[Congressional Record Volume 149, Number 68 (Thursday, May 8, 2003)]
[Senate]
[Pages S5965-S5971]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Lugar, Mrs. Lincoln, Mr.

[[Page S5966]]

        Corzine, Ms. Landrieu, Mr. Breaux, Mr. Kerry, Ms. Cantwell, 
        Mrs. Murray, Mrs. Clinton, and Mr. Miller):
  S. 1033. A bill to amend titles XIX and XXI of the Social Security 
Act to expand or add coverage of pregnant women under the medicaid and 
State children's health insurance program, and for other purposes; to 
the Committee on Finance.
  Mr. BINGAMAN. Mr. President, I rise today to introduce bipartisan 
legislation with Senators Lugar, Lincoln, Corzine, Landrieu, Breaux, 
Kerry, Murray, Cantwell, Clinton, and Miller. This legislation, 
entitled the ``Start Healthy, Stay Healthy Act of 2003,'' would 
significantly reduce the number of uninsured pregnant women and 
newborns by expanding coverage to pregnant women through Medicaid and 
the Children's Health Insurance Program, or CHIP, and to newborns 
through the first full year of life.
  Sunday is Mothers' Day. Every year, we honor our Nation's mothers and 
we should take the time to assess how we can do better by them, 
including their health and well-being.
  According to a recent report by Save the Children entitled ``The 
State of the World's Mothers,'' the United States fares no better than 
11th in the world. Why is this? According to the report, ``The United 
States earned its 11th place rank this year based on several factors: 
One of the key indicators used to calculate the well-being for mothers 
is lifetime risk of maternal mortality . . . Canada, Australia, and all 
the Western and Northern European countries in the study performed 
better than the United States in this indicator.''
  The study adds, ``Similarly, the United States did not do as well as 
the top 10 countries with regard to infant mortality rates.''
  In fact, the United States ranks 21st in maternal mortality and 28th 
in infant mortality, the worst among developed nations. We should and 
must do better by our Nation's mothers and infants.
  Throughout our Nation's history, there has been long-standing policy 
linking programs for pregnant women and infants, including Medicaid, 
WIC, and the Maternal and Child Health Block Grant. CHIP, 
unfortunately, fails to provide coverage to pregnant women beyond the 
age of 18. As a result, it is more likely that newborns eligible for 
CHIP are not covered from the moment of birth, and therefore, often 
miss having comprehensive prenatal care and those first critical months 
of life until their CHIP application is processed.
  By expanding coverage to pregnant women through CHIP, the ``Start 
Healthy, Stay Healthy Act'' recognizes the importance of prenatal care 
to the health and development of a child. As Dr. Alan Waxman of the 
University of New Mexico School of Medicine has written, ``Prenatal 
care is an important factor in the prevention of birth defects and the 
prevention of prematurity, the most common causes of infant death and 
disability. Babies born to women with no prenatal care or late prenatal 
care are nearly twice as likely to [be] low birthweight or very low 
birthweight as infants born to women who received early prenatal 
care.''
  Unfortunately, according to the Centers for Disease Control and 
Prevention, New Mexico ranked worst in the Nation in the percentage of 
mothers receiving late or no prenatal care last year. The result is 
often quite costly--both in terms of the health of the mother and 
newborn but also in terms of the long-term expenses since the result 
can be chronic, lifelong health problems.
  In fact, according to the Agency for Healthcare Research and Quality, 
``four of the top 10 most expensive conditions in the hospital are 
related to care of infants with complications (respiratory distress, 
prematurity, heart defects, and lack of oxygen).'' As a result, in 
addition to reduced infant mortality and morbidity, the provision to 
expand coverage to pregnant women can be cost effective.
  The ``Start Healthy, Stay Healthy Act'' also eliminates the 
unintended federal policy through CHIP that covers pregnant women only 
through the age of 18 and cuts off that coverage once the women turn 19 
years of age. Certainly, everybody can agree that the government should 
not be telling women that they are more likely to receive prenatal care 
coverage only if they become pregnant as a teenager.
  This bipartisan legislation has previously received or has added 
endorsements from the following organizations: the March of Dimes, The 
American Academy of Pediatrics, the American College of Obstetricians 
and Gynecologists, the What to Expect Foundation, the American Academy 
of Family Physicians, the American Academy of Pediatric Dentistry, the 
American Academy of Child and Adolescent Psychiatry, the National 
Association of Community Health Centers, the American Hospital 
Association, the National Association of Children's Hospitals, the 
Federation of American Health Systems, the National Association of 
Public Hospitals and Health Systems, Premier, Catholic Health 
Association, Catholic Charities USA, Family Voices, the Association of 
Maternal and Child Health Programs, the National Health Law Program, 
the National Association of Social Workers, Every Child By Two, the 
United Cerebral Palsy Associations, the Society for Maternal-Fetal 
Medicine, and Families USA.
  This legislation is a reintroduction of a bill that was introduced in 
2001. Throughout that year, the Administration made numerous statements 
in support of the passage of this type of legislation, but 
unfortunately, reversed course in October 2002 after publishing a 
regulation allowing states to redefine a ``child'' as an ``unborn 
child'' and to provide prenatal care through CHIP in that manner. In a 
letter to Senator Nickles dated October 8, 2002, Secretary Thompson 
argued, ``I believe the regulation is a more effective and 
comprehensive solution to this issue.''
  While a number of senators strongly disagreed with Secretary 
Thompson's assertion and sent him letters to that effect on October 10, 
2002, and on October 23, 2002, we felt it was important to get the 
testimony of our Nation's medical experts on the health and well-being 
of both pregnant women and newborns. We called for a hearing in the 
Senate Health, Education, Labor and Pensions Committee on October 24, 
2002. Witnesses included representatives from the March of Dimes, the 
American College of Obstetricians and Gynecologists, the American 
Academy of Pediatrics, and the What to Expect Foundation. They were 
asked to compare the regulation to the legislation and I will let their 
testimony speak for itself.
  Dr. Nancy Green testified on behalf of the March of Dimes Birth 
Defects Foundation. She said:

       We support giving states the flexibility they need to cover 
     income-eligible pregnant women age 19 and older, and to 
     automatically enroll infants born to SCHIP-eligible mothers. 
     By establishing a uniform eligibility threshold for coverage 
     for pregnant women and infants, states will be able to 
     improve maternal health, eliminate waiting periods for 
     infants and streamline administration of publicly supported 
     health programs. Currently, according to the Department of 
     Health and Human Services' Centers for Medicare and Medicaid 
     Services and the National Governors' Association, 36 states 
     and the District of Columbia have income eligibility 
     thresholds that are more restrictive for women than for their 
     newborns. Encouraging states to eliminate this disparity by 
     allowing them to establish a uniform eligibility threshold 
     for pregnant women and their infants should be a national 
     policy priority.

