward toward a good health care bill, but a large step backwards," 53 Progressive Caucus members said in a letter to House leaders Thursday. "Any bill that does not provide, at a minimum, for a public option with reimbursement rates based on Medicare rates — not negotiated rates — is unacceptable."

At a news conference liberal lawmakers threatened to vote against the bill if it comes to the floor without a stronger public plan. Rep. Anthony Weiner, D-N.Y., an Energy and Commerce member, said liberals probably had enough votes to block the Blue Dog deal in committee.

Some details of the deal remained murky. As part of the agreement the Blue Dogs are insisting they won't vote for a bill that costs more than $1 trillion over 10 years, but that would require Democrats to make more cuts or raise more money. It wasn't clear how much, or how it would be accomplished.

As Energy and Commerce lawmakers worked methodically through piles of Republican and Democratic amendments, Waxman's shaky majority was on display early, when the committee voted 29-28 to defeat a Republican amendment to strengthen ID requirements designed to prevent illegal immigrants from getting Medicaid benefits.

Speaker Nancy Pelosi of California expressed confidence the committee would approve the bill, and said the full House would follow suit in the fall. She also signaled flexibility on key issues, saying that despite her own backing for abortion rights, she would not allow the issue to torpedo legislation.

Pelosi provided House Democrats with talking points to take back to their districts. The headline — "Health Insurance Reform to Hold Insurance Companies Accountable" — showcased Democrats' stepped-up efforts to cast insurance companies as villains in the debate, as polls show a public increasingly wary of the health care effort.

House Minority Leader John Boehner of Ohio warned that Democrats who support the legislation are "likely to have a very, very hot summer."

In the Senate, bipartisan talks in the Senate Finance Committee sputtered. Leaders of the group have said in recent days that they were getting closer to a deal, but Sen. Mike Enzi, R-Wyo., one of six lawmakers involved in the bipartisan talks, said Thursday the legislation wasn't "ready for prime time."

Highlighting the frenetic activity the overhaul has spurred in Washington, health interests have reported spending $262 million lobbying in the first six months of 2009, more than any other portion of the economy, according to the nonpartisan Center for Responsive Politics.

That was $23 million more than health-related companies and groups spent lobbying during the first half of 2008.
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Associated Press writers Alan Fram, Ann Sanner, Ricardo Alonso-Zaldivar and David Espo contributed to this report.

The Time to Reform Health Care is Now

Today I joined Texans across the state as part of a national day of action to urge members of Congress to continue their work to deliver needed federal health reform legislation for Texas families. At events in six cities throughout the state, participants outlined the impact that our current health care system is having on every day Texans.

It is necessary that we push for changes in a system that has left 45 million Americans and 6 million Texans without health care. As the state with the highest number of uninsured residents, including 1.5 million uninsured children, doing nothing is not an option. The only people that benefit from our current system are the insurance companies who have raked in excessive profits that they don't deserve and that we all pay for.

Governor Rick Perry last week said that he might consider invoking states rights to resist any federal health reform legislation. Governor Perry's abysmal record on health care makes him a poor spokesman for a serious conversation about health reform; under his watch:

• Texans have seen their private health insurance costs go up 87 percent;
• Texas continues to lead the nation with the highest percentage of children and working families without health insurance;
• Texas slashed Medicaid and CHIP funding, shifting those costs to local county governments and public hospitals forcing local property tax payers to pick up the bill;
• Obesity, chronic disease and other public health problems continue to plague Texas families

And yesterday, Senator Kay Bailey Hutchison said of current health legislation in Congress: "[E]verything about the bill is counter intuitive."

Federal health reform legislation is centered on preventive care and will lower costs for all Americans. It will increase patient choice of doctor, and will keep insurance companies from denying coverage for pre-existing conditions. What's counter-intuitive is for members of Congress to delay or obstruct common-sense efforts to reform health care in this country.

Please contact your member of Congress and urge him or her to support necessary health reform that our country needs. The time to close the gap of the uninsured and underinsured is now. (Click here to find out who represents you).

I will continue to keep you updated on this policy matter.

Honored to Receive Patient Advocacy Award

Last weekend, I was awarded the 2009 Patient Advocacy Award by the Texas Association of Family Physicians (TAFP). As Texas' largest medical specialty organization, the TAFP promotes and assures the maintenance of high-quality health care and continues to be one of the most patient-oriented public health groups in Texas. I am proud and honored to have received this award. I want to thank the TAFP for this recognition, and applaud them for their work on behalf of patients and families.

