Cutting Deep
Imagine having to choose between paying your electric bill and taking your sick daughter to the doctor. That’s the kind of dilemma facing working-class families these days in Texas, where the state budget has been balanced on the backs of more than 150,000 kids who’ve been thrown off the health insurance rolls. Here’s what happens when the Legislature and the governor start cutting deep.
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Until Armando lost his job, in 2001, their children had health insurance. Each month, Armando had paid his employer $500 for a plan that covered him, Sonia, and the kids: Armando Junior, who was seventeen at the time; Vanessa, fourteen; Ashley, eight; and Alex, five. The cost of the policy had been a major sacrifice; besides the rent, it was the Botellos’ biggest expense. But as Sonia and Armando saw it, health insurance was a necessity, since the odds were that even healthy children were bound to have their share of cavities, sore throats, and visits to the emergency room. That necessity became harder for Armando to obtain for his family at his new job, where his employer provided him with fewer benefits on a reduced salary. Just covering the kids would cost him and Sonia $400 a month for a plan that had a $500 deductible. With Armando making little more than two thirds of his former salary, he and Sonia did the best they could, opting to pay an $80 premium that provided minimal health insurance coverage for just the two of them. (As the family’s wage earners, they reasoned, they were the ones who could least afford to get sick.) For their children, the price of private health insurance was no longer in reach. Nor was Medicaid an option. The Botellos’ combined annual income of $33,000 was well above the federal poverty line that is the cutoff for Medicaid eligibility, defined as $25,210 for a family of six.
The Botellos are hardly unique. Nine out of ten uninsured children in Texas have a parent who works, and a majority of them reside in two-parent households. Hispanic children are the most likely to be uninsured, making up 56 percent of Texans under the age of nineteen who lack health insurance. (White children account for 28 percent and black children 14 percent.) Sonia and Armando were lucky that one of their employers offered health insurance coverage at all. As the cost of premiums has become prohibitive, the number of businesses providing insurance coverage for their workers has been declining nationally for the past three years. And while most Americans—62 percent—get health insurance through their workplace, just 51 percent of Texans do. What benefits do exist are scarcest for children; many companies that offer health coverage for their employees do not provide plans for dependents. Even when employers do offer health insurance to low-wage workers like Sonia and Armando, premiums tend to be more expensive than they are for higher-paid employees. Families like the Botellos then have a harder time affording health care premiums and staying insured.
Only because of CHIP were Sonia and Armando able to obtain health insurance for their children. Under the program, in which the Botellos enrolled their kids while Armando was still unemployed, the children could continue to have dental appointments every six months. Their vision and hearing were checked once a year, and when they fell ill, they saw their pediatrician. The program not only provided them with basic medical care but also kept Sonia and Armando from falling further into debt. When Vanessa’s lower right side began to throb with pain, Sonia correctly suspected that she had appendicitis and rushed her to the emergency room. The appendectomy cost the Botellos just a $25 co-pay. CHIP also proved critical when Vanessa later detected a lump in her breast. Because the Botellos have a history of breast cancer on both sides of the family, she promptly had it biopsied, and it proved to be benign. Vanessa, who has developed subsequent lumps, will continue to be monitored. To Sonia and Armando, who struggle to pay every bill, CHIP seemed to provide the only relief in an otherwise grim slide each month toward being broke again.
When the Texas Legislature erected hurdles to keep families off of CHIP, the Botellos cleared them. They met the new income requirements and were able to pay the program’s increased premiums, which rose from $15 per year to $15 per month for their income level. Sonia and Armando consider themselves lucky that their children are among the 348,145 young Texans currently enrolled in the program; nonetheless, they are feeling the pain inflicted by the Legislature’s decision to hollow CHIP out from within. Among the benefits that the program no longer carries are dental and vision care. For a middle-class family with disposable income, the reduction in benefits might be a setback; for the Botellos, the loss of coverage had turned into a crisis by the end of the summer. Ashley, who was about to start the fifth grade, had developed piercing headaches, and her sight was blurred. When Sonia took her to an eye clinic, a $30 exam confirmed that she needed glasses. The frames and the lenses, Sonia was told, would cost a total of $216, but what money the Botellos had at the time was already earmarked for utilities. “We had to choose between paying the electric bill and buying Ashley her glasses,” Sonia said. “We bought the glasses.” Their electricity was cut off in the middle of August, when the temperature soared toward 100 degrees.
