HARRISBURG, Pa.—When Congress started discussing an expanded children's health-insurance program, aimed at families too rich for Medicaid but too poor for private insurers, Franciscan Sister Clare Christi Schiefer saw the hidden risk.

Sister Clare Christi, president of the Pennsylvania Catholic Health Association, realized that the Children's Health Insurance Program could provide opportunities for pro-abortion groups to get coverage for abortion and contraception for children 18 and under.

The 1997 CHIP legislation provided some federal funds and loose federal guidelines, but allowed each state to design its own program. Sister Clare Christi worked behind the scenes with state legislators to make sure that Pennsylvania's program stuck to pro-life principles.

She met with key legislators and administrators. Due to her advocacy, a 1999 report by the pro-abortion Alan Guttmacher Institute found that Pennsylvania was one of only two states that specifically refused to cover abortion or contraception in the CHIP plan. (The two states, Pennsylvania and Montana, were later joined by Texas.)

The federal CHIP legislation created a complex system that intertwined state and federal funds, Medicaid-based and state-designed plans, and managed care.

In Pennsylvania, prominent Catholic involvement in health care and charitable work helped the pro-life cause: “I did participate in a children's health-care coalition, and they agreed that they would not seek” abortion and contraception coverage, Sister Clare Christi said.

She added, “We're big players in the health care market. We have a lot of schools; we could have done a lot for outreach efforts.”

She explained to legislators that Catholic groups would not recruit children for a program that they considered harmful. Since outreach—getting coverage for previously uninsured children—is a major component of CHIP, losing Catholic involvement would have dealt a real blow to the program.

Mike O'Dea, executive director of the Christus Medicus Foundation, had similar success in Michigan. Michigan's CHIP coverage initially covered abortion, sterilization and contraception, but the state legislature and Gov. John Engler removed sterilization and abortion coverage. O'Dea said he is still working on removing contraception coverage.

Patchwork Coverage

Approximately 20 states still cover both abortion and all forms of contraception. Many states simply expanded their Medicaid plans in order to meet the federal guidelines and, since abortion, contraception and sterilization are covered under Medicaid, they were covered by the CHIP plans as well.

Lynne Flynn, director of Kentucky's Medicaid services for maternal and children's health, explained, “One of the big advantages [of building a Medicaid look-alike program] is that you can use an existing delivery system. You don't have to reinvent from scratch. Most of the programs that got started very quickly were Medicaid look-alikes.”

But that convenience comes at a price: “We do provide coverage for contraception,” Flynn said. Kentucky state law also allows health-care providers to give minors contraceptives without notifying their parents.

As for abortion, Flynn said that Kentucky's coverage follows the Medicaid limits.

Medicaid-based programs can only cover abortions that meet the “Hyde Amendment” conditions: when the pregnancy threatens the life of the mother or is the result of rape or incest. States can expand CHIP abortion coverage if they design their own program and use their own funds.

Then governor of Texas George W. Bush signed a state plan that expanded Medicaid, and therefore expanded abortion and contraception coverage, in order to get the program off the ground quickly. But the Texas Legislature swiftly replaced that program with an alternative plan that did not cover abortion or contraception.

The Guttmacher Institute made a rare attempt at a comprehensive list of states’ plans. The institute found that 12 states used a combination of Medicaid-expansion programs and state-designed programs. The two elements of these combination programs operate under different rules—the Medicaid-expansion portion usually applies to younger and poorer patients, and includes the same abortion and contraception coverage as Medicaid, while the state-designed program typically offers more limited coverage to older patients from family incomes closer to 200% of the poverty line.

According to the Guttmacher Institute, Hawaii and Minnesota's CHIP plans do not cover adolescents. (States can set their own age limits, though virtually all chose to cover children 18 and under.)

Many pro-life advocates say that the CHIP coverage has been able to glide under the radar. “Nobody is telling people that it's in there,” O'Dea said. “Even today, the parents buying the insurance don't know” that their children can get contraception without their consent. He also charged that some health care administrators mistakenly believed that abortion or contraception coverage was necessary to get federal approval.

Keeping It Confidential

“Most people aren't really familiar with what [CHIP] is,” said Michael Janocik, assistant director of the Right to Life Education Foundation of Kentucky. In some states, the program goes by other names, such as KidCare or MedQuest.

The national office of Health and Human Services does not keep a record of state plans’ coverage of abortion, contraception or sterilization, and it also does not keep statistics on how many minors actually use that coverage.

But O'Dea noted, “Every state had to file a document with Health and Human Services in order to be approved for federal funds. I went to our state administrator and got a copy of the document.” He told pro-life advocates in other states, “All they have to do is request that document. It's there.”

O'Dea noted that when parents aren't notified that their children have received contraception or abortions, parents can't hold doctors or legislators accountable.

The Guttmacher Institute's report argued that “even accidental notification of a teen-ager's parents—through routine insurance billing practices, for example—can delay or dissuade a teen-ager from seeking critical, sensitive care and put her at risk for unintended pregnancy, STDs and future infertility.”

But O'Dea noted the health risks involved in abortion and contraception, as well as many parents’ strong convictions that their children should not receive these procedures at all—let alone without parental consent or knowledge.

Eve Tushnet writes from Washington, D.C.