By Rose Hoban

More than 200,000 children in North Carolina receive health care via the federally funded State Children’s Health Insurance Program or SCHIP, a program that dates back to the Clinton administration and which has traditionally had bipartisan support.

Except for this year.

A deadline passed on Sept. 30 for Congress to reauthorize the program, which provides health care for more than 35 million children nationwide. But lawmakers, distracted by other priorities and horse-trading over repeal of the Affordable Care Act and tax reform, allowed the deadline to skate on by.

bar graph showing that more than half of Medicaid enrollees nationwide are children/ CHIP recipients
Medicaid Child and CHIP Total Enrollment in August 2017: Individuals enrolled in the Children’s Health Insurance Program (CHIP) and children enrolled in the Medicaid program as compared to the number of adults enrolled in the Medicaid program. Data, graphic courtesy: U.S. DHHS

Six weeks later, there’s still no reauthorization for the program and advocates for children’s health are staying optimistic, while privately sweating over what could happen next.

North Carolina’s Health and Human Services Sec. Mandy Cohen said this week that she’s had multiple conversations with the state’s Congressional delegation.

“They’re very well aware that this is a must-do, must-pass,” she said.

But that hasn’t yet translated into action, in part because most states, including North Carolina, run out of SCHIP money early next year.

“We’ve had a cushion so they’ve taken advantage of that cushion,” she said. “But that cushion is about to run out.”

headshot of Cohen
Mandy Cohen, MD Photo courtesy: NC DHHS

Cohen said that there’s no hard and fast “drop dead date” but that the pain would come in phases.

“I think January is going to be when we start to make some hard decisions and at least start notifying people that hard decisions could come,” Cohen said. Those hard decisions would include freezing enrollment, then notifying families with slightly higher incomes and healthier kids that their insurance may lapse.

Caught between chambers

There are about 938,000 kids covered by Medicaid in North Carolina, those are kids in families who make less than $32,718 per year (in a family of four).

But North Carolina has always covered kids whose families make too much for them to qualify for Medicaid. There are about 200,000 of those kids living in low-income families with incomes up to 200 percent of the poverty level ($49,200 for a family of four) who are eligible for the SCHIP, which in North Carolina is called Health Choice.

Their benefits are not as robust as for kids who qualify for children’s Medicaid. For instance, there are some copays for parents. But the prices are low enough that these kids get the essentials needed for a child to grow up healthy.

pie chart showing 47 percent of children covered under employer-sponsored insurance, 36 percent covered by CHIP and the rest by self-paid insurance or other, with 5 percent uninsured
Source: American Academy of Pediatrics

Cohen noted some kids in the higher income families could go to the individual insurance market, but there are other kids that the state is obligated to continuing covering. That would mean difficult tradeoffs.

Earlier this month, the U.S. House of Representatives has passed a bill to fund the program, but the significant cuts made to pay for it raised objections from Democrats. The bill bumps up premiums on wealthier Medicare beneficiaries, cuts $6.35 billion from the Prevention and Public Health Fund created under the Affordable Care Act, and shortens the grace period for people who buy insurance under the Affordable Care Act who fail to make premium payments from 90 days to 30 days.

The bill is stuck in the U.S. Senate, where lawmakers differ with House members over how to pay for the program. Instead of offsets, the Senate version would phase out a reimbursement increase that the House version has put in place.

“Everyone understands that it’s an important process that will get there, but timing is a problem,” said state Sen. Ralph Hise, who co-chairs the Joint Legislative Committee on Health and Human Services at the General Assembly.

“A lot of people I’ve talked to particularly in the Senate are frustrated at the inability to get anything to move,” Hise said. “I’m anxious to move ahead with the final funding and get this off the table… But like everyone else in the state, I’m frustrated Congress isn’t doing anything.”

Elizabeth Hudgins from the Pediatric Society said she’s trying to stay optimistic.

“We’re appreciative of the priority that both the House and the Senate are placing on it,” Hudgins said. “But we’re very concerned that as it moves forward there not be harmful offsets, that you need to look at child, family and community health altogether.”

Frustrated docs, parents

Right now, the Twitter feed of the North Carolina Pediatric Society is filled with stories of SCHIP children, written by their parents.

“The kids are able to get well -child check-ups, and I have two asthmatics in my home who need equipment and regular inhalers, as well as prescriptions,” reads one, written by a mother named Afisa, in Raleigh. “I am married to a veteran and only he is qualified to receive his insurance. It’s very expensive for a family of six with only one low-income job that offers insurance to its employees.”

And pediatricians are weighing in too, anxious because the state has the lowest rate of uninsured children, 4.4 percent, since the state started keeping track, and they’d like to see that continue.

“I don’t even want to think about what children’s health without CHIP health would look like,” tweeted Chapel Hill pediatrician Eliana Perrin.

“Improvements in children’s health insurance are closely tied to Medicaid, Health Choice, and the ACA, so policy or administrative changes to these programs at the state or federal level could diminish or eliminate recent gains in coverage,” noted the North Carolina Institute of Medicine earlier this year in its annual child health report card.

Cohen said that if Congress doesn’t act by January, the General Assembly has some options.

“They have a rainy day fund for times when things are hard, so you could imagine a time when… we might have to talk that through,” she said. She said that for now, she’s taking it “one month at a time,” but that January is when the hard conversations would begin.

“I think March is more the timeframe when the other shoe would drop,” Cohen said.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...