Suffer the Little Children: Harming Kids in the Congressional Cloakroom

In the health care bill before the House of Representatives, the expressed intent of the American Health Care Act (AHCA) is to “repeal and replace” the Affordable Care Act (ACA) or Obamacare. That would be an important debate that should be carefully debated and considered, in and of itself.

Unfortunately, House leadership and Rep. Bruce Westerman (R-AR) have chosen to take the legislation well beyond that role and push to also undermine the success and reverse the gains that we have made over the last two decades with respect to children’s health coverage. The legislation does so by attempting to radically change the financing of the Medicaid program for children through the imposition of per capita caps and block grants.

In a blog Rep. Westerman authored in The Hill, he says that he was “able to work with others to secure agreements from leadership and President Donald Trump that Medicaid block grants would be included in the final version of the bill scheduled for a vote this week.” This change was never heard in committee, debated, or voted upon, but will be included in a Manager’s Amendment after backroom or cloakroom discussions when it comes to the floor.

This change to block grant Medicaid has absolutely no relationship whatsoever to a “repeal and replace” of Obamacare, and it remains completely unclear as to what problem Rep. Westerman is seeking to fix other than his claim that he wanted to “give individuals and the states in which they live the freedom to do healthcare in a way that works locally. . . .”

What Rep. Westerman is missing is that the “freedom” that families with children want is for their child to be cancer-free, to receive the care and treatment their child needs for their disability, and to be free from facing bankruptcy due to an illness or injury suffered by their child.

According to a 1991 landmark report entitled Beyond Rhetoric: A New American Agenda for Children and Families by the bipartisan National Commission on Children that was created by President Ronald Reagan in 1988:

Perhaps no set of issues moved members of the National Commission on Children more than the wrenching consequences of poor health and limited access to medical care. In urban centers and rural counties, we saw young children with avoidable illnesses and injuries, pregnant women without access to prenatal care, families whose emotional and financial resources were exhausted from providing special care for children with chronic illnesses and disabilities, and burned-out health care providers asked to do more than is humanly possible.

If this nation is to succeed in protecting children’s health, there must be a major commitment from families, communities, health care providers, employers, and government to meet children’s basic health needs and to ensure that all pregnant women and children have access to health care.

That commitment to protecting the health of our nation’s children was answered by Congress in a bipartisan manner, with the passage of the Children’s Health Insurance Program (CHIP) in 1997. Subsequently, Medicaid, in tandem with CHIP, has been an enormous success story for children in this country. Since CHIP’s enactment, governors and state legislatures across the country have successfully built cost-effective, pediatric-focused health care networks and services for millions of our nation’s children and dropped the uninsured rate for children from 14.9 percent to 4.8 percent — an astounding 68 percent reduction.

In Arkansas, the State passed ARKids, which was signed into law by Governor Mike Huckabee (R-AR) 20 years ago on March 10, 1997, prior to even the federal passage of CHIP. According to the Arkansas Advocates for Children and Families (AACF), “At the time ARKids was signed, almost a quarter of Arkansas children were uninsured (one in four). These children could not get the preventive care or medical attention they needed or deserved to live healthy, successful lives and to thrive in school, at home, and later in life.”

Today, AACF reports that less than 5 percent of Arkansas’s children remain uninsured and created this video to celebrate the incredible success story that is ARKids, which is Arkansas’s name for Medicaid and CHIP coverage for children in the state.

For families with children, ARKids is a God-send. It represents the security that families want to protect their children’s health and well-being. In sharp contrast, the Congressional Budget Office (CBO) estimates that 24 million people will lose health care under the current provision included in the AHCA.

So, what was “the problem” to Rep. Westerman that he was trying to “fix”? Does he object to Arkansas and the nation having achieved record low numbers of uninsured children?

Or, is it that he wanted to “fix” the fact that Medicaid provides coverage to millions of children in a cost-effective manner?

In the field of medicine, all physicians’ pledge to the first tenet in the Oath of Hippocrates, which is: “First, do no harm.” This oath is intended to apply to interactions with patients seeking treatment and advice, but it should also be applied to changes make in health care policy. This bill would fail that simple test.

According to the CBO, the AHCA would slash $880 billion over 10 years out of Medicaid, which finances the health coverage to low-income children, people with disabilities, and senior citizens. One of the key mechanisms to reach this level of cuts is through the imposition of an arbitrary and one-sided per capita cap on funding to states that limits funding to provide care to low-income children, people with disabilities, senior citizens, and adults.

As if that wasn’t bad enough for vulnerable populations served by Medicaid, Rep. Westerman expressed his pleasure that the bill has now will be adding an amendment that includes a block grant option for states to adopt as an alternative to the per capita cap. This would be even worse for children than the per capita cap and House leadership knew it when they adopted the amendment because they explicitly exempted people with disabilities and senior citizens from the block grant. House leadership recognized the harm that the block grant would cause but chose to impose it largely upon children.

