THE PROGNOSIS

It didn’t have to be this way.

Yet one of the most bipartisan programs in the government's safety net — providing health insurance for 9 million low-income kids — is caught in the middle of the knockdown, drag-out spending battle on Capitol Hill that could lead to a government shutdown at midnight today. CHIP expired in October, but a temporary funding extension won't completely turn off the federal spigot until March.

Let’s lay out the reality upfront: Congress could reauthorize the Children’s Health Insurance Program at this very moment using legislation on which lawmakers have already agreed. And they could even save money in the process.

But that's not going to happen. CHIP has become just too valuable of a Republican bargaining chip as the GOP seeks a funding agreement devoid of the very thing Democrats demanded: legal protections for young, undocumented immigrants known as "dreamers."

It’s been 111 days since CHIP technically expired. We are just weeks away from states running dry on funds to pay health benefits for poor children and pregnant women who would not otherwise be able to afford insurance. Democrats and Republicans previously have not had problems unifying around CHIP, but events over the past few months have led things to an extraordinary brink for something pretty much everyone agrees is a worthwhile government program.

How on earth did we get here? Some of the problem's roots are in the general government dysfunction around the budget process that has been brewing for years, but seems to have gotten even worse during one-party GOP rule in the chaotic Trump administration.

But the problems surrounding CHIP precede this current mess and there's enough blame to lay on the doorstep of both parties.

The reason that Republicans decided to reauthorize CHIP within a broad government funding bill is because Democrats refused to support the GOP's proposed ways of paying for it. Last fall, a five-year reauthorization was going to cost $8.2 billion. The thought was that rolling CHIP into a year-end spending bill would solve the problem because Congress could lump it in with a bunch of other priorities for which they were seeking to pay through offsets.

Two things have changed since then:

1. Congress was only able to pass a short-term spending bill in December (which included only a temporary funding infusion for CHIP), which is why we’re facing another deadline today.

2. Republicans’ elimination in their tax overhaul package of the individual mandate for Americans to buy health coverage or pay a fine led to a surprising and unexpected effect: It makes CHIP reauthorization way, way cheaper (I explained the wonky details in this Health 202). In fact, if lawmakers were to reauthorize the program for at least six years, they would save $980 million. Re-upping it for a decade would save $6 billion, the Congressional Budget Office has said.

That all means that there really is no financial obstacle standing in the way of passing a long-term CHIP renewal -- only a political one to try and lure Democratic votes in order to keep the government open.

Here’s the key question: Will the strategy work? So far, it doesn't look like it.

As usual, President Trump hasn’t made things easier for Republicans. Yesterday, the president made it obvious with a tweet that he misunderstood his own party's approach to CHIP and the spending bill more generally.

The president apparently thought the phrase “short-term” applied to the CHIP reauthorization instead of just the spending bill containing it:

Trump's tweet led to widespread confusion around the Internet. Rodney Whitlock, vice president of health policy at ML Strategies: 

The Post's Aaron Blake: 

My colleague Aaron Blake describes the president as a "congressional arsonist" in this piece breaking down the drama his tweet caused.

Republican leaders rushed to clarify the situation, reiterating their intent to fund CHIP long term even if it’s in a short-term funding bill. House Speaker Paul Ryan (R-Wis.) said after speaking with Trump on Thursday morning that he was sure the president “fully supports passing what we’re bringing to the floor.”

 

No. 2 Senate Republican John Cornyn (R-Tex.) sought to make things crystal clear:

Politico's Eliana Johnson and Burgess Everett have some interesting if unsurprising background on what could have prompted Trump's destabilizing CHIP tweet: The GOP CHIP deal  "had been discussed at length on "Fox & Friends," the president’s favorite morning television program, in the hour before he sent the missive — and the aides immediately suspected that something on the program had prompted it." 

 But Democrats are so far not budging in refusing to support the short-term spending bill -- though to be clear, CHIP isn't the reason.

“This is like giving you a bowl of doggy doo, put a cherry on top and call it a chocolate sundae,” House Minority Leader Nancy Pelosi (D-Calif.) told reporters yesterday.

Late last night, Ryan overcame threats of an internal revolt and passed a short-term funding extension, The Post's Mike DeBonis, Ed O'Keefe and Erica Werner report. Yet there's still the strong possibility of a shutdown after Senate Democrats rallied against the House proposal because it doesn't protect "dreamers," young illegal immigrants brought into the country as children whose protections are expiring at Trump's behest.