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States Across the Country Insure More Children

Other States Maintain Children's Health as a Priority in Rough Financial Times,
Rick Perry Does Nothing

Additionally, I wanted to give you an update on the work done by states across the nation to improve access to health care to their residents. Although states across the country are facing budget shortfalls, 13 states passed legislation that will insure a quarter million more children through the Children's Health Insurance Program (CHIP). These states undertook this legislation because it is fiscally responsible, sound public policy.

Sadly, Texas was not one of these states even though it has 1.5 million uninsured children and a total of 6 million uninsured residents, the highest in the nation. Despite bipartisan support and the available financial resources, Governor Perry repeatedly vowed to veto legislation to allow working families to purchase health insurance for their kids and refused to add CHIP to the special session call. (Read articles here and here).

You can be sure that I will continue to work both in Texas and in our nation's capitol to bring affordable, accessible patient-centered health care to the people of our state.

Below, I have included an article from the New York Times discussing legislation states across the country passed to insure more children.

I will continue to keep you updated on this policy matter. Please click here to visit our new health insurance reform policy page on our website. If you are interested in receiving emails related to health reform, please sign up on the link at the top right of the new page.

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The New York Times

July 19, 2009

Defying Slump, 13 States Insure More Children

By KEVIN SACK

The expansions have come in the five months since Congress and President Obama used the reauthorization of the Children's Health Insurance Program to vastly increase its funding and encourage states to increase enrollment. Although the federal government covers the vast majority of the cost, states set their own eligibility levels and must decide whether to spend state money in order to draw even more from Washington.

In addition to increasing income eligibility levels, three states are dropping requirements that legal immigrants wait five years before joining the program, a step newly permitted by the federal legislation. Others have extended coverage to pregnant women or streamlined enrollment and eligibility procedures.

The states' willingness to spend, even under excruciating budget pressures, is a measure of the support for expanding health care coverage to the uninsured as Congress and the administration intensify their negotiations over a new federal health care bill.

But a number of states decided that their depleted coffers did not allow them to insure additional children, even as a minority partner. Several either deferred previously scheduled eligibility expansions or saw their legislatures defeat efforts to broaden coverage.

In Arizona, only opposition from Gov. Jan Brewer, a Republican, prevented lawmakers in her own party from narrowing eligibility. And in California, where Democratic legislators and Gov. Arnold Schwarzenegger, a Republican, are struggling to close the country's largest budget gap, the state on Friday imposed a freeze on new enrollments.

California officials estimate that up to 350,000 eligible children may be relegated to a waiting list, and that attrition could lower enrollment by 250,000 by June. If money is not found, the losses there might overwhelm the cumulative gains in other states.

Health and Human Services Secretary Kathleen Sebelius said the potential for major reductions in California was "a huge concern." But over all, she said, the Obama administration was "very pleased that even in what are some of the worst budget times in a very long time, children's health insurance continues to be an absolute top priority."

The Children's Health Insurance Program, known as CHIP, has been politically popular since its enactment in 1997 because it primarily benefits working families that earn too much to qualify for Medicaid but too little to afford private insurance.

In many states, eligibility expansions have passed with solid bipartisan support. In one of her final acts as governor of Kansas in April, Ms. Sebelius, a Democrat, signed a two-year expansion worth $4.4 million that had been approved by her overwhelmingly Republican Legislature.

The broadening of eligibility has made a profound difference for parents like Vicky and Dewayne McIntyre of Yakima, Wash. When their state lifted the income cutoff for its program to 300 percent of the federal poverty level (or $54,930 for their family of three) from 250 percent (or $45,775), the McIntyres learned that their 8-year-old daughter, Sarah, had become eligible for the first time.

Sarah, who endured lung surgery at 3 and heart surgery at 6 and now has asthma, had been uninsured for a year. "We were into credit card debt and payday loans," said Ms. McIntyre, 41, who works part time in a store to supplement her husband's income as a welder. "Her medicine at one point was $880 a month, and we had to pay cash, so we were struggling. It is such a relief now that I can just take her to the doctor if I need to and get her medicine."

The federal legislation, which extended the program through 2013, provided $32.8 billion in new financing over that period, paid with an increase in tobacco taxes. On the day Mr. Obama signed the bill, calling it a "down payment" on universal coverage, he also rescinded a Bush administration directive that effectively made it impossible for states to raise their eligibility limits above 250 percent of the poverty level.

The new law allows states to provide coverage to children from families living at up to three times the poverty level. States can set thresholds higher if they wish, but will be reimbursed by the federal government at a lower rate — the same paid for Medicaid recipients. A primary incentive for states to expand coverage is that Washington, on average, pays 70 percent of the cost of CHIP, compared with only 57 percent for Medicaid.

Some states, including New York and New Jersey, were already enrolling children above three times the poverty level, but the federal legislation and the rescinding of the Bush directive made it possible for about 40 states to broaden eligibility.

The reauthorization of CHIP concluded a bruising two-year political battle. President George W. Bush twice vetoed Democratic measures to expand the program in 2007, depicting the legislation as a stalking horse for government-run health care. Congressional Democrats sustained it through temporary extensions and took full political advantage of Mr. Bush's stance during the 2008 campaign.

CHIP, which served about 7.4 million people in 2008, is credited with helping reduce the number of uninsured children by 2.5 million over its first decade. The Congressional Budget Office estimated that the revitalized program would eventually reduce the number of uninsured youths by an additional 4.1 million.

Of the 8.2 million children who remain uninsured, about two-thirds are eligible for either CHIP or the much larger Medicaid program but have not been enrolled, according to the Kaiser Family Foundation. This year's reauthorization includes $100 million in grants to help states find and sign up eligible children.

Forty-eight states faced budget shortfalls this year, totaling $121.2 billion, according to the National Conference of State Legislatures. But in those that have managed to expand eligibility, governors and legislators said they viewed CHIP as a cost-effective investment.
"In a downturn, the number of people who need the safety net increases," said Gov. Bill Ritter Jr. of Colorado, a Democrat, whose state levied $600 million in fees on hospitals, some of which will be used to cover an additional 21,000 children.

In Alabama, Democratic legislators overrode the veto of Gov. Bob Riley, a Republican, to extend coverage to 14,000 children at an additional cost to the state of $8 million.

"Our economy is tough here," said State Senator Roger H. Bedford Jr., a Democrat. "But our decision was to fund the health care needs of our children because a healthy child learns better and they don't show up at the emergency room needing acute care."

Other states expanding eligibility include Arkansas, Indiana, Iowa, Montana, Nebraska, North Dakota, Oklahoma, Oregon and West Virginia. Ohio passed a budget last week that includes an expansion, but its financing depends on the resolution of a court case.

Illinois, New York and Wisconsin, which had been paying for expansions with state money, are now applying for federal matching funds. And many states are enacting measures to make it easier for children to enroll and stay enrolled, steps encouraged by the federal legislation.

But Louisiana and North Carolina chose not to proceed with previously authorized expansions this year, citing a lack of revenue. And bills to either raise eligibility levels or lower premiums failed in Alaska, Delaware, Georgia, Missouri, Rhode Island and Texas. The governor of Wyoming has imposed a cap on enrollment, and New Hampshire may follow.

Officials in those states and others said they had little choice but to leave federal money on the table.

"Michigan's hard-pressed to come up with a quarter to support a dollar's worth of expenditure," said Stephen W. Fitton, that state's acting Medicaid director.

In California, the Legislature beat back Mr. Schwarzenegger's proposal to eliminate CHIP altogether but seems to have accepted the enrollment freeze.

"It is heartbreaking," said Ginny S. Puddefoot, deputy director of the agency that administers the program there. "For those of us involved with children's health care, this is just something we never imagined we would see."

U.S. State Legislatures Endorse Federal Public Health Insurance Option

It is my pleasure to inform you that in the concluding meeting of its national conference, the full body of the National Conference of State Legislatures (NCSL) voted to include a public health insurance option in the organization’s official policy recommendations for federal health care reform. As a member of NCSL's Standing Committee on Health, Chair of the Progressive States Network (PSN), and a part of the White House Working Group of State Legislators for Health Care Reform, I worked closely with my colleagues to win this endorsement.

I am proud of our collaborative efforts to shape a policy that will improve access to quality, affordable health coverage for all Texans and Americans.

This endorsement is symbolic of a growing consensus by state legislators and the public in support of President Obama’s health care plan, which will ensure patient choice of doctor and strengthen employer based coverage. The President's plan is centered on preventive care and will lower costs both for employers and their employees. This sound public policy will benefit working families, state economies, and small businesses across the country.

In addition to the public option, the full body also recommended a series of policy proposals including strong affordability protections, assistance in expanding Medicaid programs, and freedom for states to set benefit requirements and other regulatory standards that exceed federal minimums.

Every day we are making progress towards closing the gap that has left millions of Americans without health care. We must continue working together to seize this opportunity.

I will keep you updated on this important policy matter as it continues to develop.