The block grant language would do immeasurable harm to children. It guts the pediatric benefits that are guaranteed under current law, grows the funding at a lower inflation rate than even the per capita cap, and cuts the state contribution by 30 percent. This imposes a triple-threat to children, as it vastly underfunds child health and undermines their benefits. Compounding the problem, the AHCA’s block grant option does not even adjust for population growth.

Of course, when you think about population growth for children, you are talking about babies. There are four million births in this country annually, and these children are our nation’s future. It is shocking and upsetting that Rep. Westerman would push an amendment where the federal government would effectively walk away from supporting the health services and supports that newborns need in order to thrive and survive. Our infant mortality rate is far too high and we should be doing more — not less — to protect their lives and health.

In fact, the last Congress passed the 21st Century Cures Act with Rep. Westerman’s support. In his words:

We are familiar with diseases targeted by this bill — including cancer and Alzheimer’s disease — but tick-borne illnesses such as Lyme disease are a problem occurring throughout areas in Arkansas. This bill specifically targets tick-borne illnesses through research aimed at improvement in diagnosis, care, and prevention of these ailments. The 21st Century Cures Act does much more to improve the health of citizens across Arkansas and the United States and it does it in a fiscally responsible way through offsets in discretionary spending. I was proud to vote for this bill and stand for the citizens of Arkansas.

We hope the Congressman is right and that the legislation leads to the development of important cures, treatments, and therapies to improve the lives of people across this country.

However, it is critically important to note that, while 15 percent of all children in the United States have special health care needs, Medicaid, CHIP, and other public health programs cover nearly half, or 44 percent, of children with special health care needs. Medicaid disproportionately covers this children and they should be the beneficiaries of cures, treatments, and therapies that might be developed from the 21st Century Cures Act.

Tragically, the AHCA may have the consequence of denying these vulnerable children access to the life-saving and life-improving cures, treatments, and therapies that might be developed, due to the fact that the Congressional Budget Office (CBO) estimates the AHCA would slash $880 billion out of Medicaid over 10 years due to the per capita cap and now also the block grant that Rep. Westerman supports. The result is that underfunding Medicaid will lead to the rationing of care to low-income children, harm to newborns, and harm to children with special health care needs. With all due respect, this is the opposite of pro-life.

I would urge all the Members of Congress to speak to Rep. Jaime Herrera Beutler (R-WA) before proceeding with any of the provisions that harm children under the AHCA. She understands this issue personally, as she has a child with special health care needs, and offered an amendment in the House Rules Committee that spoke perfectly to why children’s health care should be protected and not cut, capped, and rationed.

In Rep. Herrera Beutler’s words:

I know that kids matter and we’re here to make sure they have a voice and that their protected as we move forward. . .My amendment would exempt children from the Medicaid per capita cap and block grants under the AHCA reimbursement provisions.

She adds:

Long before the enactment of Obamacare, Medicaid was the largest source of funding for children’s health in our nation. Millions of kids, many of them with complex medical needs, including serious disabilities depend on Medicaid.

Health care costs for children under Medicaid are relatively low. While children are nearly half of all Medicaid enrollees, they only account for 20 percent of the cost. Under the underlying bill, federal funding for the program would be capped on a 2016 spending adjusted level for Medicaid for medical inflation. And if applied to all children, over time my concern is that the cap could create a large shortfall, and more particularly, harm these vulnerable populations.

As for growing costs for children, she pointed out, that technology advances have lead to children to live longer lives than in the past. She said:

But today there are more [children with complex medical needs]. Their lives and the quality of their lives is expanding. That is a great, great challenge to have.

Her amendment would protect children, including children with disabilities, from being subjected to the proposed per capita caps and block grants rather than subjecting them to arbitrary limits that “could put children’s access to health care at risk.”

The Congresswoman concluded:

A fundamental reason that the Medicaid program exists is to protect access for underserved kids. Please help me make sure they don’t fall through the cracks. It is true that kiddos don’t vote, but we get the chance and opportunity to vote for those kids.

Or, will they? While Congress has appears to be making changes to the legislation to gain votes from the House Republican Study Group and the Freedom Caucus, children do not seem to matter in this process, as the bill seems to keep getting worse for vulnerable children.

Just hours before the vote on the legislation, we still don’t have final legislative language on the bill. We still don’t have a CBO score that specifically addresses the impact to children.

And now, we are having hearing that the bill, as a result of a push by the Freedom Caucus, may gut critical child-friendly pediatric benefits that children benefit from under current law.

In this debate and for the sake of children, let’s hope that the position of Rep. Herrera Beutler prevails over that of Rep. Westerman and the Freedom Caucus.

But don’t hold your breath. The health and well-being of millions of people, intentionally and unintentionally, are already being put at risk.