The Washington PostDemocracy Dies in Darkness

The Health 202: Will CHIP crumble? States are getting really nervous.

with Paulina Firozi


9 million children and 370,000 pregnant women could see the end to their health insurance, if lawmakers don't act. (Video: Joyce Koh/The Washington Post)

Congress is perfectly illustrating a potential pitfall with the GOP’s idea of capping Medicaid spending. Just look at how it’s neglecting another federal program that covers low-income children.

Never have lawmakers let funding lapse so long for the Children’s Health Insurance Program, a uniquely bipartisan U.S. safety net program that covers about 9 million low-income children and pregnant women. It’s been two months since the last authorization ran out, and although states had some initial wiggle room in their finances, that window is rapidly closing.

On Friday, Utah posted a notice online saying it probably will run out of CHIP funding by the end of January. Earlier in the week, Colorado notified families that their coverage might end early next year. Arizona, California, Ohio, Minnesota and the District are also nearing the end of their funding, as is Oregon, whose Democratic governor, Kate Brown, has directed the state’s health authority to continue financing CHIP through April out of its reserves.

It’s a situation prompting deep frustration from state authorities, who face the prospect of hundreds of thousands of their residents suddenly losing coverage. Now imagine this same situation, but applied to Medicaid, the program that covers far more Americans — around 70 million.

The reason Congress must reauthorize funding for CHIP is because it’s a block grant program, meaning that states are provided with a set amount of federal dollars instead of an ongoing funding stream (as with Medicaid).

Were Congress to convert Medicaid into block grants, as Republicans tried to do in multiple health-care bills this year, it’s feasible lawmakers might show the same delay in letting funding lapse, throwing states into uncertainty on an even larger scale.

“This is not a good advertisement for the people who want to bring you block grants in Medicaid,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

What’s also befuddling here is that Democrats and Republicans are in agreement to fund CHIP for five years. What they’re divided over is how to pay for it.

Democrats are refusing to sign onto a package passed by the House, which would pay for CHIP by charging higher Medicare premiums to wealthy seniors, shortening the grace period for marketplace enrollees who don’t pay their premiums and redirecting money away from the Affordable Care Act’s public health fund.

In 2007, CHIP funding was technically expired for months as President George W. Bush vetoed two funding bills. The difference then, however, was that Congress tided states over with short-term funding bills.

Brown told me she’s thankful her state has enough of its own resources to shore up CHIP for a while; otherwise, Oregon would be forced to notify people they would be losing their coverage right around the holiday season. The state has one of the largest CHIP populations  in the country; it covers one in every 10 Oregon children.

“That is absurd and bizarre and unacceptable,” Brown told me. “I can’t believe there isn’t more outrage … Congress is neglecting our most vulnerable children.”

Brown has recently held public events to pressure Congress to pass a CHIP bill (although it’s not at all apparent they’re paying attention on the other side of the country). Last week, she visited the Doernbecher Children’s Hospital in Portland, where she met with families who depend on the program for their coverage.

“This level of uncertainty is causing chaos on the ground,” Brown said.

The situation is extra infuriating for health advocates because ensuring kids have insurance is one of the few health-care policies both parties agree on. It’s largely because of CHIP that the rate of uninsured children has fallen to a record low of 4.5 percent. Under match rates boosted by the ACA, the federal government now provides 88 percent or more of every state’s CHIP costs.

“I have tried to look at this with a glass-half-full lens for some time, but it’s getting extremely difficult,” Alker said. “The fact they still haven’t gotten it across the finish line is enormously frustrating.”

Even Texas, a state with one of the highest uninsured rates that has often been slow to embrace coverage-expanding policies, has asked CMS for $90 million in leftover funds so it can delay starting to shut down its program. Texas Health and Human Services spokeswoman Carrie Williams told me that after conversations with CMS last week, the state is fairly confident it will get the extra cash infusion, which will allow it to keep running CHIP through February.

“We’re closely monitoring congressional efforts to reauthorize the program and are hopeful that it will be extended prior to the exhaustion of our current allotment,” Williams wrote.


--Whelp, Senate Republicans couldn't get to 50 votes on health care, but they managed to get there with taxes -- and even had a vote to spare. In the wee hours of Saturday morning, they approved 51 to 49 their $1.5 trillion tax overhaul (making me doubly glad I'm a health not a tax reporter). The measure must still be reconciled with an earlier House-passed version before being sent to President Trump, but it's a huge step for GOP leaders who engaged in a mad scramble to win over hesitant senators at the last minute.

Senate Majority Leader Mitch McConnell told the New York Times over the weekend that all his members were "just more comfortable" with taxes than health care. “Everybody really wanted to get to yes," McConnell told the Times. "There was a widespread belief that this was just a good thing to do for the country and for us politically.”

If you read The Health 202 with any regularity, you know the Senate bill would repeal the ACA's individual mandate to buy health insurance, but it does a lot of other stuff too. Its centerpiece is lowering the corporate tax rate from 35 percent to 20 percent; it also temporarily cuts tax rates for families and individuals until 2025 and kills a number of tax breaks. It would subject fewer people to the estate tax, a levy charged on huge inheritances, but stop short of eliminating that tax altogether.

"The tax package still must clear a couple more hurdles before it can become law," The Post's Erica Werner and Damian Paletta write. "There are numerous differences between the House and Senate versions, ranging from when certain tax cuts expire to how the estate tax is handled, and though none are seen as showstoppers, complications could arise...And the negotiations over the tax bill will proceed as Congress simultaneously faces a Dec. 8 deadline for government funding to expire. Nonetheless, GOP leaders still aim to get a final bill on Trump’s desk before Christmas."

--The tax overhaul could also trigger another health-care element, though -- big cuts to future Medicare spending, if Congress doesn't duck "paygo" rules. If paygo applies, than automatic cuts to mandatory spending would have to take place, including a $25 billion cut to Medicare next year (4 percent of its total spending) and subsequent annual cuts.

But McConnell and top House Republican Paul Ryan (Wis.) pledged in a joint statement Friday to waive the 2010 "paygo" law, saying opponents of their tax overhaul who have been drawing attention to the potential for cuts are making false assumptions.

“Critics of tax reform are claiming the legislation would lead to massive, across-the-board spending cuts in vital programs...This will not happen," McConnell and Ryan said. "Congress has readily available methods to waive this law, which has never been enforced since its enactment. There is no reason to believe that Congress would not act again to prevent a sequester, and we will work to ensure these spending cuts are prevented."

--Hmmm. Congress has rammed major legislation through Congress down partisan lines. Sound familiar? For years, Republicans have criticized Democrats for using that approach to passing the 2010 ACA Yet when given the opportunity, they did exactly the same thing to get their tax overhaul across the finish line, my colleague Dave Weigel notes. What's more, Republicans basically made no effort to win over even moderate Democrats who might have been gettable with a little more effort.

"The passage of the Tax Cuts and Jobs Act was often covered as a Republican family drama," Dave writes. "Senate Democrats, 10 of whom face reelection next year in states won by President Trump, made cameo appearances — often when the president campaigned in their states. But even the most gettable Democrats, such as Sen. Joe Manchin III (D-W.Va.), were generally ignored by Republican negotiators as they brought their own party in line. Republicans have admitted as much."


AHH: For the first time in the United States, a woman born without a uterus has delivered a baby. Doctors at Baylor University say the baby was born to a woman who had a successful uterus transplant, making it the first such birth outside a Swedish hospital that pioneered the procedure in 2014, The Post’s Cleve R. Wootson reports. (That was Sahlgrenska University Hospital in Gothenburg, Sweden, where a total of eight babies have been born with the assistance of uterus transplants, per the New York Times.)

The successful transplant and birth are a major step for thousands of women unable to conceive, although Cleve notes that the transplants are meant to be temporary. The transplant gives women enough time to have a child and then the uterus is removed so the woman can stop taking the required immune-suppressing drugs. Baylor’s clinical trial is meant to include 10 woman and eight have received transplants so far, including the new mother. One woman is pregnant, two are trying to conceive and four others had failed transplants and had to have the organs removed.

“To make the field grow and expand and have the procedure come out to more women, it has to be reproduced,” Liza Johannesson, a uterus transplant surgeon who left the Swedish team to join Baylor’s group, told the New York Times. “It was a very exciting birth. I’ve seen so many births and delivered so many babies, but this was a very special one.”

OOF: The group Save My Care has launched this television ad against Sen. Susan Collins (R-Maine) for voting for the Senate tax bill that repeals the ACA's individual mandate. Collins, who had voted against the Senate's previous health-care bills, has said she supports repealing the mandate alone because its penalty is paid predominantly by lower and middle-income Americans. But supporters of the health-care law are outraged because the Congressional Budget Office has said 13 million fewer Americans would choose to get coverage without the mandate.

OUCH: Residents of Albemarle, Va., which includes the college town of Charlottesville, are seeing the biggest premium spikes in the country on the Obamacare marketplaces -- and they're directly feeling the pain because many of the town’s residents are people who buy their own insurance plans and earn too much money to qualify for federal subsidies.

The Wall Street Journal’s Stephanie Armour reports some area residents have grouped together, writing letters to lawmakers and starting a Facebook page to urge Congress not to repeal the individual mandate and to approve cost-sharing subsidies that help offset costs for lower-income consumers. They have access to only one insurer – Optima Health -- after other insurers exited this year under heavy losses.

Residents told the Wall Street Journal they are making a personal plea to lawmakers. Before the overnight vote late last week, a few people drove to Capitol Hill to talk to staffers of Virginia members.

“People feel we’re victims in a really ugly political game,” 38-year-old Ian Dixon told the Journal. Dixon, an app developer in Charlottesville, said he will see his premiums for his family of four spike from $988 a month to $3,158 a month. “We have to take this up to Capitol Hill,” he said. 

--A few more readables from The Post and elsewhere:

A Radical Move: Giving Up Income to Get Health Insurance (The New York Times)

Senate’s huge tax bill would have potent ripple effects for health-care system (Amy Goldstein)

GOP Medicaid work rules imperil care for opioid abusers (Politico)


What the opioid epidemic looks like on the screen of a brain scan (Sandra Block)

'The Woebot will see you now' — the rise of chatbot therapy (Amy Ellis Nutt)

A model tattooed her eyeball purple. She now could lose her eye. (Amy B Wang)


Why a CVS-Aetna Merger Could Benefit Consumers (New York Times)


POST PROGRAMMING: The Washington Post will gather top health officials, practitioners, thought leaders and advocates for a discussion about the fight against HIV/AIDS on Tuesday.

Coming Up

  • Axios hosts an event on the new era in health care on Tuesday.
  • Former vice president Al Gore will host a 24-hour live broadcast about climate activism through The Climate Reality Project on today and Tuesday.
  • The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies holds a hearing on addressing the opioid crisis on Tuesday.
  • The Center for Strategic and International Studies will host the launch of OPEC’s World Oil Outlook 2017 on Thursday.
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the “Implementation of the 21st Century Cures Act: Responding to Mental Health Needs” on Wednesday.
  • The Senate Special Committee on Aging holds a hearing on “America’s Aging Workforce” on Wednesday.
  •  The Senate Health, Education, Labor and Pensions Committee holds a hearing on the “Implementation of the 21st Century Cures Act: Progress and Path Forward for Medical Innovation” on Thursday.
  • The House Veterans Affairs Committee holds a hearing on the VA Medical Surgical Prime Vendor Program on Thursday.

GOP 'optimistic' as tax bill heads to conference:

GOP senators brushed off concerns about the tax bill's impact on the national debt and discussed the corporate tax rate on Dec. 3, as it heads to conference. (Video: Jenny Starrs/The Washington Post)

President Trump takes a victory lap after tax overhaul passes Senate:

Speaking at a fundraising breakfast, President Trump touts the tax cut vote in the Senate, saying "It's the largest tax decrease in the history of our country by far -- it's not even close." (Video: Reuters)

"Saturday Night Live" addressed Michael Flynn's cooperation in the Russia probe and the new allegations of sexual misconduct against powerful men:

"Saturday Night Live" addressed Michael Flynn's cooperation in the Russia probe and the new allegations of sexual misconduct against powerful men Dec. 2. (Video: Elyse Samuels/The Washington Post)

Australian politician Tim Wilson asked his longtime partner to marry him during a speech on same-sex marriage:

Australian politician Tim Wilson asked his longtime partner to marry him during a speech on the same-sex marriage debate on the House floor on Dec. 4. (Video: Reuters)