  Dr. Green adds:

       Specifically, we are deeply concerned that final regulation 
     fails to provide to the mother the standard scope of 
     maternity care services recommended by the American College 
     of Obstetricians and Gynecologists (ACOG) and the American 
     Academy of Pediatrics (AAP). Of particular concern, the 
     regulation explicitly states that postpartum care is not 
     covered and, therefore, federal reimbursement will not be 
     available for these services. In addition, because of the 
     contentious collateral issues raised by this regulation 
     groups like the March of Dimes will find it even more 
     difficult to work in the states to generate support for 
     legislation to extend coverage to uninsured pregnant women.

  Dr. Laura Riley testified on behalf of ACOG. In her testimony, she 
stated:

       ACOG is very concerned that mothers will not have access to 
     postpartum services under the regulation. The rule clearly 
     states that ``. . . care after delivery, such as postpartum 
     services could not be covered as part of the Title XXI State 
     Plan . . . because they are not services for an eligible 
     child.''

  On the importance of postpartum care, Dr. Riley adds:


[[Page S5967]]


       When new mothers develop postpartum complications, quick 
     access to their physicians is absolutely critical. Postpartum 
     care is especially important for women who have preexisting 
     medical conditions, and for those whose medical conditions 
     were induced by their pregnancies, such as gestational 
     diabetes or hypertension, and for whom it is necessary to 
     ensure that their conditions are stabilized and treated.

  As a result, Dr. Riley concludes:

       Limiting coverage to the fetus instead of the mother omits 
     a critical component of postpartum care that physicians 
     regard as essential for the health of the mother and the 
     child. Covering the fetus as opposed to the mother also 
     raises questions of whether certain services will be 
     available during pregnancy and labor if the condition is one 
     that more directly affects the woman. The best way to address 
     this coverage issue is to pass S. 724, supported by Senators 
     Bond, Bingaman and Lincoln and many others, and which 
     provides a full range of medical services during and after 
     pregnancy directly to the pregnant woman.

  Dr. Richard Bucciarelli testified on behalf of the American Academy 
of Pediatrics. He said:

       Recently, the Administration published a final rule 
     expanding SCHIP cover unborn children. The Academy is 
     concerned that, as written, this regulation falls dangerously 
     short of the clinical standards of care outlined in our 
     guidelines, which describe the importance of covering all 
     stages of a birth--pregnancy, delivery, and postpartum care.

  It is important to note that the regulation subtracts the time that 
an ``unborn child'' is covered from the period of continuously 
eligibility after birth. Consequently, children would be denied 
insurance coverage at very critical points during the first full year 
of life. As such, Dr. Bucciarelli expressed support for the legislation 
over the regulation because it, in his words:

       . . . takes an important step to decrease the number of 
     uninsured children by providing 12 months of continuous 
     eligibility for those children born. . . . This legislation 
     ensures that children born to women enrolled in Medicaid or 
     SCHIP are immediately enrolled in the program for which they 
     are eligible. Additionally, this provision prevents newborns 
     eligible for SCHIP from being subject to enrollment waiting 
     periods, ensuring that infants receive appropriate health 
     care in their first year of life.

  And finally, Lisa Bernstein testified as Executive Director of The 
What to Expect Foundation, which takes its name from the bestselling 
What to Expect pregnancy and parenting series that has helped over 20 
million families from pregnancy through their child's toddler years. 
Ms. Bernstein also supported the legislation as a far superior option 
over the regulation and make this simple but eloquent point:

       . . . only a healthy parent can provide a healthy future 
     for a healthy child.

  The testimony of these experts speak for themselves and I urge my 
colleagues to pass this legislation as soon as possible.
  I ask unanimous consent that the text of the bill and a series of 
letters be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1033

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Start Healthy, Stay Healthy 
     Act of 2003''.

     SEC. 2. STATE OPTION TO EXPAND OR ADD COVERAGE OF CERTAIN 
                   PREGNANT WOMEN UNDER MEDICAID AND SCHIP.

       (a) Medicaid.--
       (1) Authority to expand coverage.--Section 1902(l)(2)(A)(i) 
     of the Social Security Act (42 U.S.C. 1396a(l)(2)(A)(i)) is 
     amended by inserting ``(or such higher percent as the State 
     may elect for purposes of expenditures for medical assistance 
     for pregnant women described in section 1905(u)(4)(A))'' 
     after ``185 percent''.
       (2) Enhanced matching funds available if certain conditions 
     met.--Section 1905 of the Social Security Act (42 U.S.C. 
     1396d) is amended--
       (A) in the fourth sentence of subsection (b), by striking 
     ``or subsection (u)(3)'' and inserting ``, (u)(3), or 
     (u)(4)''; and
       (B) in subsection (u)--
       (i) by redesignating paragraph (4) as paragraph (5); and
       (ii) by inserting after paragraph (3) the following:
       ``(4) For purposes of the fourth sentence of subsection (b) 
     and section 2105(a), the expenditures described in this 
     paragraph are the following:
       ``(A) Certain pregnant women.--If the conditions described 
     in subparagraph (B) are met, expenditures for medical 
     assistance for pregnant women described in subsection (n) or 
     under section 1902(l)(1)(A) in a family the income of which 
     exceeds the effective income level (expressed as a percent of 
     the poverty line and considering applicable income 
     disregards) that has been specified under subsection 
     (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of 
     January 1, 2003, but does not exceed the income eligibility 
     level established under title XXI for a targeted low-income 
     child.
       ``(B) Conditions.--The conditions described in this 
     subparagraph are the following:
       ``(i) The State plans under this title and title XXI do not 
     provide coverage for pregnant women described in subparagraph 
     (A) with higher family income without covering such pregnant 
     women with a lower family income.
       ``(ii) The State does not apply an effective income level 
     for pregnant women that is lower than the effective income 
     level (expressed as a percent of the poverty line and 
     considering applicable income disregards) that has been 
     specified under the State plan under subsection 
     (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of 
     January 1, 2003, to be eligible for medical assistance as a 
     pregnant woman.
       ``(C) Definition of poverty line.--In this subsection, the 
     term `poverty line' has the meaning given such term in 
     section 2110(c)(5).''.
       (3) Payment from title xxi allotment for medicaid expansion 
     costs; elimination of counting medicaid child presumptive 
     eligibility costs against title xxi allotment.--Section 
     2105(a)(1) of the Social Security Act (42 U.S.C. 
     1397ee(a)(1)) is amended--
       (A) in the matter preceding subparagraph (A), by striking 
     ``(or, in the case of expenditures described in subparagraph 
     (B), the Federal medical assistance percentage (as defined in 
     the first sentence of section 1905(b)))''; and
       (B) by striking subparagraph (B) and inserting the 
     following:
       ``(B) for the provision of medical assistance that is 
     attributable to expenditures described in section 
     1905(u)(4)(A);''.
       (4) Additional amendments to medicaid.--
       (A) Eligibility of a newborn.--Section 1902(e)(4) of the 
     Social Security Act (42 U.S.C. 1396a(e)(4)) is amended in the 
     first sentence by striking ``so long as the child is a member 
     of the woman's household and the woman remains (or would 
     remain if pregnant) eligible for such assistance''.
       (B) Application of qualified entities to presumptive 
     eligibility for pregnant women under medicaid.--Section 
     1920(b) of the Social Security Act (42 U.S.C. 1396r-1(b)) is 
     amended by adding at the end after and below paragraph (2) 
     the following flush sentence:

     ``The term `qualified provider' includes a qualified entity 
     as defined in section 1920A(b)(3).''.
       (b) SCHIP.--
       (1) Coverage.--Title XXI of the Social Security Act (42 
     U.S.C. 1397aa et seq.) is amended by adding at the end the 
     following:

     ``SEC. 2111. OPTIONAL COVERAGE OF TARGETED LOW-INCOME 
                   PREGNANT WOMEN.

       ``(a) Optional Coverage.--Notwithstanding any other 
     provision of this title, a State may provide for coverage, 
     through an amendment to its State child health plan under 
     section 2102, of pregnancy-related assistance for targeted 
     low-income pregnant women in accordance with this section, 
     but only if the State meets the conditions described in 
     section 1905(u)(4)(B).
       ``(b) Definitions.--For purposes of this title:
       ``(1) Pregnancy-related assistance.--The term `pregnancy-
     related assistance' has the meaning given the term child 
     health assistance in section 2110(a) as if any reference to 
     targeted low-income children were a reference to targeted 
     low-income pregnant women, except that the assistance shall 
     be limited to services related to pregnancy (which include 
     prenatal, delivery, and postpartum services and services 
     described in section 1905(a)(4)(C)) and to other conditions 
     that may complicate pregnancy.
       ``(2) Targeted low-income pregnant woman.--The term 
     `targeted low-income pregnant woman' means a woman--
       ``(A) during pregnancy and through the end of the month in 
     which the 60-day period (beginning on the last day of her 
     pregnancy) ends;
       ``(B) whose family income exceeds the effective income 
     level (expressed as a percent of the poverty line and 
     considering applicable income disregards) that has been 
     specified under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of 
     section 1902, as of January 1, 2003, to be eligible for 
     medical assistance as a pregnant woman under title XIX but 
     does not exceed the income eligibility level established 
     under the State child health plan under this title for a 
     targeted low-income child; and
       ``(C) who satisfies the requirements of paragraphs (1)(A), 
     (1)(C), (2), and (3) of section 2110(b).
       ``(c) References to Terms and Special Rules.--In the case 
     of, and with respect to, a State providing for coverage of 
     pregnancy-related assistance to targeted low-income pregnant 
     women under subsection (a), the following special rules 
     apply:
       ``(1) Any reference in this title (other than in subsection 
     (b)) to a targeted low-income child is deemed to include a 
     reference to a targeted low-income pregnant woman.
       ``(2) Any such reference to child health assistance with 
     respect to such women is deemed a reference to pregnancy-
     related assistance.

[[Page S5968]]

