Mr. President, I remember it so vividly. I remember it as if it were yesterday. But it was 10 years ago that Senator Kennedy and I stood outside this great building, we stood on the Capitol lawn…
Mr. President, I remember it so vividly.
I remember it as if it were yesterday.
But it was 10 years ago that Senator Kennedy and I stood outside this great building, we stood on the Capitol lawn under a great oak tree, and announced final passage of the Children's Health Insurance Program legislation.
History was made that day, and it has been made every day since.
A true, bipartisan partnership--forged on the strength of good intentions, motivated by a simple desire to help our country's most vulnerable citizens, and nurtured in a politics-free atmosphere--led to enactment of CHIP, arguably the most significant advancement in children's health in this modern era.
Ten years ago, Senator John Chafee and Senator Rockefeller, Senator Kennedy and I, began a partnership that led to the Children's Health Insurance Program. That legislation, enacted in under 5 months--to show you its potency--was founded on a very basic premise: that we needed to provide incentives to States to help them design plans to provide health insurance to the poorest of the poor families not eligible for Medicaid.
Senators Rockefeller and Chafee argued for a Medicaid expansion. Senator Kennedy and I argued for a State-directed block grant. The final law was an innovative, workable blend of the two.
Since that time, almost 6 million children have become insured under CHIP. They are leading healthier, more productive lives.
Their parents can sleep at night, resting easy that their children will be taken care of if they become ill.
That peace of mind, that giant step toward a healthier population, is the mark of a compassionate, caring Congress. It was a mark toward reassuring the American people that the Government hears their concerns loud and clear and stands ready to act.
Let us hear that same message today and let us provide our constituents with that same measure of reassurance as we consider this bipartisan agreement to extend CHIP for another 5 years.
This year, as Finance Committee Chairman Max Baucus, Ranking Republican Chuck Grassley, Subcommittee Chairman Jay Rockefeller, HELP Committee Chairman Kennedy, and I began our discussions of the Child Health Insurance Program Reauthorization Act--or CHIPRA--we agreed there were several key principles that must be embodied in any extension of the original act.
The bill we consider today is built on those principles.
First, we agreed that the proposal must be fully financed or else it would be irresponsible for us to legislate.
Next, it must retain the original character of CHIP--that is, it must be a flexible, State-directed program. Senator Kennedy talked about that this morning.
We worked to see the budget resolution provide $25 billion in its baseline to extend the current levels of coverage, and up to $50 billion more if it were fully financed.
Indeed, this bill is fully financed.
The costs above the budget baseline have been certified by Joint Tax to be covered by an increase in the tobacco excise tax.
We agreed that we wanted to continue coverage for those who are currently eligible, but also to conduct extensive outreach to enroll those who may be eligible but aren't enrolled.
Our bill provides health coverage to almost 4 million low-income, uninsured children through incentives to states to enroll these uninsured children in their programs.
We agreed that coverage of childless adults--a policy Senator Kennedy and I never intended nor envisioned when we wrote our original proposal--we agreed that policy needed to stop.
Under our bill, childless adults currently covered under CHIP will be phased out of the program and transitioned into Medicaid.
I cannot emphasize this enough. Today, 6 million children receive health care through the CHIP program--25,095 of these children are from Utah.
That would not have happened absent congressional action in 1997.
In addition, there are an added 6 million children in families with income under 200 percent of the Federal poverty level--or FPL--who are uninsured and eligible for either CHIP or Medicaid.
According to the Congressional Budget Office, the bipartisan, compromise bill covers close to 4 million of these children--3.7 million to be precise--a significant step by any measure. This is a crucial, crucial part of the bill, an achievement that, while expensive, really goes to the heart of what we are trying to achieve with the original CHIP, and now CHIPRA.
For several weeks now, we have heard a crescendo of opposition to our legislation from officials at the White House, and most recently, our President.
Needless to say, this is disheartening for me. It is difficult for me to be against a man I care for, my own personal President, on such an important bill. I have been and will continue to be one of the President's strongest supporters in the Congress. He is a good man. He means well, but he does have to listen to his staff--or at least does listen to his staff, and I believe he has listened to them in a way that throws barriers up to this bill.
I wish I had had an opportunity to persuade him on the merits of this bill before he issued a veto threat. I did send messages down there, talked to top people in the administration, but I wish I had had a greater opportunity.
Indeed, I am sympathetic to many of the concerns he raises.
When he says that we need to be careful about creating a one-size- fits-all health plan for our children, I believe he is right. When we wrote this program in 1997, we wrote it based on the foundation of giving States the flexibility to design their own CHIP programs. Each State is different--what is good for Utah may not be good for California or Massachusetts.
It is important for States, not the Federal Government, to determine which benefits should be covered. After
all, CHIP is a State block grant program, not a Federal entitlement. That is why we are debating its reauthorization today.
The President has also raised concerns about the Federal dollars that our bill spends on the CHIP program over the next 5 years.
I agree that $60 billion is a lot of money. But in comparison to what the House passed bill proposed earlier this year--they started at $100 billion and came down to $75 billion--it is much more reasonable.
And, as the Congressional Budget Office has told us, it is relatively more expensive to find and cover the low-income children who still do not have health coverage compared to those who are enrolled today.
That is why I was able to agree with the Senate number of $35 billion, in addition to the $25 billion already built in the budget baseline for CHIP--although, to be fair, it is higher than I would have liked. But this is a classic compromise and friends in the House wanted more. Some of them.
It is unfortunate that the President has chosen to be on what--to me--is clearly the wrong side of the issue.
Indeed, this is not the bill I would have written if I had full license to draft. That is true for the original SCHIP law as well.
But, it is hard to envision any major law being written by one person and enacted without change. That is not how good legislation is made.
Indeed, 10 years ago, Senator Kennedy and I spent many, many hours proposing, arguing, compromising, and refining, in drafting session after drafting session.
Some days it seemed we disagreed more than we agreed.
It was hard, hard work.
But it was a labor of love.
We had a full discussion. We explored all the issues together.
We found compromises where we needed to.
That is how good legislation is made. Sometimes even bad legislation, but this is good legislation.
It pains me that we did not have this full discourse with the administration on CHIPRA.
It pains me that some have been slow to recognize the realities of this new Congress.
Indeed, what some political pundits termed The Trifecta--a Republican House, Senate, and Presidency, is no more.
I thought I should point out this fact for those in this body who may not have noticed.
And so it is no secret, no surprise, that a Democrat-led Congress would seek a more expansive program.
Yet it is to the great credit of our Democratic leaders that they recognize our country's fiscal realities and that they held the line at the additional $35 billion figure.
To be sure, I would have been comfortable with a lower number, just as Speaker Pelosi and Chairman Rangel and Chairman Dingell and Chairman Baucus and Chairman Rockefeller advocated for a much higher number.
So, again, we have that spirit of compromise which was the hallmark of CHIP in 1997.
I must say it has also been difficult to conflict with my good friend from Utah, Health and Human Services Secretary Mike Leavitt.
He was an expert in health care policy when he was Governor of Utah, and he is even more of a leader on the national level now.
I know the concerns he expressed to me about the CHIP bill in 1997.
I recall our many conversations when he advocated for a greater Federal role in health coverage for needy children. And I also recall his admonitions that we could do better by the children and their parents if we were to provide the States with much-needed flexibility.
The final CHIP block grant reflected that flexibility I believe, and Mike Leavitt's good counsel helped us improve the law. I hear Secretary Leavitt's concerns when he says that he is concerned about paying for the reauthorization of this program through tobacco taxes. I am not comfortable with raising taxes either. However, when we first created the CHIP program in 1997, we believed that it was entirely fitting that the bill be funded through incentives to decrease the use of tobacco, a leading killer of Americans young and old. And, therefore, I am comfortable with raising tobacco taxes to pay for our CHIP program.
I understand his concerns about crowd-out and higher income children dropping their private health coverage in order to be covered through CHIP when CHIP was created to provide health care for low-income children.
And I agree with him 100 percent when he says that we are only fixing part of the problem by reauthorizing CHIP and not addressing what's wrong with the entire health care system.
He and I have visited on several occasions on these issues. I have benefited by that guidance, and I sincerely regret that ultimately we disagree on this bill. But I am willing to work with him to try to come up with an overall health care plan that will work.
I might add that I believe we have had an honest misunderstanding which has not only been raised by Secretary Leavitt but the President as well. They say that our legislation allows families with annual incomes of $83,000 to be covered under a State CHIP plan.
Let me be clear. Our legislation does not permit a State to cover these families unless the Secretary of Health and Human Services approves the State's application to cover individuals at that income level.
We do not change current law and put Congress in charge. We leave that decision in the hands of the Secretary.
We do not take away the Secretary's authority to make that decision.
I hope that point is clear.
At this point, it may be helpful for me to outline for my colleagues exactly what this bill does.
As I stated earlier, CHIPRA is a 5-year reauthorization which spends an additional $35 billion in Federal dollars on the CHIP program, in addition to the $25 billion in Federal dollars already built into the budget baseline.
So, in total, we are spending $60 billion in Federal dollars over the next 5 years on the CHIP program.
And I know that sounds very expensive, especially to my Republican colleagues. In contrast, the bill passed by the House in August would have spent an additional $50 billion on CHIP on top of the $25 billion in the budget baseline for a grand total of $75 billion.
As this chart indicates, we spend far more Federal money on Federal health programs then we are suggesting that we spend on the CHIP program over the next 5 years.
This chart compares projected spending in Medicare, Medicaid and the National Institutes of Health to the spending that we authorize for the CHIP program from fiscal year 2008 to fiscal year 2012.
For the Medicare Program, CBO projects that the Federal Government will spend $2.6 trillion, yes, trillion dollars over the next 5 years.
For the Medicaid Program, CBO projects that the Federal Government will spend $1.22 trillion over the next 5 years.
For the NIH, we project that the Federal Government will spend approximately $150 billion over the next 5 years.
In contrast, our bill authorizes $60 billion over the next 5 years. I think these numbers speak for themselves. We can spend billions, even trillions of dollars on programs for the elderly, disabled, very poor and for medical research but spending $60 billion to provide health care for the children of the working poor causes the President to issue a veto threat? Something here just doesn't add up, especially when you look at these numbers on this chart. The spending for the CHIP program hardly shows up on this chart compared to the other three programs.
Let me remind my colleagues that this legislation is built on compromise.
Is it perfect?
Far from it.
But does it cover more CHIP-eligible kids, our ultimate goal? Absolutely.
And that's why I am a strong advocate for this bill and urge my colleagues to support it.
This is a good compromise.
It is a $35 billion bill--not a $50 billion bill. The House ultimately agreed with the Senate on this issue. I do not blame them. They are very sincere in thinking you can just throw money at these things and you will do more good.
It does not include Medicare provisions. The House also dropped its insistence on this issue, even though
there was tremendous pressure to include Medicare provisions such as a fix for the sustainable growth rate formula flaw, which is the physician reimbursement rate, in 2008.
But let me be clear, all of us agree that these important Medicare issues must be addressed by the end of this year. Just not in this bill.
Before I continue, I would like to note that both the $35 billion limit and agreement not to include Medicare provisions were huge concessions by the House of Representatives.
Honestly, I never thought that the House leadership would agree to those terms; and, trust me, those were the two conditions that were nonnegotiable as far as I was concerned.
The moderation on the part of House leaders is a true indication that they are serious about getting a bipartisan CHIP reauthorization bill signed into law.
Key provisions of this legislation are the tools and resources it provides to enroll more of the CHIP-eligible children. As I previously stated, in addition to the 6 million children already covered by CHIP, this bipartisan compromise bill would provide coverage to almost 4 million more uninsured, low-income children.
The bill no longer allows new State waivers for adults to receive their health care through CHIP. Childless adults will be phased out of CHIP and will be covered through Medicaid.
States that currently cover parents may continue to do so; but after a transition period, States will no longer receive the enhanced CHIP match rate for covering parents.
The legislation rewards States for covering more low-income children by establishing a CHIP performance bonus payment for States that exceed their child enrollment targets.
We worked hard to make certain there will be no funding shortfalls with this legislation.
The bill provides States adequate money in their CHIP allotments so they will not experience funding shortfalls in their CHIP program.
As a safeguard, we created a Child enrollment contingency fund for States that experience a funding shortfall as a result of enrolling more low-income children.
Shortfalls have been a serious problem. They are something we want to avoid.
In addition, the proposal clarifies that States will only have 2 years to spend their CHIP allotments. Today, States have 3 years to spend their CHIP allotments.
It gives States a new option to provide coverage to pregnant women. Today, pregnant women are only covered in CHIP if the State has been granted a waiver to cover pregnant women or through the Administration's unborn child policy.
This is a proposal Senator Kennedy and I seriously considered including in 1997. We ultimately concluded that the cost of childbirth hospitalization was so expensive, then, about $4,000 a birth, that the greater public good could be achieved if we focused those resources on providing more insurance policies to needy children.
It was not a policy we undertook with great comfort. Indeed, Senator Kennedy argued strongly for coverage of pregnant women. But ultimately, we chose to advocate for the policy that covered the most children.
Today, we are both satisfied that the bill embodies the correct policy, if I may speak for the Senator from Massachusetts on this point.
CHIPRA provides beneficiaries and their families with coverage choices. If the State provides premium assistance through its CHIP program, CHIP beneficiaries may choose to be covered through the State CHIP program or receive premium assistance to receive health care through a private health plan. And States like Utah that already have premium assistance programs for their CHIP beneficiaries would have their programs grandfathered in, in other words, their programs would continue to exist.
It also provides CHIP beneficiaries with dental benefits, states will have a choice of four dental benchmark plans to provide to their CHIP beneficiaries, the dental benefits included in the House-passed bill; a benefit package equivalent to the federal employee health plan dental benefit that covers the most children; a benefit package equivalent to the State employee dental plan that covers the most children; or a benefit package equivalent to the most popular commercial dental plan that covers the most children.
As my colleagues are aware, I have a long record of advocating for better dental care for children. It alleviates so many health problems in the future.
In fact, in 2000, I introduced the Early Childhood Oral Health Improvement Act, which created grant programs to improve the oral health of children under 6 years of age. This bill was included in the Children's Health Act which was signed into law on October 17, 2000.
So, I know how important dental health is for children.
At the same time, it is fair to say that I have been concerned about mandating that States provide dental coverage for two basic reasons.
First, the inherent nature of CHIP, and a primary reason it could be enacted in a Republican-led Congress, is that it was a State block grant.
Mandates move us away from that important framework.
Second, the dental coverage that some advocated be included in this bill is more generous than most private-sector policies. Thus, including such coverage would be a giant incentive for crowd-out, that is, dropping private coverage in order to seek a more generous public coverage.
Ten years ago we called it substitution. Today, we call it crowd out. But it is the same thing.
I will not sugar coat it. It is a problem. It is a concern. And, we should take every step we can to keep it from occurring.
I think the dental policy we adopted was a good compromise, and I appreciate my colleagues agreeing to my suggestion for this coverage.
Our legislation also limits the Federal matching rate that States will receive for covering individuals with family incomes over 300 percent of FPL in their CHIP plans.
It clarifies the Administration's policy on crowd-out and provides States with guidance on how to ensure that their low-income children are covered through the CHIP plan before expanding coverage to higher income children.
Another key element of this bill is that it provides States with funds for outreach and enrollment.
It gives States a time-limited option to speed up enrollment in CHIP and Medicaid by using eligibility information from designated express lane agencies.
The bill gives States the option of verifying citizenship for both Medicaid and CHIP by submitting names and Social Security numbers to the Commissioner of Social Security.
It creates a new quality initiative through the Secretary of Health and Human Services, in consultation with the States, to develop evidence-based pediatric quality measures in order to evaluate the quality of care for children.
I introduced legislation to develop pediatric quality measures with Senators Bayh and Lincoln and much of our bill is incorporated in this bipartisan compromise legislation.
The proposal includes mental health parity in the state CHIP programs so that if a State offers mental health coverage in its CHIP plan, it must be on par with limits for medical and surgical services.
Senator Gordon Smith has done a stellar job bringing awareness about the need for mental health benefits for children and this provision is modeled after legislation that he introduced with Senator John Kerry of Massachusetts.
At this point, I would also like to refute some of the inaccurate statements that I have heard the last few days regarding our bill.
First, some have alleged that our bill allows the Federal Government to continue covering childless adults and parents through CHIP.
Our bill puts the emphasis back on low-income, uninsured children. Simply put, our bill puts an immediate stop to States being granted future waivers to cover nonpregnant adults. In fact, the provisions included in the Senate-passed CHIP bill were included in the compromise, bipartisan CHIP bill.
At the beginning of fiscal year 2009, States will receive lower Federal matching rates for childless adults and
in fiscal year 2010, childless adults will not be covered under CHIP, they will be transitioned into Medicaid.
At the beginning of fiscal year 2010, only States with significant outreach efforts for low-income uninsured children will receive enhanced match rates for parents; others will receive the lower Medicaid match rate FMAP for adults.
Starting in fiscal year 2011, all States will receive a lower Federal match rate for parents. Those States covering more lower income kids or with significant outreach efforts will receive a Federal matching rate for parents covered under CHIP which is a midpoint between the Federal CHIP matching rate and the lower Medicaid matching rate. Other States will receive the lower Medicaid Federal matching rate, known as FMAP, for CHIP parents. Simply put, beginning in fiscal year 2011, States will no longer receive the higher CHIP matching rate for covering parents.
Second, some criticize our bill and say it allows higher income children to be covered under the CHIP program.
Today, States may receive an enhanced Federal matching rate for their CHIP program through waivers for all income levels. Our bill discourages States from covering higher income individuals in the CHIP program.
After enactment of our bill, States with new waivers approved to cover those with family incomes over 300 percent of FPL would only receive the lower FMAP payment for these higher income individuals.
In addition, States that cover individuals with incomes over 300 percent of FPL in their CHIP plans will have to submit a State plan to the HHS Secretary to show how it is addressing crowd-out for higher income children covered under CHIP.
The State plan must be approved by the HHS Secretary before October 1, 2010; otherwise, the State will no longer receive Federal matching dollars for covering those over 300 percent of FPL in their CHIP plans.
Third, some say our bill makes CHIP an entitlement program and almost doubles the Federal dollars spent on CHIP over the last 10 years.
CHIP is not an entitlement program, it is a capped, block grant program, where States are given flexibility to cover their low-income, uninsured children.
I admit that it works so well, nobody wants to abolish it, including the President and most everyone in this body. As to its cost, as I noted earlier, the 6 million children who are already covered by CHIP were easier to find that the current 6 million, low-income, uninsured children under 200 percent of FPL.
CBO has explained it is much more expensive to find these uncovered children. That is why our bill gives States bonus payments for enrolling them. I hope their prediction does not prove true. If it doesn't, we will save money in the program. But if their prediction does prove true, there is still no excuse for enrolling these kids.
I also believe it is important to note that, according to the Centers for Medicare and Medicaid Services, in 2005, we spent a total $1.98 trillion on our Nation's health care system.
Private expenditures were $1.08 trillion and Federal spending was $900 billion.
Total Medicare spending was $342 billion in 2005 and Medicaid was $177 billion in Federal dollars.
Our bill today funds CHIP at $60 billion over five years--a fraction of the cost to provide care for low-income, uninsured children. Covering these children is worth every cent.
Another common criticism is the myth that our bill allows States to cover children from families with annual incomes of $83,000.
I have addressed this before, but it bears repeating.
Our bill neither prevents, nor requires, States' coverage of families at higher income levels. Only the Secretary of Health and Human Services decides whether a State may cover families with incomes up to $83,000 per year under their State CHIP program, not Congress.
Many have suggested, in error, that our bill allows illegal immigrants to be covered under CHIP.
In fact, during the House debate, I heard some state incorrectly that our bill provides benefits to illegal immigrants and opens the door for CHIP and Medicaid benefits for illegal immigrants by substantially weakening a requirement that persons applying for such services show proof of citizenship.
Nothing could be further from the truth.
In fact, our legislation has specific language stating that no illegal immigrants will be covered under CHIP.
For those who still don't believe me, it can be found under section 605, entitled No Federal Funding for Illegal Aliens.
Let me just read what it says: ``Nothing in this Act allows Federal payment for individuals who are not legal residents.''
Finally, much has been said about the Centers for Medicare and Medicaid Services' recent guidance on crowd out.
I will include for the Record a letter dated August 17, 2007, to the State Medicaid Directors from Dennis Smith, the director of the Center for Medicaid and State Operations for CMS.
The purpose of this letter was to give the State Medicaid Directors guidance on how CMS will review state plan amendments or waivers to raise income eligibility limits under the CHIP program in the future.
In this letter, CMS made it perfectly clear that the agency was very concerned about crowd-out and wanted States to target low-income, uninsured children under 200 percent of poverty before covering higher income children under CHIP.
So in order for States to cover higher income children, CMS made it clear that States must cover 95 percent of their children under 200 percent of poverty before expanding coverage to higher income children.
While I agree with the thrust of what the administration intended to achieve, I am not certain what Mr. Smith asks the States to do can be achieved.
States have told us it is virtually impossible for them to determine how many of those low-income children are currently covered.
Currently, good, solid data on the uninsured simply do not exist. So it is almost impossible to find good, solid numbers on the uninsured. On top of that, currently, States do not have to report income data to
I yield the floor.
