Earlier this week, members of the Senate Finance Committee announced an agreement to extend funding for the Children’s Health Insurance Program. The announcement had been anxiously awaited by families and advocates across the nation, as the program’s federal funding expires in about two weeks. The agreement is good news, but coverage for CHIP’s 8.9 million children isn’t safe just yet.
According to reports, the agreement would extend CHIP’s funding for five years — a win for advocates worried that lawmakers might propose another two-year extension as it did in 2015. The agreement would also maintain the Affordable Care Act’s enhanced CHIP matching rate — a measure that boosted the federal share by 23 percent — for another two years and then begin a phase-down to pre-ACA matching rates. CHIP currently provides nearly 9 million U.S. children with timely access to medical care, covering kids whose families make too much to qualify for Medicaid but not enough to access affordable coverage in the private sector.
While news of the Senate CHIP agreement is encouraging, there are still big questions and concerns. Senate Finance Committee leaders — Sens. Orrin Hatch, R-Utah, and Ron Wyden, D-Ore. — haven’t yet identified how they’ll offset the cost of re-funding CHIP, which is between $5 billion and $10 billion. That omission has some worried that CHIP funding could come at the expense of other critical health funding. Two other big questions: Will members of the House agree to a five-year CHIP extension? And will lawmakers attempt to attach CHIP funding to more divisive measures that could hinder its quick passage?
And quickness is key. Most states set their CHIP budgets months ago, and most made those budgets assuming federal lawmakers would reauthorize CHIP funding at its enhanced rate, according to a recent Kaiser Family Foundation survey of state Medicaid officials. That means if Congress doesn’t follow through on CHIP funding, states will face serious funding shortfalls and officials will be forced to find ways to make up the money gap (not likely) or reduce costs (such as cutting back on services and eligibility). The Kaiser survey found that of the 42 states that provided information on when they will exhaust their current CHIP funds, 10 states said funding will likely run out by the end of 2017. Some states, the survey noted, have statutes on the book that require officials to shut down their CHIP programs if federal lawmakers stop funding CHIP.
Just the fact that lawmakers have allowed CHIP’s funding reauthorization to come down to the wire is unprecedented, said Carrie Fitzgerald, vice president for Children’s Health Programs at First Focus.
“We were hoping and working hard to try to get CHIP done early in the year, but the larger health care debate took precedent and it was impossible to get this going,” Fitzgerald told me. “But it does seem that (lawmakers) know this has to get done and that it will get done. …Still, it’s tough on states. They’re doing the best they can to keep things moving smoothly, but everyone needs to see this done.”
Echoing the Kaiser findings, Fitzgerald said she hadn’t heard from any state officials worried about running out of CHIP funds on Oct. 1 — as far as she knew, none were planning to shut down their CHIP programs or scale back either. In fact, she said state CHIP officials are “trying to walk a fine line” — they want to raise awareness about CHIP’s importance, but they don’t want to worry families during CHIP’s crucial fall enrollment period. But if Congress doesn’t act by the Sept. 30 expiration date, she said it would force states to start considering their options, none of which bode well for children’s health coverage.
“There isn’t another option that’s as affordable and child-specific as CHIP,” Fitzgerald said.
The consequences of Congress’ inaction vary depending on how a state organizes its CHIP program. According to the National Academy for State Health Policy, the ACA requires that Medicaid expansion CHIP programs maintain eligibility levels for kids through 2019, regardless of federal funding. However, the 42 states that run separate CHIP programs can scale back enrollment if federal funds cease.
Eva Marie Stahl, director of the Children’s Health Initiative at Community Catalyst, said if children did begin to lose CHIP coverage, some might find coverage in Medicaid and some may be able to access employer-sponsored insurance (though employer coverage is generally more expensive than CHIP for many working families). Families who lose CHIP could turn to the ACA marketplace, but Stahl said many would face another hurdle known as the “family glitch.” The way the ACA was written, part of eligibility for marketplace subsidies is whether a family has access to affordable employer-based coverage. However, the ACA’s definition of “affordable” employer coverage is based on the cost of covering the individual, not the whole family — hence, the family glitch.
“There’s no question that Congress should move swiftly to refund CHIP and they should cleanly extend it for five years at a minimum — especially with so much uncertainty around other forms of health coverage” Stahl told me. “This program is 20 years old, enjoys bipartisan support and works well. It’s good for keeping children healthy and it’s a really important program for helping working families.”
Across the U.S., more than one in three children are covered by either Medicaid or CHIP — in fact, the two programs have helped drive the children’s uninsured rate to record lows. (The newest Census data puts the 2016 children’s uninsured rate at 5.4 percent.) Medicaid and CHIP typically offer more comprehensive children’s coverage than private insurance, such as covering dental care and myriad services for children with special health care needs. Research finds that children with Medicaid or CHIP coverage have better access to primary care and preventive care than uninsured children and fare just as well as on those two indicators as privately insured kids.
Dennis Cooley, a general pediatrician in Topeka, Kansas, for 37 years, said about 30 percent of his patients get coverage through the state’s combined Medicaid/CHIP program, KanCare. Statewide, more than 73,000 Kansas children get their coverage thanks to CHIP. For many low- and moderate-income Kansas families, CHIP provides affordable care that’s also high-quality care, said Cooley, who chairs the American Academy of Pediatrics’ Subcommittee on Access. For example, CHIP follows Early and Periodic Screening, Diagnostic and Treatment guidelines, which ensure children get appropriate medical and preventive care. In other words, CHIP is designed specifically to support the needs of children, whereas private insurance is typically designed for a more general population.
Cooley said he’s been traveling to Washington, D.C., and talking with legislators about the importance of CHIP for years now — and he agrees that CHIP does enjoy bipartisan support. But he’s still worried.
“Each time, legislators say ‘no one’s against CHIP’ or ‘don’t worry,’” he told me. “But then politics gets involved.”
CHIP’s federal funding officially expires on Sept. 30. For more on CHIP, visit First Focus.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.