WASHINGTON - President Barack Obama and his congressional allies took a modest step toward reshaping the nation's health care system yesterday as the Senate passed legislation to expand health insurance for children.
But rather than building momentum for the sweeping health care reform that Obama has promised, the victory on Capitol Hill - a largely party-line 66-32 vote - marked a rocky start for what many hope will be the biggest reform campaign in a generation.
"To start out the year on this note does not bode well for future health care discussions, including health reform," Sen. Orrin G. Hatch, a Utah Republican, warned colleagues as the Senate debated the children's health insurance bill, which would enlarge the current program for helping children of the so-called working poor.
Like Wednesday's battle over the economic stimulus package, expansion of the State Children's Health Insurance Program became engulfed in a partisan struggle.
The stimulus debate also showcased several skirmishes among interest groups, despite the consensus that seemed to be developing among many around health reform last year.
Business and consumer groups scuffled over federally subsidized health insurance for jobless Americans in the stimulus package. Insurers faced off with privacy advocates over access to patients' electronic health records, which the stimulus bill would promote.
And foreshadowing what will likely be a much larger debate, Republicans rebelled at Democratic moves to expand the federal government's role in providing health insurance.
Just nine GOP senators backed the children's health insurance bill yesterday, nine fewer than backed similar legislation in 2007.
The current bill - which parallels one approved in the House two weeks ago - would cover an additional 4 million children at an estimated cost of nearly $33 billion over the next 4 1/2 years.
SCHIP, as the program is called, helps states provide health insurance for families that earn too much to qualify for Medicaid, the federal medical insurance program for the poor, but not enough to buy private insurance.
In the past, the program has enjoyed extensive bipartisan support, though Democrats and Republicans have differed over how much families could earn before their children became ineligible.
State rules vary, but some cover children in families with incomes more than twice the federal poverty line, which is $21,200 for a family of four.
In Maryland, state officials and health care advocates cheered the Senate's passage of the program, saying it would extend coverage to more needy children.
The SCHIP expansion is expected to mean $184 million for Maryland this year, $18 million more than state officials had budgeted for the program, according to estimates from the state Department of Health and Mental Hygiene.
Today, about 110,000 children are enrolled in Maryland's program, which covers children in families earning up to three times the poverty limit, or $66,200 for a family of four.
"This reauthorization will ensure us the ability to continue this program and allow for modest growth," said John M. Colmers, secretary of the Maryland Department of Health and Mental Hygiene. At a time when the economy is faltering, the kind of protection it affords children is essential."
The legislation includes expansion of health care to legal immigrant children. While this is new in the federal legislation, Maryland has been providing coverage to such residents for years, using state money. Now, the state can use matching federal funds to provide that coverage, said Vincent DeMarco, president of Maryland Citizens Health Initiative.
"That's wonderful," he said. "It's good for Maryland and it's also good for legal immigrant children elsewhere who haven't had it before."
DeMarco said the legislation is a sign that the new administration will place health care expansion and reform in the forefront.
"It is a wonderful symbol that this is going to be one of the first actions of the Obama administration," he said. "This is a sign of change in Washington."
Baltimore Health Commissioner Joshua M. Sharfstein called SCHIP "a pillar of access to care for kids in Baltimore."
"Strengthening the program is just a great step forward," he said. "It sends a really strong message that we are in a different world where the country's leaders are really supporting critical public health issue."
Advocates of overhauling the whole health care system had hoped broad support for SCHIP would pave the way for similar consideration of the larger health care issues.
But the largely party-line votes on SCHIP and the stimulus raised the prospect that the health care overhaul promised by Obama this year may soon become a one-party exercise.
Several senior Democrats seemed unconcerned by that possibility.
"You try to get bipartisan support," said Rep. Henry A. Waxman, a California Democrat who chairs the powerful House Energy and Commerce Committee. "But if they don't want to be for it, that's their choice. They'll have to answer to their voters."
Other Democrats noted that bipartisan discussions about broader health legislation are continuing.
"This is going to work out well," said Senate Finance Committee chairman Max Baucus, a Montana Democrat and one of the leading architects of planned heath reform legislation.
Baucus and other Democrats have been meeting regularly with Senate Republicans to talk about health care reform for months, as have a host of interest groups, including insurers, doctors, hospitals, business leaders and consumer advocates.
"Health care reform will be on a different track," said Ron Pollack, head of Families USA, an influential consumer group that has led efforts to build consensus around the current reform campaign.
With control of the White House and commanding majorities in the House and Senate, Democrats need only a handful of GOP votes in the Senate to push through their agenda.
But many advocates believe that major health care reform will need substantial GOP support to endure, much as Medicare has since it passed four decades ago with substantial bipartisan support.
In contrast, the Medicare drug benefit, which Republicans pushed through in 2003 on a largely party-line vote, has been fiercely debated since and remains a top target for some Democrats.
"Nobody wants ... to see reform get repealed," said Karen Ignagni, president of America's Health Insurance Plans, an insurance industry lobbying group that has been intensely involved in the current health reform talks.
Baltimore Sun reporter Kelly Brewington contributed to this article.