How the House Stimulus Bill Undercuts Parental Authority
Buried in the economic stimulus legislation is a provision
further undercutting parental authority and expanding control of
taxpayer dollars by family planning clinics. No doubt these
provisions are embodied in the economic stimulus package because
their congressional sponsors believe that they would not be enacted
if considered separately on their own merits.
Section 5004, "State Eligibility Option for Family Planning
Services," would make Medicaid into a virtual money-machine for
family planning clinics. The federal government already provides a
90 percent match rate for family planning services in Medicaid.
States therefore have little at stake in Congress's oversight and
accountability of Medicaid. Under Section 5004, eligibility and
benefits can be expanded in several ways:
- Contrary to current law, the income of parents or even a spouse
may not be counted in determining eligibility. A state would have
the option to "consider only the income of the applicant or
recipient." In other words, a child in a family at any
income level may be eligible for free family planning
- A child would be able to receive benefits through a
"presumptive eligibility period" and beyond without parental
knowledge that he or she applied for Medicaid.
- Typically, Medicaid eligibility is restricted to individuals in
a family with a dependent child. Section 5004 creates a new
eligibility group that would include college students, adults
without children, and even adults in a household that has
significant income but little or no income for the applicant.
Moreover, applicants would not have to prove their citizenship
before their "presumptive eligibility" is determined.
- Benefits are not limited to "family planning services and
supplies." Section 5004 expands benefits at state option to include
"medical diagnosis and treatment services that are provided in
conjunction with a family planning service in a family planning
setting." This is a massive loophole. Providers would quickly learn
that all they have to do is ask certain questions to qualify as "a
family planning service in a family planning setting." For
instance, all a provider has to do is ask a patient, "Are you
sexually active?" and that encounter automatically meets the new,
broad test, thereby triggering Medicaid payment for other services
as well, paid for with a 90 percent match rate from the federal
government. While family planning clinics are clearly intended to
become the sites for delivering services, there is nothing to
prevent other types of providers (such as a hospital outpatient
department, which has access to an even broader array of tests and
treatments) from doing the same. Since states have little of their
own funds at stake, they would have incentive to raise
reimbursement rates to clinics and steer individuals to them. The
provision of additional benefits would also create new inequities.
Individuals who are not pregnant will qualify for all the new
benefits. All the while, expectant mothers, by definition, are not
intended to be eligible for this coverage.
- Since family planning services can include services to achieve
pregnancy, it will be up to the Obama Administration to interpret
the language as to whether the expansion of benefits would include
expensive fertility treatment. Fertility drugs are not currently
covered by Medicaid, but as a new benefit to be defined by the
states, it is not clear whether these restrictions would still
apply. Without a doubt, special interest groups would pressure the
states to expand such benefits, given the 90 percent match rate. If
allowed, this would create another new inequity. The newly eligible
individuals at higher income levels could receive fertility
services while lower-income individuals served through regular
Medicaid would not.
- Debate over family planning coverage reveals a deep ideological
division among the proponents. In general, congressional leaders
have strongly insisted that all children covered by Medicaid
receive the comprehensive benefits of Early Periodic Screening
Diagnosis and Treatment (EPSDT) services. It seems inconsistent to
maintain that a "family planning only" benefit is appropriate for
some children while a benefit package that includes
hospitalization, physician services, dental care, and prescription
drugs--but not EPSDT--is insufficient to merit public funding.
- Providers will be empowered to give at least two months of
benefits under the "presumptive eligibility" provisions. Benefits
could be extended further through additional presumptive
eligibility periods. Typically, presumptive eligibility has been
reserved to public entities. This provision will give the power to
private clinics to provide easy access to so-called "emergency
contraceptives" and be reimbursed with taxpayer dollars.
- The Obama Administration will interpret whether the payment
language ("[n]otwithstanding any other provision of law") may be
used as a backdoor means of overturning Hyde Amendment restrictions
on federal funding of abortions.
Section 5004 will also reverse current law in respect to state
benefit flexibility. Since the enactment of the Deficit Reduction
Act of 2005, states have had the authority to offer "benchmark
plans" and were allowed by federal law to provide coverage that
does not include family planning services. Some religious
organizations believe low-income families should be able to
participate in a health benefit program that does not include
contraceptives or sterilization. In a statement on reauthorization
of the State Children's Health Insurance Program (SCHIP), for
example, the Catholic Medical Association recommends that "at a
minimum, state and federal regulations should permit parents to
have access to SCHIP funds to enable them to choose health
insurance coverage that does not conflict with their values and
that does not separate funding mechanisms from parental
oversight." Under Section 5004, that choice would not
be available to parents of children on Medicaid.
Finally, the legislation provides a special "safe harbor"
protection to the state of California. Under procedures dating back
to the Clinton Administration, California created an eligibility
process that bypasses the county welfare agencies. As a result,
California is allowed to provide coverage to individuals--including
immigrant populations--who are not eligible for Medicaid. The Bush
Administration attempted to bring California into conformance with
standard eligibility procedures. Section 5004 would allow
California to continue to use the same procedures that have been
abused in the past.
A Hidden Agenda?
A radical social agenda does not belong in the economic stimulus
package. At a minimum, congressional sponsors should be required to
present it for a full debate with the potential for amendments in
the House of Representatives and the Senate. It should not be
buried in the economic stimulus package.
Dennis G. Smith is Senior
Fellow in the Center for Health Policy Studies at The Heritage