As the Botellos have always done, they managed. Sonia bought bags of ice and salvaged food from the refrigerator. The kids took cold baths before bed. They slept on the floor of the living room, where Sonia kept the front and back doors open in case a breeze drifted through. Armando negotiated a payment plan with the electric company, and their service was turned back on. Now Sonia braces herself for the next time they find themselves out of luck. She buys clothes at yard sales and stretches out meals with large helpings of noodles and rice. She puts only as much gasoline as she and Armando need into the pickup, a few dollars at a time. Her children can see the strain; Vanessa, who has an after-school job at a video arcade, sometimes presses a $10 bill into her mother’s hand to help cover expenses. Without CHIP, Sonia knows that her children would have no health insurance, so she does not complain too loudly about the benefits they have lost. She is grateful for what limited coverage her kids still have. “So far, we’ve been blessed,” she said brightly, trying to strike an upbeat note. “No one’s had any cavities so far. I tell the kids every night: ‘Brush your teeth real good.’”
THE RELATIVELY COLLEGIAL mood that dominated the Seventy-sixth Legislature in 1999, when CHIP was written into law, seems almost quaint in comparison with the last regular session, when House Democrats bolted to Oklahoma during the heated battle over congressional redistricting. In 1999 George W. Bush was beginning his second term as governor, burnishing his record as a compassionate conservative, with an eye on a higher office. Democrats controlled the House and Republicans ruled the Senate, making the two parties more inclined to reach across the aisle. Perhaps most unusual, the state was flush with not only a $6 billion budget surplus but a $17.3 billion windfall from its legal settlement with tobacco companies. It was in this more magnanimous environment that CHIP came into being, two years after federal legislation created the program for states to adopt. So different was the mood in Austin then that Rick Perry, who was lieutenant governor at the time, penned a newspaper editorial in the spring of 2000, extolling the virtues of CHIP. “The children’s health insurance program is an investment that will pay big dividends down the road,” he wrote, enumerating its merits and providing a toll-free phone number to call for more information. “[It] extends a helping hand to the most fragile Texans—uninsured children—and in doing so, ensures that the future of the Lone Star state is healthier, brighter, and more productive for us all.”
Not that CHIP had been won without a fight. During the 1999 session, then-governor Bush had first backed a version of the bill that limited eligibility to families who earned no more than 150 percent of the federal poverty level, rather than the 200 percent cutoff that most Democrats and many Republicans supported; the lower ceiling would have prevented families like the Botellos from receiving CHIP benefits. Some conservatives in both parties tried to scale back the benefits package by reducing the income limit and lowering the cutoff age for children, arguing that Texas did not need more government programs or drains on its tax dollars. But after repeated attempts to restrict eligibility were turned back, a compromise bill won approval. In the end, Democrats got most of what they had wanted: CHIP would cover children under the age of nineteen who did not qualify for Medicaid, in families earning up to 200 percent of the poverty level. Only a veto from the governor could nix the program. On the eve of a bid for the presidency that would strive to appeal to soccer moms and swing voters, Bush was not inclined to shoot down legislation for needy children. He signed the bill into law, and to the annoyance of some Democrats, he would later claim it on the campaign trail as evidence of his compassionate conservatism.
CHIP was one of the few tools that the Legislature had to counter the growing number of uninsured children in Texas. The underlying reasons that Texas has the highest percentage of both children and adults without health insurance have to do with deeply entrenched economic forces that the Legislature can affect only marginally. Texas has relatively few manufacturing jobs, which usually have generous benefits, and a large concentration of jobs in service, retail, and agriculture, which frequently lack benefits. Fewer of the state’s small businesses offer health plans than do similar businesses in most other states. Add to the mix a high rate of unemployment, which has fueled the numbers of the uninsured, and a substantial migrant population that is not eligible for federal programs like CHIP or Medicaid. Finally, as a right-to-work state, Texas has never been fertile ground for labor unions, which could bargain aggressively for employee benefits. Despite all this, the Legislature succeeded in significantly reducing the number of uninsured kids in Texas when it adopted CHIP. A massive bilingual outreach program and advertising campaign paid off: A year later, more than half a million Texas children who had previously had no health insurance were enrolled in CHIP.
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