"By Thursday evening, nine Senate Democrats who had voted for a prior spending measure in December said they would not support the latest proposed four-week extension, joining 30 other Democrats and at least two Senate Republicans — and leaving the bill short of the 60 votes needed to advance," my colleagues write.

Senators of both parties voted to open debate on the House bill late last night. But Senate Minority Leader Chuck Schumer (D-N.Y.) instead proposed a spending extension that would last just a few days, while Republican leaders rejected that suggestion but didn't lay out a Plan B to pursue if the House bill is ultimately rejected.

(As an aside, here's HHS' most recent contingency plan in case of a government shutdown. And here's a graphic from The Post showing which federal employees would be furloughed.)

Republicans are now mounting a concerted effort to blame Democrats for the dire CHIP situation in the same way Democrats spent the past few months heaping blame on Republicans for not renewing the program long-term (even though Democrats disagreed with the GOP's strategy to pay for a renewal).

It’s the typical blame game on Capitol Hill that isn’t going to let up until the program eventually gets funded (see below). But there are real consequences for women and children if the impasse doesn't get solved soon.

Senate Majority Leader Mitch McConnell (R-Ky.): 

Sen. Orrin Hatch (R-Utah): 

Sen. Kamala Harris (D-Calif.): 

Rep. David Price (D-N.C.): 

MSNBC's Chris Hayes: 

AGENCY ALERT

— There's a new conscience and religious freedom division at the Department of Health and Human Services aimed at protecting doctors, nurses and other health-care workers who decline to participate in care that violates their moral or religious convictions, The Post's Ariana Eunjung Cha and Juliet Eilperin report. The new initiative represents the Trump administration's latest effort to elevate religious liberty claims when such personal beliefs come into conflict with certain types of medical care. 

At a rollout event yesterday at the Humphrey Building, acting HHS secretary Eric Hargan noted many of the nation's hospitals, clinics and hospices are run by faith-based groups — and many have found themselves forced to provide services or referrals that violate what they believe. “For too long, too many of these health-care practitioners have been bullied and discriminated against,” he said.

HHS Civil Rights Director Roger Severino, whose office will house the new initiative, told Ariana and Juliet it would not only consider complaints that might have previously languished but engage in public education and, possibly, policymaking. He said there has been a “pretty dramatic uptick” in health-care workers’ complaints related to moral and religious beliefs — from 10 during the previous administration to 34 since Trump’s election. He said a “career senior executive” would be appointed to investigate those issues and would be at the same level as the person who oversees health privacy for his office, “creating parity with other civil rights.”

“We are trying to signal to the world that we are open for business, and we hope to have an effect,” Severino said.

Conservatives and Republicans were thrilled. The Family Research Council: 

House Majority Leader Kevin McCarthy (R-Calif): 

Antiabortion group Susan B. Anthony List:

Not so much for liberal groups and abortion-rights activists. From NARAL: 

Center for Reproductive Rights: 

Human Rights Campaign's Charlotte Clymer: 

From the ACLU:

--The “conscience protections" promoted by the new office have become a flash point in culture war debates, especially about contraception and LGBT rights, my colleague Sarah Pulliam Bailey reports. While many religious liberty watchdog groups on the right see the new HHS office as a big win, others cite concerns that religious freedom is becoming a partisan issue dependent on whoever sits in office.

Michael Wear, who did religious outreach for then-President Barack Obama, said he thinks the Trump administration has done little on religious freedom issues that will have much lasting change. “The next administration could scrap this office their first day in,” Wear told Sarah. “It’s not necessarily putting [religious conservatives] in a better situation when they’re not in a favorable position politically.”

Wear said he would be more excited about the new office if the Trump administration prioritized civil-rights issues more broadly, such as the Voting Rights Act. “In the end, I think this office is going to be a target and more of a political firestorm than anything,” Wear said.

AHH, OOF and OUCH

AHH: Governors across the country are calling for additional resources to fight opioid abuse, nearly three months after Trump declared the opioid crisis a public health emergency. Yesterday, the National Governors Association sent the Trump administration a list of more than two dozen recommendations, the Associated Press’s Geoff Mulvihill reports.

"While progress has been made, the consequences of opioid addiction continue reverberating throughout society, devastating families and overwhelming health care providers, law enforcement and social services," the governors wrote.

The governors requested from the feds increased access to naloxone -- used to reverse the effects of an opioid overdose -- as well as Medicare coverage of methadone treatment for seniors and a requirement that drug prescribers go through substance abuse training. It's the first coordinated and bipartisan response from the governors group since the president's announcement in October -- and takes a more conciliatory tone than the harsh rebuke on Wednesday from ten Senate Democrats, who said Trump was leaving open key administrative positions in agencies tasked with dealing with the opioid crisis, Geoff writes.

OOF: It might be simply the extra paperwork that proves too much of a barrier for Medicaid recipients facing a slew of new requirements to stay enrolled, the New York Times's Margot Sanger-Katz writes. Critics of Kentucky's recently approved Medicaid waiver instituting work requirements on recipients worry that beneficiaries might be unable to find a job or keep it. But they also fret that additional paperwork, as well as some additional mandates, might be the bigger problem, Margot writes. 

For example, many beneficiaries will need to start paying monthly premiums in addition to documenting work hours. They must notify officials if their income changes. A few missed premiums or filings could cost them their coverage, even if beneficiaries continue to work the required number of hours, Margot notes. Research indicates that participation falls when states make their programs more complicated.

“Anyone who has ever forgotten to pay a bill on time, or struggled to assemble all the necessary forms of identification before heading to the D.M.V., is likely to sympathize with how administrative hurdles can stymie someone,” she writes. “But these may be especially daunting for the poor, who tend to have less stable work schedules and less access to resources that can simplify compliance: reliable transportation, a bank account, internet access."

OUCH: "Girthers" refusing to accept the report on Trump's health from his doctor are the biggest losers, political science professor Joseph Uscinski writes for Politico Magazine. Even though Trump is said to be in fine health by a physician who examined him, many of the president’s detractors believe there is a conspiracy afoot to conceal the president’s true deteriorating condition.

To be sure,  theories about Trump's health may seem fair when considering the president's own well-publicized conspiracy theories about President Obama, Hillary Clinton, Sen. Ted Cruz’s (R-Texas) dad, Mexicans, Muslims, refugees, voter fraud and the news media. Yet there's a strategic logic to such theories, Uscinski says: They bind groups closer together, focus attention and motivate action. Which might be why some Democrats are now engaging in unfounded speculation abut Trump's health.

"Electoral losers have a strong incentive—consciously or not—to motivate their co-partisans with a unifying narrative of a terrifying enemy," he writes. "No matter their party affiliation, partisans fall victim to their biases. What counts as conspiracy theory and what counts as facts are determined by our partisan biases as well. Who we view as smart, sane and tethered to facts also depends largely on our party. It looks as though the left will become exactly what they spent the past eight years railing against: a bunch of conspiracy theorists."

--A few more good reads from The Post and beyond:

HEALTH ON THE HILL
The Trump administration’s new policy allowing state work requirements for Medicaid recipients is legally questionable, more than two dozen Democratic senators said Thursday, framing an argument likely to be aired in court.
AP
Brenda Fitzgerald has not appeared before Congress in seven months on the job.
Politico
Vice President Mike Pence publicly threw his support behind efforts to help terminally ill patients access experimental treatments in a Thursday morning tweet.
Stat News
MEDICAL MISSIVES
Since 2003, the percentage of women filling prescriptions for drugs like Ritalin has increased nearly fivefold in some age groups.
New York Times
INDUSTRY RX
Four nonprofit hospital groups, frustrated with common shortages and price spikes that they say have hampered patient care, are joining forces to manufacture and market generic drugs.
Wall Street Journal
DAYBOOK

Our colleague Tory Newmyer's newsletter, Finance 202, will be coming to you with a special edition from the World Economic Forum in Davos next week. Check out his dispatches by signing up here.

Today

  • The 45th annual March for Life takes place in Washington, D.C.

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on “Facing 21st Century Public Health Threats: Our Nation’s Preparedness and Response Capabilities, Part 2” on Jan. 23. 
SUGAR RUSH

House passes spending bill. Senate Democrats threaten to defeat it:

Vice President Pence spoke to March for Life organizers and participants ahead of the pro-life event:

Fact-checking President Trump’s "Fake News Awards:"

Jimmy Kimmel talks about a potential government shutdown and funding CHIP: