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Journal Issue: Children and Divorce Volume 4 Number 1 Spring/Summer 1994

REVISITING THE ISSUES: Children and National Health Care Reform
Sara Rosenbaum


A basic issue in national health care reform is the nature and extent of the coverage envisioned under a proposal. As the accompanying table indicates, all of the bills would extend coverage for children, but the similarities end there. Only the President's proposal and the McDermott/ Wellstone bill unconditionally guarantee coverage for all eligible persons. The Thomas/Chafee bill conditionally guarantees coverage if sufficient savings are achieved through reductions in Medicare and Medicaid and through other cost containment measures to underwrite subsidies for lower-income persons. The measures sponsored by Cooper/Breaux, Michel/Lott, and Stearns/Nickles attempt to make coverage more affordable but do not guarantee coverage.

Beyond the issue of guaranteed coverage are the eligibility criteria used to determine coverage: legal residency status, state residence, membership in a unified purchasing pool, and place of residence.

U.S. citizenship or legal residency status: Of the six measures reviewed here, four (the President's bill, McDermott/Wellstone, Thomas/Chafee, and Cooper/ Breaux) contain legal residence requirements. Cooper/Breaux limits the legal residence test to employees only. The three other measures require legal residence for all other persons as well; however, the McDermott/Wellstone measure allows the American Health Security Board to override this exclusion if it is in the public interest to do so. Legal residency requirements will leave many undocumented immigrants without health insurance. Children of undocumented immigrants who are themselves legal residents technically would be covered as individuals under several proposals; however, enrolling them in the system could be quite messy.

State residency: Because all six measures are state administered, all contain a state residency test. For children in families that move for work-related or other reasons (such as children of migrant workers), a state residency test may pose barriers to coverage, particularly if these children are required to reside in each state for a period of time before being permitted to register for health coverage in that state.

Unified coverage: Mechanisms for creating unified systems of coverage are important to achieve equity in coverage, payment levels, and benefits and to eliminate the current problems associated with separate types of public and private coverage depending on family income. The McDermott/Wellstone plan achieves this unity by extending identical, government-sponsored coverage to all eligible persons and by incorporating Medicare, Medicaid, and other public programs into a single system.

The other plans rely on insurance purchasing pools to achieve a more unified health care system. The President's bill uses very large health insurance purchasing pools known as regional health alliances. Enrollment in alliances is compulsory for all persons not receiving Medicare who reside in families with a family member who is employed in a firm with 5,000 full-time workers or fewer. The other bills call for far smaller purchasing pools comprised of small employers and nonworking and publicly subsidized individuals. Several bills make membership in a purchasing pool voluntary. Small pools increase the likelihood that children in poorer families with more health problems and fewer resources may be segregated into less-well-financed purchasing arrangements.

Children living apart from their families: Students, children living in foster care and other out-of-home arrangements, and children residing in institutions live apart from their families. They would be covered as individuals under the McDermott/ Wellstone plan and would be subject to special coverage rules under the President's plan.