Thursday, October 11, 2007

An S-CHIP On His Shoulder

This weekend, Anonymous (and I don't think that's his real name) asked,

"Could you write a little something on Bush's recent veto of SCHIP, the health care program for poor kids? I have tried to find some reasoning behind his veto it just seems illogical and foolish. I was wondering if there was some, more rational, reason that I just can't grasp for saying poor kids shouldn't get to be healthy when all of the money for the program's increase is coming from smokers having to pay more."
With S-CHIP you have the model of a government program -- it's been incredibly effective at covering uninsured children who are not poor enough to qualify for Medicaid, now reaching six million young people, and gives each state the flexibility to figure out what is the best way to address the specific needs of their particular population. It is having a marked effect on medical problems that tend to effect children. It is working and even the Republican governors of very conservative states want the program continued. If you want an example of an effective use of government resources to make a real difference in human lives, this is it. But, there are approximately another nine million children eligible, who are not enrolled.

Because of health care cost increases, maintaining the coverage of those currently enrolled would take an additional $12 billion. The President is proposing an increase of only $5 billion, and adding federal restrictions on income and who can be enrolled by the states in order to decrease those covered by S-CHIP. Democrats wanted to greatly expand the program to capitalize on its success, but a bipartisan compromise scaled it back and created a more modest expansion of the program. This bipartisan bill was passed, only to be vetoed by the President.

The question, then, is on what grounds could the veto be morally justified? In logic we have what is called the principle of charity which requires us to set up the strongest version of an argument before analyzing it, invoking this principle here, what is the strongest argument one could give for not expanding, but decreasing the size of an effective program that helps those who are needy, vulnerable, and helpless?

Some, like Dennis Kucinich, opposed the bill because he thought it was a bad compromise and didn't go far enough. A classic case of the perfect being the enemy of the good. But, of course, this is not the White House's argument.

Their arguments come in two flavors: an opposition to the tax increase needed and a fear that it would cause better off families to opt out of private coverage.

The first argument is that an expansion would require a tax increase, in this case, an increased tax on cigarettes. The opposition could be a simple ideological, all taxes are bad, argument, but there is a better basis on which to oppose the hike. There tends to be in the population that smokes a class disparity and raising the cigarette tax to pay for S-CHIP would be a regressive tax. In other words, the health care of children would be subsidized on the backs of those who can least afford it. If we are going to pay for the program, shouldn't we have a more fair way of spreading out the burden?

The second argument is one based on faith in the superiority of market solutions. The designed expansion moves the program from its target of the children of uninsured families below double the poverty line and moves the line up to those below triple the poverty line. The President and his people are worried that such a move would cause an avalanche of people who currently have their own coverage to drop it for S-CHIP and therefore the increase in taxes would not help additional children, but cause a decrease in those who shop in the marketplace and it is market pressures, he argues that bring about progress in health care. Take away the profits from the insurance companies and they won't have the incentive to do as good a job.

This line, of course, requires a sense that the marketplace -- which is very, very good at some things -- is the maximal institution for overseeing the delivery of all services. But if you look at countries that have universal government sponsored health care systems, like Sweden and Germany, you see better results, shorter waits, and less expensive care. It is not a matter of religious belief in the marketplace, but an empirical concern and the evidence does not seem to point in the President's direction.

I think one could easily build a strawman out of the Republican position here, and we need to avoid doing such a thing playing the rational game fairly -- even if those on the other side fail to behave as we expect from adults (it is to the point where even conservatives are embarrassed by the spectacle of attacking a twelve-year old boy who was in a terrible car accident because he wants the country to know that the program helped save his life).