The Washington PostDemocracy Dies in Darkness

The Health 202: CHIP won in the government shutdown. But community health centers did not.

with Paulina Firozi


Congress has finally hauled the health insurance program for low-income kids to dry land, but community health centers are still out at sea.

After an unprecedented 114-day funding lapse, lawmakers voted yesterday to reauthorize the Children’s Health Insurance Program for another six years as part of the spending bill to reopen the government. But while we certainly applaud lawmakers for meeting their CHIP deadline a mere four months after the fact, let’s not forget that Congress has only really done half the job here.

Funding for the nation’s community health centers, which serve one out of every dozen Americans, also technically expired Sept. 30. These centers, which provide a range of services to the low-income population, would lose $3.6 billion this year without renewal by Congress.

It was definitely a surprise that lawmakers allowed the bipartisan CHIP program to go so long without renewal — especially because Democrats and Republicans both typically praise the program and have repeatedly voted overwhelmingly to fund it. But it’s even more shocking to some health-care advocates that Congress has permitted community health center funding to lapse this long.

After all, long-term CHIP funding has run out before (although Congress patched the program with short-term fixes), but community health centers haven't faced the same dilemma. In fact, Republicans would have beefed up community health center funding in their health-care bills last summer by diverting Medicaid dollars from Planned Parenthood clinics.

The word on Capitol Hill is that Congress will tackle funding for community health centers in the next spending bill it takes up three weeks from now. Lawmakers agreed yesterday to fund the government through Feb. 8 after Senate Majority Leader Mitch McConnell (R-Ky.) said he would address the status of young immigrants called “dreamers” who were brought to this country illegally as children, my colleagues Sean Sullivan, Ed O'Keefe and Elise Viebeck reportBut with few details of what that plan might look like, health-center advocates remain worried.

“I am genuinely shocked at how hard it has been to get community health center funding extended,” Eliot Fishman, senior director of health policy at Families USA, told me. “That has been completely uncontroversial for very good reason for a long time.”

The National Association of Community Health Centers:

NACHC Senior Vice President Dan Hawkins said he's “very disappointed” and warned that some of the health centers his group represents have started reducing services — including opioid treatment and prenatal care — because of the uncertainty they face.

“While we have supported and are very pleased that CHIP relief is included, the failure to do the same for health centers leaves them increasingly anxious that many more will face a loss of clinical health professionals, who are seeking other more stable work options, and some are facing closure of their clinic facilities because they cannot sign longer-term lease agreements,” Hawkins said. “This will only get worse if relief is not forthcoming very soon.”

Sen. Bernie Sanders (I-Vt.) pointed to the lack of community health center funding as a reason he voted against yesterday's spending bill. “We're talking about 27 million Americans who will find it harder and harder to get their health care through community health centers because that program has not yet been reauthorized,” Sanders said on the Senate floor.

But for right now, there’s some cause to celebrate. For at least half a decade, The Health 202 won’t have to write again about reauthorizing CHIP.

More importantly, states that cover about 9 million poor children and pregnant moms through the mostly federally funded program won’t need to prepare notices of coverage cancellation or try to scrape together enough state funds to keep going. As of last week, nine states had issued some kind of notification that diminishing funds were threatening the program.

Sen. Sheldon Whitehouse (D-R.I.): 

The GOP strategy to use CHIP as leverage in spending negotiations worked — sort of. Republicans arm-twisted Democrats into reopening the government for three weeks without giving in to their demands for legal protections for young undocumented immigrants. Yet the spending bill lasts only until Feb. 8. At that point, both parties will have to return to the negotiating table — and Republicans will no longer have CHIP funding in their back pocket.

Some judged it a pretty good deal for Dems. Bloomberg's Joe Weisenthal: 

Economist Paul Krugman: 

HuffPost's Matt Fuller: 

Democratic Coalition co-founder Scott Dworkin: 

But some argued Democrats still got the short end of the stick. Daily Caller's Benny Johnson: 


AHH: Vermont has become the ninth state in the nation allowing recreational use of pot, but the first to approve it legislatively. Yesterday, the state's Republican Gov. Phil Scott signed a bill legalizing the possession and consumption of marijuana for recreational use, The Post's Christopher Ingraham and Tauhid Chappell report. But unlike the other eight states allowing recreational use of pot, Vermont's law doesn't allow for a commercial marijuana industry to be established there.

