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Congress has 11 days before the CHIP nightmare gets very real

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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The stakes of Congress's inability to reauthorize funding for the Children's Health Insurance Program (CHIP) are getting dire.

Congress let the program's funding technically expire at the end of September. States and the feds have been getting by with some creative budgeting to make sure no kids are kicked off the rolls.

But they're running out of options. Now Congress is looking likely to leave town until the new year without permanently extending CHIP's funding, per one Republican lobbyist and a statement from two GOP senators.

A string of reports this week made clear that several states are on the cusp of more dramatic measures. These could mean either kids who become eligible for CHIP aren't able to enroll or, the worst-case scenario, current enrollees lose their coverage.

By the end of January, according to a report released today by the Georgetown University Center for Children and Families, 25 states would run out of CHIP funding. In those states, 1.9 million children would be at risk of losing coverage in the coming weeks.

"Never before has Congress let CHIP funding lapse for this length of time," Joan Alker, the center's executive director, told reporters today. "Families need the peace of mind as they head into this holiday season that their CHIP coverage will be secure."

Getting down to the ground level, the Daily Beast's Gideon Resnick had a great story this week about the situation in Alabama and families suddenly confronted with the possibility that their children could lose coverage:

The [Alabama] department posted a stark warning on its website on Friday telling families of the perilous path ahead—a warning that it plans to reissue on Dec. 28 with formal letters to families like the Johnsons. On Jan. 1, the state will functionally stop accepting children into All Kids, absent Congress reauthorizing funding for CHIP. By Feb. 1, All Kids will have to start disenrolling current enrollees as well. Separately, Alabama has 74,000 other kids enrolled in CHIP via the state’s Medicaid program, Caldwell explained, who would not be impacted by this contingency plan.

[Kristy] Johnson wasn’t even aware of the possibility that her kids may soon lack insurance until she got a phone call on Tuesday morning from Dr. Marsha Raulerson, a pediatrician in Brewton.

“We had no clue,” Johnson said, remembering how she called her husband incredulously saying, “Did you know? What does that mean?”

Read that again: Alabama will effectively freeze CHIP enrollment on January 1, 11 days from today, without congressional action.

"Our phones are ringing off the wall," Alabama CHIP Director Cathy Caldwell told reporters Wednesday. "We have panicked families wondering what in the world they have as options."

Connecticut announced this week that it would end its CHIP program entirely at the end of January unless Congress acts, as the Hill's Rachel Roubein reported.

Ironically, the only action Congress has taken so far has actually accelerated the crisis in one sense. Lawmakers approved a temporary patch earlier this month. It did not create any new funding, but gave the Trump administration more leeway to move CHIP money around.

The result, according to the Georgetown researchers, is that half the states, up from 16 before the so-called patch, will run out of CHIP funding by the end of January.

What now? House Democratic leader Nancy Pelosi suggested today Republicans might propose another temporary patch. CHIP directors warned strongly against such a course, given the way the previous patch started to dry up funding even faster in nine states.

A statement from Sens. Lamar Alexander (R-TN) and Susan Collins (R-ME) announced that their Obamacare stabilization bills won't pass this week and indicated CHIP would also not be dealt with until January, when the short-term spending bill Congress is expected to soon pass expires.

CHIP advocates want the five-year extension that has been agreed to, at least in principle, by top Republicans and Democrats. The deal has been stalled by some partisan bickering over the $8 billion needed to pay for the five-year extension and the GOP's decision to prioritize its tax overhaul.

The plan has been to finally extend CHIP for good in the government spending bill that Congress needs to pass to prevent a shutdown. But the spending talks are a bit of a mess right now, with lawmakers now eyeing this short-term spending extension into January.

In the meantime, we are 11 days away from a state like Alabama freezing enrollment and Congress's inaction having a real effect on some number of American children's ability to access health care.

(Remember: We have good reason to believe the uncertainty of the last few months is already doing real and lasting damage to CHIP's credibility.)

"At some point, states will reach a point of no return," Georgetown CCF's Tricia Brooks told us. "We are reaching that critical point if Congress goes home without taking care of CHIP."

Table of the Day

Georgetown CCF

The state-by-state CHIP stakes. This is where each state stands on CHIP, as they are now just weeks away from running out of funding. Two things to note: CHIP both helps support Medicaid coverage for kids and funds its own separate insurance program. The kids covered by Medicaid may be able to keep their coverage, though at a higher cost to the state. But the kids on a separate CHIP program are most at risk of immediately losing their insurance: 1.9 million at the end of January and 2.9 million at the end of February.

Kliff’s Notes

Today's top news

  • “Ryan and McConnell head for clash over Obamacare”: “McConnell promised moderate GOP Sen. Susan Collins of Maine that he would prop up President Barack Obama’s signature health law in a must-pass, year-end spending bill — so long as she backs tax reform. But Ryan’s more conservative conference is flatly rejecting that idea and urging the Wisconsin Republican to stand firm against his Senate counterpart.” —Rachel Bade and Jennifer Haberkorn, Politico
  • “House GOPers Say Susan Collins’ Health Care Demands Are Dead On Arrival”: “Many Republicans, including Rep. Tom Cole (R-OK), said there is widespread opposition in the House to these policies, which they see as propping up Obamacare. “Our guys do not want to be in the position of upholding a system that we all oppose and that we tried to repeal and did repeal in this chamber. That’s a real problem,” Cole said, before taking aim at Collins.” —Alice Ollstein, Talking Points Memo
  • “Hickenlooper makes emergency plea for lawmakers to extend children’s health insurance program”: “Colorado may use state money to extend the life of a health insurance program for children, as Congress continues to delay reauthorizing the federal funds that normally pay for it.” —John Ingold, Denver Post

Analysis and longer reads

  • “Flurry of Health-Care Deals Reflects Shift Away From Hospitals”: “A recent burst of deal-making among health-care companies is set to accelerate the shift in how and where Americans get medical care—away from hospitals and toward clinics, doctors’ offices, surgery centers and even drugstores.” —Anna Wilde Mathews and Melanie Evans, Wall Street Journal
  • “Bundled Payments: Balancing Incentives, Quality, And Affordability”: “In contrast to a traditional fee-for-service payment, the fundamental principle of bundled payments is that physicians receive a predetermined payment based on the disease they are treating, and possibly on the outcomes of their treatment, but not based on how they treat it. The alignment of financial incentives with high-quality clinical outcomes for patients requires care and foresight.” —Jacquelyn W. Chou, Glenn M. Chertow, Darius N. Lakdawalla, Alon Yehoshua and Vasily Belozeroff, Health Affairs
  • “How Racism May Cause Black Mothers To Suffer The Death Of Their Infants”: “Scientists and doctors have spent decades trying to understand what makes African-American women so vulnerable to losing their babies. Now, there is growing consensus that racial discrimination experienced by black mothers during their lifetime makes them less likely to carry their babies to full term.” —Rhitu Chatterjee, NPR

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