WASHINGTON -- For years, it has been one of the few issues that liberals and conservatives in Congress could agree on: continuing and expanding a state-federal partnership to provide health insurance for children, mainly those of the working poor.
So when senators of both parties reached a compromise this summer and then beat back efforts by House Democrats to triple the program's budget, the measure's many GOP backers thought they had a political victory that President Bush could embrace.
Instead, the issue has become an ideological flash point, and Bush is threatening a veto. In the process, he could create new intraparty turmoil for fellow Republicans who have looked to passage of a bill to brighten an otherwise grim political outlook.
The question will come to the floor of Congress this week, days before the current program is set to expire Sept. 30. At that point, 6 million children, including more than 100,000 in Maryland, could lose coverage.
One snag is cost. Even the final compromise, while far less open-handed than the House wanted, calls for more money. And the White House is trying to draw a tighter line on domestic spending.
The bigger stumbling block has turned out to be ideological. After 10 years of sailing along as a feel-good idea that just about everyone supported, the State Children's Health Insurance Program has suddenly been drawn into the contentious debate about health care in general.
Bush has attacked the compromise bill because it would expand coverage to some middle-class families instead of retaining the plan's original focus on those with low incomes. The bill could lay the groundwork for government-run national health care, he has said.
In effect, the White House says, Democrats see the bill as a way to begin doing for children what Medicare does for the elderly: make medical care a national entitlement.
Democrats and Republicans supporting the expansion answer that their concern is with economic reality. With the cost of family coverage averaging about $12,000 a year, even some parents with middle-class incomes can't afford it if their employers don't help shoulder the cost. And when uninsured children get seriously sick, supporters say, the burden falls on society as a whole.
The program began as an attempt to salvage something positive from the rancorous collapse of the 1990s national health-care reform debate. States got generous federal matching funds and flexibility to design their own coverage.
At first, the program was aimed at uninsured children whose parents earned too much to qualify for coverage under Medicaid but too little to afford private coverage. The goal was to reach families earning up to twice the federal poverty level, now about $41,000 for a family of four. The vast majority covered by the program are still in that category.
But as health-care costs soared, states began to grapple with knowing that many families - especially in urban areas where the cost of living was higher than average - had trouble paying for private health insurance even though they earned more than twice the poverty level.
Fourteen states - including Maryland, where a family of four with an income of up to $61,950 is eligible - have higher eligibility cutoffs. The pending bill would allow states to go to three times the poverty level.
Utah Sen. Orrin G. Hatch, a conservative Republican who was one of the creators of the program, says that is well short of providing what the White House says it fears: government-financed health care for the middle class.
He joined forces with such liberal Democratic senators as Edward M. Kennedy of Massachusetts and John D. Rockefeller IV of West Virginia to push the compromise.
"The administration [is] making it clear they do not want it to be morphed into one-size-fits-all government health care, but to be honest with you, this bill doesn't do that," Hatch said. "I believe the president has had bad advice on this, but I understand the president's desire to keep spending under control."
Funding for the program has run about $5 billion a year. Bush wants to increase it by an average of $1 billion a year during the next five years. Independent analysts say that's not enough to sustain the current caseload.
Congress wants to add $35 billion over five years by raising tobacco taxes. That would sustain the current caseload and also cover 3 million to 4 million more children. About 9 million children are uninsured nationwide.
Bush wants to set a limit, discouraging states from covering uninsured children in families with incomes above $50,000. The administration recently denied a request by New York to extend help to families earning as much as $80,000.
Congress would face an uphill struggle to overturn a presidential veto, Hatch said, and would probably pass a temporary extension of the current program.
Ricardo Alonso-Zaldivar writes for the Los Angeles Times. Sun staff reports contributed to this article.