"Individuals may possess up to an ounce of marijuana for personal consumption and grow up to six plants, but buying and selling the drug remains prohibited," Christopher and Tauhid write. "Public health experts say the lack of a commercial market could be a good thing...While marijuana is generally regarded as less harmful than other drugs such as alcohol or opioids, its use does bring a number of health risks...Opponents of legalization have contended that the commercialization of marijuana will lead to more widespread use of the drug and hence be harmful to public health."

OOF: A bit of confusing regulatory language may have led drug companies to incorrectly classify drugs, leading to charges by federal authorities and watchdogs that they stiffed Medicaid millions of dollars, Stat News reports. Companies have to give Medicaid a 23 percent discount for “innovator” (typically branded) drugs and a 13 percent discount for non-innovator (typically generic) drugs. Yet those categories don't perfectly match up to the branded and generic categories, meaning it's not always been clear which drugs fit into which category.

Companies say for the most part, they've correctly classified their drugs, Ike Swetlitz writes. But last month, the Health and Human Services inspector general issued a report saying drugmakers could have avoided more than a billion dollars in discounts by pricing some generic drugs like brand-name drugs. In August, the company Mylan paid a $465 million settlement and agreed to a review of its pricing practices to resolve claims it overcharged Medicaid for its EpiPen.

The alleged errors may not be industry's fault. “At the heart of the issue, legal experts say, is an arcane bit of regulatory language — a single ambiguous word written by Congress and poorly clarified by Medicaid’s overseers in the decades since,” Ike writes. “I think there’s an ambiguity in terms of the original Medicaid legislation, in terms of how it defined innovator versus non-innovator,” MIT professor Ernst Berndt told Ike.

OUCH: Oregon vastly expanded Medicaid under the Affordable Care Act to the point where just 5 percent of residents remain uninsured. But as the federal government is now set to reduce Medicaid payments, Oregon needs help paying for that expanded coverage. Today, Oregon residents vote in a special election on whether to approve a new "0.7 percent tax on some hospitals and a 1.5 percent tax on the gross health insurance premiums collected by insurers and on managed care organizations," the Associated Press reports. The tax would raise between $210 million and $320 million over the next two years to help cover more than 350,000 low-income Oregonians added to Medicaid since 2014.

When Oregon expanded Medicaid coverage in 2014 (as have 32 other states plus D.C.), the federal government initially covered the full cost of the new enrollees. But last year, that match dropped to 95 percent, and will decrease further to 90 percent in 2020. 

As of Monday afternoon, Oregon Public Broadcasting reported turnout appeared to be low but was leaning Democratic. "The latest ballot return numbers from the Oregon Election Department showed that Democrats have cast about 94,000 more ballots than Republicans," OPB's Jeff Mapes reported. "That’s an encouraging sign for supporters of the measure to impose taxes on hospitals and insurers as a way to help pay for Medicaid."


--Besides funding CHIP, there are a couple other big health-care policies included in the three-week spending deal Congress passed yesterday -- namely, a delay of a trio of industry taxes under the ACA. The law's 2.3 percent medical device tax won a two-year delay; its so-called "Cadillac tax," a 40 percent levy on high-cost employer insurance, was put in hold until 2022; and the health insurance tax (known to industry as "HIT") got a one-year reprieve next year. The New York Times gives a good explanation here of the impact of the taxes and the effects of delaying them.

--House Majority Whip Steve Scalise was discharged from the hospital yesterday morning just in time for the vote on reopening the government. The Louisiana Republican was recovering from a follow-up surgery at MedStar Washington Hospital Center, per his office, after he was shot last year at a practice for the congressional baseball game. 