       ``(3) Any such reference to a child is deemed a reference 
     to a woman during pregnancy and the period described in 
     subsection (b)(2)(A).
       ``(4) In applying section 2102(b)(3)(B), any reference to 
     children found through screening to be eligible for medical 
     assistance under the State medicaid plan under title XIX is 
     deemed a reference to pregnant women.
       ``(5) There shall be no exclusion of benefits for services 
     described in subsection (b)(1) based on any preexisting 
     condition and no waiting period (including any waiting period 
     imposed to carry out section 2102(b)(3)(C)) shall apply.
       ``(6) Subsection (a) of section 2103 (relating to required 
     scope of health insurance coverage) shall not apply insofar 
     as a State limits coverage to services described in 
     subsection (b)(1) and the reference to such section in 
     section 2105(a)(1)(C) is deemed not to require, in such case, 
     compliance with the requirements of section 2103(a).
       ``(7) In applying section 2103(e)(3)(B) in the case of a 
     pregnant woman provided coverage under this section, the 
     limitation on total annual aggregate cost-sharing shall be 
     applied to the entire family of such pregnant woman.
       ``(d) Automatic Enrollment for Children Born to Women 
     Receiving Pregnancy-Related Assistance.--If a child is born 
     to a targeted low-income pregnant woman who was receiving 
     pregnancy-related assistance under this section on the date 
     of the child's birth, the child shall be deemed to have 
     applied for child health assistance under the State child 
     health plan and to have been found eligible for such 
     assistance under such plan or to have applied for medical 
     assistance under title XIX and to have been found eligible 
     for such assistance under such title, as appropriate, on the 
     date of such birth and to remain eligible for such assistance 
     until the child attains 1 year of age. During the period in 
     which a child is deemed under the preceding sentence to be 
     eligible for child health or medical assistance, the child 
     health or medical assistance eligibility identification 
     number of the mother shall also serve as the identification 
     number of the child, and all claims shall be submitted and 
     paid under such number (unless the State issues a separate 
     identification number for the child before such period 
     expires).''.
       (2) Additional allotments for providing coverage of 
     pregnant women.--
       (A) In general.--Section 2104 of the Social Security Act 
     (42 U.S.C. 1397dd) is amended by inserting after subsection 
     (c) the following:
       ``(d) Additional Allotments for Providing Coverage of 
     Pregnant Women.--
       ``(1) Appropriation; total allotment.--For the purpose of 
     providing additional allotments to States under this title, 
     there is appropriated, out of any money in the Treasury not 
     otherwise appropriated, for each of fiscal years 2004 through 
     2007, $200,000,000.
       ``(2) State and territorial allotments.--In addition to the 
     allotments provided under subsections (b) and (c), subject to 
     paragraphs (3) and (4), of the amount available for the 
     additional allotments under paragraph (1) for a fiscal year, 
     the Secretary shall allot to each State with a State child 
     health plan approved under this title--
       ``(A) in the case of such a State other than a commonwealth 
     or territory described in subparagraph (B), the same 
     proportion as the proportion of the State's allotment under 
     subsection (b) (determined without regard to subsection (f)) 
     to the total amount of the allotments under subsection (b) 
     for such States eligible for an allotment under this 
     paragraph for such fiscal year; and
       ``(B) in the case of a commonwealth or territory described 
     in subsection (c)(3), the same proportion as the proportion 
     of the commonwealth's or territory's allotment under 
     subsection (c) (determined without regard to subsection (f)) 
     to the total amount of the allotments under subsection (c) 
     for commonwealths and territories eligible for an allotment 
     under this paragraph for such fiscal year.
       ``(3) Use of additional allotment.--Additional allotments 
     provided under this subsection are not available for amounts 
     expended before October 1, 2003. Such amounts are available 
     for amounts expended on or after such date for child health 
     assistance for targeted low-income children, as well as for 
     pregnancy-related assistance for targeted low-income pregnant 
     women.
       ``(4) No payments unless election to expand coverage of 
     pregnant women.--No payments may be made to a State under 
     this title from an allotment provided under this subsection 
     unless the State provides pregnancy-related assistance for 
     targeted low-income pregnant women under this title, or 
     provides medical assistance for pregnant women under title 
     XIX, whose family income exceeds the effective income level 
     applicable under subsection (a)(10)(A)(i)(III) or (l)(2)(A) 
     of section 1902 to a family of the size involved as of 
     January 1, 2003.''.
       (B) Conforming amendments.--Section 2104 of the Social 
     Security Act (42 U.S.C. 1397dd) is amended--
       (i) in subsection (a), in the matter preceding paragraph 
     (1), by inserting ``subject to subsection (d),'' after 
     ``under this section,'';
       (ii) in subsection (b)(1), by inserting ``and subsection 
     (d)'' after ``Subject to paragraph (4)''; and
       (iii) in subsection (c)(1), by inserting ``subject to 
     subsection (d),'' after ``for a fiscal year,''.
       (3) Presumptive eligibility under title xxi.--
       (A) Application to pregnant women.--Section 2107(e)(1)(D) 
     of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is 
     amended to read as follows:
       ``(D) Sections 1920 and 1920A (relating to presumptive 
     eligibility).''.
       (B) Exception from limitation on administrative expenses.--
     Section 2105(c)(2) of the Social Security Act (42 U.S.C. 
     1397ee(c)(2)) is amended by adding at the end the following 
     new subparagraph:
       ``(C) Exception for presumptive eligibility expenditures.--
     The limitation under subparagraph (A) on expenditures shall 
     not apply to expenditures attributable to the application of 
     section 1920 or 1920A (pursuant to section 2107(e)(1)(D)), 
     regardless of whether the child or pregnant woman is 
     determined to be ineligible for the program under this title 
     or title XIX.''.
       (4) Additional amendments to title xxi.--
       (A) No cost-sharing for pregnancy-related services.--
     Section 2103(e)(2) of the Social Security Act (42 U.S.C. 
     1397cc(e)(2)) is amended--
       (i) in the heading, by inserting ``or pregnancy-related 
     services'' after ``preventive services''; and
       (ii) by inserting before the period at the end the 
     following: ``or for pregnancy-related services''.
       (B) No waiting period.--Section 2102(b)(1)(B) of the Social 
     Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
       (i) by striking ``, and'' at the end of clause (i) and 
     inserting a semicolon;
       (ii) by striking the period at the end of clause (ii) and 
     inserting ``; and''; and
       (iii) by adding at the end the following:
       ``(iii) may not apply a waiting period (including a waiting 
     period to carry out paragraph (3)(C)) in the case of a 
     targeted low-income pregnant woman.''.
       (c) Effective Date.--The amendments made by this section 
     apply to items and services furnished on or after October 1, 
     2003, without regard to whether regulations implementing such 
     amendments have been promulgated.

     SEC. 3. COORDINATION WITH THE MATERNAL AND CHILD HEALTH 
                   PROGRAM.

       (a) In General.--Section 2102(b)(3) of the Social Security 
     Act (42 U.S.C. 1397bb(b)(3)) is amended--
       (1) in subparagraph (D), by striking ``and'' at the end;
       (2) in subparagraph (E), by striking the period and 
     inserting ``; and''; and
       (3) by adding at the end the following new subparagraph:
       ``(F) that operations and activities under this title are 
     developed and implemented in consultation and coordination 
     with the program operated by the State under title V in areas 
     including outreach and enrollment, benefits and services, 
     service delivery standards, public health and social service 
     agency relationships, and quality assurance and data 
     reporting.''.
       (b) Conforming Medicaid Amendment.--Section 1902(a)(11) of 
     such Act (42 U.S.C. 1396a(a)(11)) is amended--
       (1) by striking ``and'' before ``(C)''; and
       (2) by inserting before the semicolon at the end the 
     following: ``, and (D) provide that operations and activities 
     under this title are developed and implemented in 
     consultation and coordination with the program operated by 
     the State under title V in areas including outreach and 
     enrollment, benefits and services, service delivery 
     standards, public health and social service agency 
     relationships, and quality assurance and data reporting''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2004.

     SEC. 4. INCREASE IN SCHIP INCOME ELIGIBILITY.

       (a) Definition of Low-Income Child.--Section 2110(c)(4) of 
     the Social Security Act (42 U.S.C. 42 U.S.C. 1397jj(c)(4)) is 
     amended by striking ``200'' and inserting ``250''.
       (b) Effective Date.--The amendment made by subsection (a) 
     applies to child health assistance provided, and allotments 
     determined under section 2104 of the Social Security Act (42 
     U.S.C. 1397dd), for fiscal years beginning with fiscal year 
     2004.

     SEC. 5. REVIEW OF STATE AGENCY BLINDNESS AND DISABILITY 
                   DETERMINATIONS.

       Section 1633 of the Social Security Act (42 U.S.C. 1383b) 
     is amended by adding at the end the following:
       ``(e)(1) The Commissioner of Social Security shall review 
     determinations, made by State agencies pursuant to subsection 
     (a) in connection with applications for benefits under this 
     title on the basis of blindness or disability, that 
     individuals who have attained 18 years of age are blind or 
     disabled as of a specified onset date. The Commissioner of 
     Social Security shall review such a determination before any 
     action is taken to implement the determination.
       ``(2)(A) In carrying out paragraph (1), the Commissioner of 
     Social Security shall review--
       ``(i) at least 25 percent of all determinations referred to 
     in paragraph (1) that are made in fiscal year 2004; and
       ``(ii) at least 50 percent of all such determinations that 
     are made in fiscal year 2005 or thereafter.
       ``(B) In carrying out subparagraph (A), the Commissioner of 
     Social Security shall, to the extent feasible, select for 
     review the determinations which the Commissioner of Social 
     Security identifies as being the most likely to be 
     incorrect.''.


[[Page S5969]]




                                       The Secretary of Health

                                           and Human Services,

                                   Washington, DC, April 12, 2002.
     Hon. Jeff Bingaman,
     U.S. Senate,
     Washington, DC.
       Dear Senator Bingaman: Thank you for sharing your views on 
     our new proposal to expand health care coverage for low-
     income pregnant women under the State Children's Health 
     Insurance Program (SCHIP). I believe it is not only 
     appropriate, but indeed, medically necessary that our 
     approach to child health care include the prenatal stage.
       Prenatal care for women and their babies is a crucial part 
     of medical care. These services can be a vital, life-long 
     determinant of health, and we should do everything we can to 
     make this care available for all pregnant women. It is one of 
     the most important investments we can make for the long-term 
     good health of our nation.
       Our regulation would enable states to make use of funding 
     already available under SCHIP to provide prenatal care for 
     more low-income pregnant women and their babies. The proposed 
     regulation, published in the Federal Register March 5, would 
     clarify the definition of ``child'' under the SCHIP program. 
     At present, SCHIP allows states to provide health care 
     coverage to targeted low-income children under age 19. States 
     may further limit their coverage to age groups within that 
     range. The new regulation would clarify that states may 
     include coverage for children from conception to age 19, 
     enabling SCHIP coverage to include prenatal and delivery care 
     to ensure the birth of healthy infants.
       Although Medicaid currently provides coverage for prenatal 
     care for some women with low incomes, implementing this new 
     regulation will allow states to offer such coverage to 
     additional women. States would not be required to go through 
     the section 1115 waiver process to expand coverage for 
     prenatal care.
       By explicitly recognizing in our SCHIP regulations the 
     health needs of children before birth, we can help states 
     provide vital prenatal health care. I believe our approach is 
     entirely appropriate to serve these health purposes. It has 
     been an option for states in their Medicaid programs in the 
     past and it should be made an option for states in their 
     SCHIP program now. As I testified recently at a hearing held 
     by the Health Subcommittee of the House Energy and Commerce 
     Committee, I also support legislation to expand SCHIP to 
     cover pregnant women. However, because legislation has not 
     moved and because of the importance of prenatal care, I felt 
     it was important to take this action.
       I know we share the same commitment to achieving the goal 
     of expanding health insurance coverage in order to reduce the 
     number of uninsured.
       A similar letter is being sent to the cosigners of your 
     letter. Please feel free to call me if you have any questions 
     or concerns.
           Sincerely,
     Tommy G. Thompson.
                                  ____

                                           The Secretary of Health


                                           and Human Services,

                                  Washington, DC, October 8, 2002.
     Hon. Don Nickles,
     Assistant Republican Leader,
     Washington, DC.
       Dear Senator Nickles: Thank you for contacting me about the 
     Department of Health and Human Services' final regulation to 
     expand pre-natal and pregnancy related services to unborn 
     children under the State Children's Health Insurance Program 
     (SCHIP).
       The final rule allows states the option to extend such 
     services under SCHIP to low-income pregnant women and their 
     unborn children immediately. The rule also enables states to 
     cover a broader population of low-income women and children 
     because it extends coverage to unborn children regardless of 
     their mothers' immigrant status.
       In your letter, you ask if ``this regulation has obviated 
     the need for additional legislation, and has addressed this 
     issue in a more timely and effective manner.'' As I have 
     stated many times this year, my overarching goal has been to 
     extend prenatal and pregnancy related services to low-income 
     women and their children as quickly as possible so that those 
     mothers are cared for during their pregnancy and their 
     children are born healthy and strong. The law provided me the 
     flexibility to do that and I believe the rule that was 
     published this week achieves this universally desired goal. 
     The proposed legislation, which has been pending in Congress 
     for some time, would amend the SCHIP law so as to duplicate 
     what we have already established as administration policy. I 
     believe the regulation is a more effective and comprehensive 
     solution to this issue. Therefore, there is no need for the 
     Senate to pursue this legislation now.
       Thank you for inquiring on this important policy matter.
           Sincerely,
     Tommy G. Thompson.
                                  ____



                                                  U.S. Senate,

                                 Washington, DC, October 10, 2002.
     Hon. Tommy Thompson,
     Secretary, Department of Health and Human Services, 
         Washington, DC.
       Dear Secretary Thompson: Over the course of the past year, 
     you have issued press releases, written letters, and 
     responded to direct questions in both Senate and House 
     hearings in support of passing legislation to provide health 
     care coverage to pregnant women through the State Children's 
     Health Insurance Program (SCHIP). You have repeatedly stated 
     that you were proceeding with the regulation to expand SCHIP 
     to ``unborn children'' only because legislation to expand 
     coverage to pregnant women had not passed.
       Your own regulation explicitly makes that very point and 
     acknowledges that ``gaps remain'' and that a number of 
     important health services for pregnant women, including 
     postpartum care, are not provided for in the regulation. And 
     yet, we now read in a letter from you to Senator Nickles 
     dated October 8, 2002, that the ``gaps'' have somehow 
     disappeared. As you write, ``The proposed legislation, which 
     has been pending in Congress for some time, would amend the 
     SCHIP law so as to duplicate what we have already established 
     as administration policy. I believe the regulation is a more 
     effective and comprehensive solution to this issue. 
     Therefore, there is no need for the Senate to pursue this 
     legislation now.''
       Yet, your own regulation contradicts that statement and 
     notes that ``there are still gaps'' and repeatedly points out 
     those coverage gaps for pregnant women and children. With 
     respect to care for women, under the regulation, it is 
     explicitly stated that ``there must be a connection between 
     the benefits provided and the health of the unborn child.'' A 
     whole range of health services to pregnant women during 
     pregnancy and delivery could be potentially denied as a 
     result. In the case of epidurals, for example, the best the 
     regulation can say is that you ``expect'' coverage.
       For postpartum care, the regulation explicitly states that 
     any care during that period, including but not limited to 
     hemorrhage, infection, episiotomy repair, C-section repair, 
     family planning counseling, treatment of complications after 
     delivery (including life-saving surgery), and postpartum 
     depression, would be denied. As the regulation reads, 
     ``Commenters are correct that care after delivery, such as 
     postpartum services could not be covered as part of [SCHIP], 
     (unless the mother is under age 19 and eligible for SCHIP in 
     her own right), because they are not services for an eligible 
     child.''
       According to the Centers for Disease Control and Prevention 
     (CDC), the United States ranks 21st in the world in maternal 
     mortality. The major causes of which were hemorrhage, ectopic 
     pregnancy, pregnancy-induced hypertension, embolism, 
     infection, and other complications of pregnancy and 
     childbirth. Again, health coverage for many of these 
     conditions is denied under the regulation but not in S. 724. 
     How then do you argue the regulation is ``more effective and 
     comprehensive'' and that the legislation is ``duplicat[ive]'' 
     of the regulation with respect to care for pregnant women?
       With respect to coverage of children, under the regulation, 
     the 12-month continuous eligibility for children is not from 
     the time of birth but the clock begins running during the 
     time of coverage prior to birth. S. 724 provides 
     comprehensive pediatric care to children throughout the first 
     and most fragile year of life. In contrast, for prenatal care 
     delivered to an ``unborn child'' under this regulation, that 
     time is subtracted from the 12-month period after birth. 
     Therefore, under the regulation, if nine months of prenatal 
     care are provided, the child could lose coverage at the end 
     of the 3rd month after birth. Potentially lost would be a 
     number of important well-baby visits, immunizations, and 
     access to their pediatric caregiver. Once again, how then do 
     you argue the regulation is ``more effective and 
     comprehensive'' and that the legislation is 
     ``duplicat[ative]'' to the regulation for children?
       Furthermore, according to the rule, the Administration 
     estimates that only 13 states will elect to adopt this 
     definition to include ``unborn children'' in their SCHIP 
     state plans. The other 37 states will either not expand SCHIP 
     to provide prenatal care to additional populations or be 
     forced to seek a federal waiver to also cover pregnant women, 
     as Colorado did just two weeks ago. However, the regulation 
     was right on the mark in stating that it is ``an inferior 
     option'' to require states to have to get waivers to provide 
     the full range of care to pregnant women and 12-month 
     continuous eligibility for children after birth.
       As the regulation reads, ``. . . the Secretary's ability to 
     intervene through one mechanism (a waiver) should not be the 
     sole option for States and may in fact be an inferior option. 
     Waivers are discretionary on the part of the Secretary and 
     time limited while State plan amendments are permanent, and 
     are subject to budget neutrality.'' For a third time, how can 
     you now argue, less than a week after issuing the regulation, 
     that it is ``more effective and comprehensive'' than the 
     legislation?
       The States agree, as you know. The National Governors' 
     Association has clear policy expressing support for the 
     passage of such legislation. As their policy position (HR-15. 
     ``The State Children's Health Insurance Program (S-CHIP) 
     Policy'') reads:
       ``The Governors have a long tradition of expanding coverage 
     options for pregnant women through the Medicaid program. 
     However, pregnant women in working families are not eligible 
     for SCHIP coverage. The Governors call on Congress to create 
     a state option that would allow states to provide health 
     coverage to income-eligible pregnant women under SCHIP. This 
     small shift in federal policy would allow states to provide 
     critical prenatal care and would increase the likelihood that 
     children born to SCHIP mothers would have a healthy start.''

[[Page S5970]]

       Finally, unlike S. 724, the regulation provides absolutely 
     no additional resources (despite estimating the cost to be 
     $330 million over the next five years) for covering ``unborn 
     children'' and certain pregnancy-related services. Current 
     projections by the Office of Management and Budget indicate 
     that SCHIP funds will ultimately be inadequate to cover all 
     the children currently enrolled, even though millions of 
     additional children are eligible but not currently covered. 
     In sharp contrast, just as S. 724 does, we must provide 
     adequate resources to serve both low-income children and low-
     income pregnant women.
       Mr. Secretary, just as you said in your press release on 
     January 31, 2002, we also praise Senators Bond, Breaux, and 
     Collins for ``bipartisan leadership in supporting S. 724, a 
     bill that would allow states to provide prenatal coverage for 
     low-income women through the SCHIP program. We support this 
     legislative effort in this Congress.'' We agreed with you on 
     January 31, 2002, and hope that you will once again support 
     the passage of S. 724, the ``Mothers and Newborns Health 
     Insurance Act.''
       We eagerly await your response to this very important 
     matter with respect to the health and well-being of our 
     nation's children and mothers.
           Sincerely,
         Jeff Bingaman, Jon Corzine, Edward M. Kennedy, Maria 
           Cantwell, Hillary Rodham Clinton, Dianne Feinstein, 
           Blanche L. Lincoln, Mary Landrieu, Patty Murray, James 
           M. Jeffords, John B. Breaux, Jack Reed, Patrick J. 
           Leahy, Barbara A. Mikulski, Charles E. Schumer.
                                  ____

                                           The Secretary of Health


                                           and Human Services,

                                 Washington, DC, October 15, 2002.
     Hon. Jeff Bingaman,
     U.S. Senate,
     Washington, DC.
       Dear Senator Bingaman: Thank you for your letter of last 
     week and your continued interest in finding effective ways to 
     increase prenatal coverage.
       I have frequently stated in the past that my chief 
     objective in proposing the rule to extend coverage to unborn 
     children was to ensure that pregnant women and children who 
     are currently ineligible for health care under either 
     Medicaid or S-CHIP are given the support they need for a 
     healthy pregnancy and a safe delivery. This is clearly a goal 
     we share. When asked my position on pending legislation 
     earlier this year, I expressed general support because my 
     overriding interest and concern has always been to provide 
     prenatal care to more women and children. If legislation 
     could provide that coverage more expeditiously, then it 
     seemed to me it would be advantageous to women and children 
     to see that go forward.
       However, despite years of committed effort by you and other 
     members, Congress has yet to move legislation through the 
     process. Legislation was introduced in the 106th Congress but 
     was never reported out of Committee in either the House or 
     Senate. In this current Congress, the Senate Finance 
     Committee reported S. 724 in early August of this year, but 
     no floor time was scheduled for its consideration. 
     Consequently, after seven months without any legislative 
     action, I issued a final regulation.
       Last year, when I saw that I had the authority under 
     current law to provide prenatal and delivery care to low-
     income pregnant mothers and their unborn children, I was 
     excited because I realized the Department could accomplish 
     what we all wish to achieve: helping those children get a 
     healthy start in life. A great deal of thought went into the 
     regulation and, with the exception of postpartum care after 
     hospitalization, we were able to give the states the same 
     flexibility the would have under the proposed legislation to 
     provide prenatal and delivery care to unborn children and 
     their mothers.
       Under current law, however, we have the authority to grant 
     waivers that include coverage for women if they become 
     pregnant, including postpartum care. Since January 2001, I 
     have granted approval to a number of states to allow for 
     expanded health insurance coverage through comprehensive 1115 
     waivers, which also include postpartum care. In fact, this 
     summer I approved a waiver for New Mexico which included 
     prenatal care, labor and delivery, and postpartum care. This 
     regulation simply adds to the options available to the states 
     in expanding health insurance coverage.
       In addition to making it possible for states to use federal 
     funds to provide the prenatal and pregnancy-related coverage 
     options available under S. 724, the regulation provides 
     additional opportunities and assistance for states to reach 
     low-income women. For example, under the regulation, we were 
     able to reach an even broader population of vulnerable women 
     and children because we could offer prenatal care to the 
     children of immigrants who are otherwise ineligible for any 
     coverage. The establishment of eligibility regardless of 
     immigrant status is possible under the regulation but not 
     under S. 724, making the regulation more comprehensive. I am 
     sure you appreciate the importance of the new opportunity to 
     provide prenatal care and pregnancy-related services to 
     immigrant mothers, given the substantial immigrant population 
     in New Mexico.
       Additionally, the regulation provides more opportunities 
     for states to access enhanced-match funds than S. 724. Under 
     the bill, states with current eligibility levels for pregnant 
     women below 185 percent of poverty would not be eligible for 
     the enhanced match until they raised their eligibility at 
     their regular match rate. States have already had the option 
     to raise eligibility for pregnant women at their regular 
     match rate, but many have not done so. Thus, we expect that 
     many states will not expand prenatal coverage under S. 724. 
     However, access to enhanced-match funds under the regulation 
     will provide them a more affordable opportunity to do so.
       With regard to specific criticisms of the rule, you have 
     raised concerns about the reference in the S-CHIP regulation 
     to ``gaps.'' It is important to put the use of the term 
     ``gaps'' in the proper context. This reference is to the 
     eleigbility gap between Medicaid and S-CHIP, which the 
     regulation and S. 724 both seek to close. The response in the 
     regulation does not refer to benefits, so the reference in 
     your recent letter that ``gaps remain'' is taken out of 
     context and, in fact, an incorrect referencing of the 
     regulation.
       Under both the regulation and the legislation, the states 
     ultimately determine the benefit package. That feature of 
     your legislation does not differ from the rule. And, we have 
     clearly indicated federal funds will be available for 
     services including prenatal care and labor and delivery. Your 
     letter makes assumptions regarding medical services during 
     pregnancy and delivery that HHS does not. The letter confuses 
     medical decisions that are made by physicians with payment of 
     claims under a public assistance program. The regulation is 
     used to establish eligibility for benefits and does not 
     itself extend into medical decision-making between a woman 
     and her physician. HHS responded to a number of questions 
     regarding services and clearly indicated federal financial 
     participation would be available. There is no need to further 
     question whether a claim for a service already provided will 
     receive federal matching funds.
       The issue of 12 months continuous eligibility is an option 
     for the states. Under the regulation, states that want to 
     extend eligibility can easily do so.
       I hope this explanation of the regulation and where it 
     extends beyond the reach of S. 724 will give you confidence 
     in our policy and it's ability to meet the ultimate goal that 
     you and I have worked over the years to meet. You are due a 
     large measure of credit for your efforts on behalf of low-
     income women and their children. The regulation is a victory 
     for those women and children and will give otherwise 
     uncovered needy mothers and their babies a healthy start in 
     life.
           Sincerely,
     Tommy G. Thomspon.
                                  ____



                                                  U.S. Senate,

                                 Washington, DC, October 23, 2002.
     Hon. Tommy Thompson,
     Secretary, Department of Health and Human Services, 
         Washington, DC.
       Dear Senator Thompson: Thank you for your letter yesterday 
     with regard to improving health coverage for pregnant women 
     and children. We appreciate your stated desire to ``give 
     otherwise uncovered needy mothers and their babies a healthy 
     start in life'' by adding ``to the options available to the 
     states in expanding health insurance options.'' We believe we 
     can take the best aspects of the legislation and the 
     regulation to truly improve the health and well-being of our 
     nation's children and mothers.
       In light of the fact that our nation ranks 26th in infant 
     mortality and 21st in maternal mortality in the world, which 
     is the worst among developed nations, we would be remiss to 
     not take the simple but critical step of increasing access to 
     prenatal, delivery, and postpartum care through the State 
     Children's Health Insurance Program (SCHIP) to help prevent 
     birth defects and prematurity, the most common causes of 
     infant death and disability, and maternal death and 
     disability.
       As your letter acknowledges, postpartum care is not covered 
     under the regulation. This gap in coverage includes a range 
     of critical care for women, including potentially life-saving 
     postpartum care for hemorrhage, pregnancy-induced 
     hypertension, infection, ectopic pregnancy, embolism, 
     episiotomy repair, Caesarean section repair, family planning 
     counseling, postpartum depression, and other complications of 
     pregnancy and childbirth. In fact, according to the National 
     Committee for Quality Assurance (NCQA), ``Hemorrhage, 
     pregnancy-induced hypertension, infection, and ectopic 
     pregnancy continue to account for more than half of all 
     maternal deaths (59 percent).''
       According to the Centers for Disease Control and Prevention 
     (CDC), there were 3,193 pregnancy-related deaths in this 
     country between 1991 and 1997 for an overall pregnancy-
     related mortality ratio (PRMR) of 11.5 per 100,000 live 
     births. Racial disparities are rather dramatic with respect 
     to maternal mortality. African-American women had mortality 
     rates over four times higher than that of non-Hispanic whites 
     over the period. American Indian/Alaska Natives, Asian/
     Pacific Islanders, and Hispanic women had mortality rates 67 
     percent, 55 percent, and 41 percent, respectively, higher 
     than non-Hispanic whites.
       Those disparities are even more pronounced in some states. 
     For example, in Wisconsin, the maternal mortality rate for 
     African-American women was 4.2 times that of white women 
     between 1987 and 1996. Certainly, this is something that we 
     can all agree should be addressed.

[[Page S5971]]

       To allow states the option to provide comprehensive 
     coverage to pregnant women, including postpartum care, 
     through SCHIP would help achieve that important goal. S. 724, 
     the ``Mothers and Newborns Health Insurance Act,'' gives 
     states that important coverage option while the regulation 
     does not.
       While your letter correctly notes that states may receive 
     comprehensive 1115 waivers to provide coverage to pregnant 
     women, your regulation is correct in noting that is an 
     inferior option. As the regulation reads, ``. . . the 
     Secretary's ability to intervene through one mechanism (a 
     waiver) should not be the sole option for States and may in 
     fact be an inferior option. Waivers are discretionary on the 
     part of the Secretary and time limited while State plan 
     amendments are permanent, and are subject to budget 
     neutrality.'' We should remove those barriers and give states 
     the option to provide pregnant women coverage without having 
     to seek waivers.
       We would add that the waiver option is allowed for the 
     purposes of giving the Secretary demonstration authority. We 
     certainly can all acknowledge that coverage of pregnant women 
     has reduced both infant mortality and maternal mortality and 
     need not be demonstrated any further. The waiver process 
     seems inappropriate for this purpose. Instead, we should 
     remove those barriers for states to provide comprehensive 
     coverage to pregnant women. As the National Governors' 
     Association has stated in its policy (HR-15. ``The State 
     Children's Health Insurance Program (S-CHIP) Policy''): The 
     Governors call on Congress to create a state option that 
     would allow states to provide health coverage to income-
     eligible women under SCHIP. This small shift in federal 
     policy would allow states to provide critical prenatal care 
     and would increase the likelihood that children born to SCHIP 
     mothers would have a healthy start.
       Just as the governors have requested, we can still make 
     that ``small shift'' in policy through the passage of S. 724.
       As for the coverage of infants, your letter did not address 
     the issues raised in a previous letter to you from 15 
     senators, including many of us, dated October 10, 2002. Your 
     letter restates the fact that states have the option to 
     provide children 12 months of continuous eligibility in 
     Medicaid and SCHIP. However, under the regulation, the 12-
     month continuous eligibility for children is not from the 
     time of birth. Rather, the clock begins running during the 
     time of coverage prior to birth. Thus, it is likely that most 
     newborns would have far less than 12 months of coverage after 
     birth if a State chooses to use the option to provide care to 
     ``unborn children.'' If covered for the full nine months of 
     pregnancy, the child could lose eligibility for SCHIP after 
     the third month of life and consequently lose important 
     coverage for well-baby visits, immunizations, and access to 
     their pediatric caregiver. That would be an outright 
     reduction of coverage for some children after birth.
       We would note that the legislation continues to have the 
     strong support of a number of groups, including some who 
     support the regulation but acknowledge its shortcomings and 
     continue to support passing legislation. Those groups include 
     the American Association of University Affiliated Programs, 
     the American Academy of Pediatrics, the American College of 
     Nurse Midwives, the American College of Obstetrics and 
     Gynecologists, the American Hospital Association, the 
     American Medical Association, the American Public Health 
     Association, the Association of Women's Health, Obstetric and 
     Neonatal Nurses, the Association of Maternal and Child Health 
     Programs, the Catholic Health Association, Catholic Charities 
     USA, the Council of Women's and Infants' Specialty Hospitals, 
     the Easter Seals, FamilyVoices, the March of Dimes, the 
     National Association of Children's Hospitals, the National 
     Association of Public Hospitals and Health Systems, the 
     National Women's Health Network, the National Association of 
     County and City Health Officials, the Society for Maternal-
     Fetal Medicine, the Spina Bifida Association of America, the 
     Alan Guttmacher Institute, and the United Cerebral Palsy 
     Associations.
       There are certainly areas where the regulation is more 
     comprehensive than the legislation, such as providing 
     coverage to the ``unborn children'' of immigrant mothers and 
     by providing states easier access to enhanced matching funds. 
     We believe we could certainly amend S. 724 to address these 
     shortcomings rather easily. It would be easy to drop the 
     requirement in the bill for a state to expand eligibility to 
     185 percent of poverty before receiving the enhanced matching 
     rate. However, this begs the question about the need for 
     providing additional resources in SCHIP to cover these 
     options. Current projections by the Office of Management and 
     Budget indicate that SCHIP funds will ultimately be 
     inadequate to cover all the children currently enrolled, even 
     though millions of additional children are eligible but not 
     currently covered. S. 724 provides such funding, which the 
     regulation does not and cannot.
       In short, we believe that we can rather quickly achieve the 
     best of both the legislation and the regulation. S. 724 
     expands state options to cover critically important 
     postpartum services for women, ensures children are eligible 
     for coverage throughout the first and most critical year of 
     life, and provides much needed resources to provide such 
     care. In contrast, the regulation provides states with more 
     opportunities to access enhanced matching funds and provides 
     certain prenatal care services to immigrant mothers that S. 
     724 does not provide.
       We would like to arrange a meeting with you or your staff 
     to jointly modify S. 724 to address, as best as we can, the 
     concerns we have discussed above and that you have raised 
     with the legislation to accomplish the objective we all share 
     of improving the health and well-being of out nation's 
     children and mothers.
           Sincerely,
         Jeff Bingaman. Blanche L. Lincoln. Jon Corzine. Maria 
           Cantwell. Patty Murray. Mary Landrieu. James M. 
           Jeffords. Edward M. Kennedy. Hillary Rodham Clinton. 
           Charles E. Schumer. John F. Kerry. John R. Edwards. 
           Daniel K. Akaka. Jack Reed. Robert G. Torricelli.

  Mr. LUGAR. Mr. President, I rise today with my colleague Senator 
Bingaman to re-introduce the Start Healthy, Stay Healthy Act of 2003.
  The United States ranks 26th in infant mortality and 21st in maternal 
mortality in the world, the worst among developed nations. Study after 
study shows that providing prenatal care to pregnant women reduces 
maternal and infant mortality and the incidence of low birth weight 
babies. According to the American Medical Association, ``Babies born to 
women who do not receive prenatal care are four times more likely to 
die before their first birthday.''
  The Start Healthy, Stay Healthy Act of 2003 would significantly 
reduce the number of uninsured pregnant women and newborns by providing 
States with the option to further extend coverage to pregnant women 
through Medicaid and CHIP, to reduce infant and maternal mortality and 
low birth weight babies, and to cover newborns through the first full 
year of life.
  Current federal law allows pregnant women to receive coverage through 
CHIP through age 18--creating a perverse Federal incentive of covering 
only teenage pregnant women and cutting off that coverage once they 
turn 19 years of age. This legislation would eliminate this problem by 
allowing States to cover pregnant women through CHIP, regardless of 
age. This also eliminates the unfortunate separation between pregnant 
women and infants that has been created through CHIP, and is contrary 
to longstanding federal policy through programs such as Medicaid, Women 
with Infants and Children, WIC, Maternal and Child Health, MCH, etc.
  An estimated 4.3 million, or 32 percent, of mothers below 200 percent 
of poverty are uninsured. According to the March of Dimes, ``Over 95 
percent of all uninsured pregnant women could be covered through a 
combination of aggressive Medicaid outreach, maximizing coverage for 
young women through [CHIP], and expanding CHIP to cover income-eligible 
pregnant women regardless of age.''
  Increasing the availability of affordable health care is certainly an 
issue of great importance to our Nation--particularly those who are 
uninsured. While our bill will not solve the problem of the uninsured, 
we believe that helping more pregnant women and babies receive care is 
a significant step in the right direction.
  I ask our colleagues to support the Start Healthy, Stay Healthy Act 
of 2003, and help us take this important step in improving health care 
for the mothers of tomorrow.
                                 ______