In this great country there are problems over which Americans should hang their collective heads in shame, and one of them is that more than 8 million children in the world’s richest nation have no health insurance.

A third of children without insurance for a year do not see a doctor during that time. They are less likely to have poor vision treated, asthma under good control, to attend school, to get immunizations against serious diseases, etc. They are more likely to be hospitalized for chronic diseases. Most of these children have parents who work, but do so in jobs that provide no health insurance. Because private health insurance for a family of four costs about $11,000 a year or more, it is unaffordable for many working families.

The number of uninsured children would be at least 4 million higher but for the State Children’s Health Insurance Program (SCHIP), started in 1997 and up for renewal this year. Between SCHIP and expansions in Medicaid enrollment, the number of uninsured children was reduced every year between 1997 and 2005, while the number of uninsured adults has grown by more than 6 million.

These “good old days” may be over, however. The U.S. Census Bureau recently reported the number of uninsured children increased by almost 360,000 in 2005 (the latest year with available data). It was the first increase in the number of uninsured children in almost a decade. Tight state budgets around the country have reined in SCHIP and Medicaid enrollments, and made many states less aggressive about reaching out to enroll children who would qualify for one program or the other. At the same time the number of Americans whose employer does not provide health insurance for employees’ children has also grown.

The debate about the future of SCHIP has brought into sharp relief many of the most important issues of America’s health care debates, because some of what keeps us from securing health insurance for all adults looks less defensible when the same issues prevent us from insuring children.

One example is the cost of SCHIP. For about $40 billion over seven years, the program has insured 4 million to 6 million children. Maintenance of the program at current enrollment levels will require additional funds, something that would spell its doom if it were anything but a debate about health care for children.

Another example is that the SCHIP debate has centered on the perennial battle over whether subsidized private insurance or government insurance should be preferred in efforts to cover the uninsured. Many SCHIP opponents want private insurance to be promoted by government. But several states now allow SCHIP enrollment for children in families of four with incomes up to $60,000 (three times federal poverty level or FPL), and some want to increase eligibility to children of families earning up to $80,000 (four times FPL).

In the past it would have seemed preposterous that taxpayers-funded government insurance should be used to cover a family making $60,000 to $80,000. But breadwinners in growing numbers of middle-class families have no health insurance provided by their employers. That means millions more families casting about for some way to insure their children. With private insurance premiums topping $11,000 for a family of four and increasing by 10 percent or more a year, and other costs such as mortgages also increasing rapidly, health insurance is becoming a luxury for many typical middle class families, and government programs such as SCHIP are becoming their only alternative.

The SCHIP debate points out a profound change in the United States as it confronts the problem of the uninsured; lack of health insurance is becoming a problem of the American middle class, not just our working poor. That is why SCHIP, which was designed to extend federal health insurance to working poor making too much to qualify for Medicaid, is being extended in some states to the middle class.

The expansion of the ranks of the uninsured into the American middle class is also why many Republicans are caught on the horns of a dilemma over the issue of uninsured children. While many Republican politicians have generally opposed federally funded expansions in health insurance, they are often reluctant to oppose measures that increase health insurance coverage for children, even if those measures are federal programs such as SCHIP. Republicans may be even more uncomfortable if they have failed to address the problem in election years when more and more voters have health care on their minds. Rising numbers of uninsured children after seven years of federal government controlled by a Republican Party that gave wealthy Americans a trillion dollars in tax cuts and has laid claim to being the family values party raises questions about those values, questions Republicans are nervous about facing come November 2008.

Expansion of SCHIP via a model that taxes employers who do not insure workers and uses tobacco tax dollars to subsidize federal or private health insurance for parents up to a certain income on a sliding scale is a path to universal insurance for American children. In that scenario, Medicaid covers the poor, employer insurance covers many other children, and SCHIP could cover the rest. We are so close to doing it that fewer and fewer arguments and opponents can stand in sustained opposition.

The day is coming when no one running for political office in the world’s richest country – the one that says its children are its most precious treasure – will dare to say no to guaranteed health insurance for every child. It’s about damn time.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.