--What are government shutdowns all about, anyway? One answer is “branding” for lawmakers, The Post's Fred Barbash writes in a fascinating piece looking at why Congress decides to shut down the government even though polls show voters oppose the heavy-handed tactis. There have been four true government shutdowns in modern times, including the latest one. The 16-day-shutdown back in 2013, which centered around Obamacare, is a prime example of how conservative Republicans from places where the ACA was unpopular used the shutdown to highlight their diehard opposition to the ACA.

Remember how Sen. Ted Cruz (R-Tex.) read “Green Eggs and Ham” to his daughters on C-SPAN while holding the Senate floor for 24 hours? Cruz's obstruction “helped make the otherwise obscure freshman a national figure, loathed and ridiculed by many but lionized by the most fervent opponents of the ACA,” Fred writes. “It turned him into a plausible, albeit ultimately unsuccessful, contender for the 2016 presidential nomination.”

Cruz's take on the 2018 version? He told reporters Monday that he “consistently opposed shutdowns. In 2013, I said we shouldn’t shut the government.” Ummm, that's not really the case.

-- Recall those dual bills to stabilize the Obamacare marketplaces by giving insurers more funding? Yes, the ones that got so much media coverage last fall. They're not included in the three-week spending bill Congress passed yesterday, but lobbyists and aides say they're still potentially alive. 

That's also the line from Sen. Susan Collins (R-Maine), a top Republican who hinged her vote for the tax overhaul on passing these measures (and is co-sponsoring one of them). Collins said negotiations with the House on the cost-sharing reductions bill from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) are "going very well," per the Washington Examiner. She also stressed that passing the measures right now isn't crucial. "We do have a little time here," she said.

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


Women are now a majority of entering medical students nationwide (Michael Alison Chandler)

A fifth-grader thought she brought gummy candies to school. They were laced with marijuana. (Kristine Phillips)


Working Americans are using less health care, but spending more (Carolyn Y. Johnson)


West Virginia dispensed 31 million fewer pills — but opioid OD deaths still rose (CNBC)


On the 45th anniversary of Roe v. Wade, the culture war over abortion continues (Eugene Scott)



  • The Senate Health, Education, Labor and Pensions Committee is scheduled to hold a hearing on “Facing 21st Century Public Health Threats: Our Nation’s Preparedness and Response Capabilities, Part 2.”
  • The National Institutes of Health is scheduled to hold a meeting of the National Heart, Lung, and Blood Institute's Sickle Cell Disease Advisory Committee for presentations and discussion of programs.
  • The National Institutes of Health is scheduled to hold a meeting of the National Institute of Nursing Research to discuss program policies and issues.
  • The Advisory Board holds a web conference on BPCI Advanced.

Coming Up

  • The Families USA Health Action Conference begins on Wednesday.
  • The Senate Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations is scheduled to hold a hearing on combatting the opioid crisis on Thursday.
  • The National Institutes of Health is scheduled to hold a meeting of the National Advisory Mental Health Council on Thursday.
  • The Medicaid and CHIP Payment and Access Commission holds its January meeting starting on Thursday. 
  • Tivity Health sponsors an event on “Aging in Rural America: The Growing Crisis, a Movement for Change” with remarks from Sen. Chuck Grassley (R-Iowa) on Thursday.

Why women could sway the 2018 midterms:

A Post-ABC poll released Jan. 22 found Democrats have an advantage ahead of 2018 congressional elections. (Video: Elyse Samuels/The Washington Post)

Senators relieved after vote to end shutdown:

Senators from both parties cited negotiations among a bipartisan group, after voting for a temporary spending bill to end the government shutdown on Jan. 22. (Video: Jordan Frasier, Patrick Martin/The Washington Post)

A woman battling cancer is surprised with every puppy from an animal shelter:

Courtney Gessford, 28, was “showered” with puppies in a video shared by Front Street Animal Shelter in Sacramento on Jan. 10. (Video: Front Street Animal Shelter — City of Sacramento)

Seth Meyers takes a closer look at the Women's March and the government shutdown: