Government Relations Update

President Barack Obama signed the Children's Health Insurance Program Reauthorization Act of 2009 on Feb. 4, renewing a critical program that will provide health insurance to more than 11 million American children in low-income families.

The new law reinstates the State Children's Health Insurance Program through FY 2013 and increases its federal funding by almost $33 billion for a total cost of $73 billion. This increase will be funded by a 62-cents-per-pack increase in the federal cigarette tax.

What is the State Children's Health Insurance Program?

It's one of the most popular federal programs. The State Children's Health Insurance Program was created in 1997 to act as a safety net for the nearly 25 percent of low-income children who were uninsured. The program provides health insurance coverage to children and other family members whose incomes make them ineligible for Medicaid but who cannot access or afford private insurance.

Like Medicaid, the program is financed through a federal-state partnership. Unlike Medicaid, the program has funding caps and once a state has reached that cap it cannot enroll more children. Under the program, the federal government provides an enhanced match beyond Medicaid matching rates to states as an incentive to expand their health insurance coverage for low-income children. On average, the federal share of Medicaid is 57 percent, but it is 70 percent under this program.

Why is this program so important?

Uninsured children have higher rates of unmet needs than publicly insured children, suggesting that Medicaid and the State Children's Health Insurance Program offer an important safety net. Those enrolled in the children's program are more likely to report a consistent source of care compared with their uninsured counterparts, are far less likely to have unmet health-care needs, and are more likely to receive regular dental and vision care.

Congress allocated more than $40 billion for the program over 10 years, making it the largest federal expansion of health insurance coverage since the federal government launched Medicaid in 1965. In fact, 43 states and the District of Columbia use the program to cover children at or above 200 percent of the federal poverty level ($35,200 per year for a family of three in 2008). That's coverage for more than 7 million children. Since the program's inception, the number of uninsured children has been reduced to 15 percent.

In addition, outreach and enrollment efforts have had a significant effect on Medicaid programs. When families apply for the State Children's Health Insurance Program, many children are found to be eligible for Medicaid, increasing enrollment in that program.

Over the next five years, another $15 billion will be required to maintain the children's program enrollment levels. This does not include funding for the 9 million children who are eligible for but not yet enrolled in the program or Medicaid.

What has APA done to support this legislation?

APA's Public Interest Government Relations Office, working with the APA Practice Organization, supported expanding the State Children's Health Insurance Program. Specifically, APA sought:

• The end of the five-year ban on legal immigrants' access to the children's program and Medicaid. In 1996, Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act, which imposed a five-year ban on documented immigrants' ability to get federal benefits, including health care. Immigrants face many barriers to receiving care, including financial difficulties, the lack of culturally and linguistically appropriate services and mistrust of mental health providers. In fact, 36.8 percent of foreign-born children are uninsured, more than triple the rates for U.S. citizen children. APA successfully advocated for the removal of the five-year limitation on access to Medicaid and the children's program for documented immigrant children as well as pregnant women.

• Mental health parity. Many states set seemingly arbitrary limits on the number of outpatient sessions or inpatient days that children could access under the State Children's Health Insurance Program. To change that, APA sought language to ensure that any state child health plan that provides both medical and surgical benefits would guarantee that the cost and treatment limitations that apply to mental health or substance use disorder benefits would be equal to those of other health services.

• Expanded outreach for minority populations. On average, 22 percent of Latino children, 19.7 percent of African-American children and 12.4 percent of Asian/Pacific Islander children are uninsured, compared with 11.3 percent of non-Hispanic white children, according to the 2005 U.S. census. Research shows that culture and language profoundly affect the health and quality of care received by children of color, especially those who don't speak English. Failure to consider cultural and linguistic factors in outreach, engagement, screening, assessment and treatment can lead to adverse consequences, including harm or unintentional effects.

APA was successful in securing a 10 percent set-aside for a national campaign that would seek to enroll children in geographic areas where there are high rates of racial and ethnic minorities and health disparities. APA also successfully secured another 10 percent to reach American Indian children.

APA will continue to advocate for policies that ensure health insurance coverage for all. We invite all APA members to participate in this vital process.


Day Williams Al-Mohamed, JD, is a senior officer for legislative and federal affairs in APA's Public Interest Government Relations Office. For more information, contact her by e-mail.