As Congress remains idle over the future of the Children’s Health Insurance Program, Virginia last week began the process of unwinding a program that insures 65,000 children and 1,100 pregnant women in the state.
The Department of Medical Assistance Services, or DMAS, has to be ready by the beginning of December so it can give families at least 60 days notice that their children will no longer be covered by the program when money runs out at the end of January.
“Congress is acting as if it’s just a matter of when the money runs out, and they’re not acknowledging the work and the investment that states have to make in trying to do this in the least chaotic way possible,” said Linda Nablo, DMAS’ chief deputy director.
Amidst wrangling over repeal of the Affordable Care Act, Congress did not meet a deadline to renew the program, often called CHIP, that has previously enjoyed bipartisan support.
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Unless state lawmakers decide to pick up the multimillion-dollar tab, thousands in Virginia will lose coverage.
The result would look like this: A child with asthma who loses health insurance will have nothing to prevent future asthmatic episodes and will almost certainly end up in the emergency room, said Dr. Richard Bennett, a local pediatrician at Bon Secours Richmond Community Hospital.
“The coverage that would have cost a few dollars to hundreds of dollars will now cost a family thousands to tens of thousands of dollars,” Bennett said.
The ripples would expand from there. The child would likely miss school and parents would then miss work, placing their employment at risk while they grapple with a mountain of medical debt.
And, Bennett asks, what about kids with diabetes? What about kids with cancer?
“Any chronically ill patient is going to have the same story,” he said. “What means anything if you don’t have health?”
That scenario is on the brink of morphing into reality. The federal government stopped funding CHIP on Sept. 30, at the end of the fiscal year. Now, states like Virginia are running on leftover funds — if they have anything leftover in the first place.
At least 32 states expect to run out of money for the program by early spring, according to an analysis by the Kaiser Family Foundation.
As DMAS pulls together work groups and briefs the governor’s office, hanging over the entire process is hope — the tugging wish that all the work is for nothing and tens of thousands of Virginia’s most vulnerable children will not be left without health insurance in the new year.
“I hope it’s a waste,” Nablo said. “Best case, this is going to be an unnecessary drain on limited resources that will produce nothing, we hope. I guess that’s the best and the worst.”
She said she could not give an estimate as to how much it will cost DMAS to dismantle CHIP — which is operated in Virginia as FAMIS, or Family Access to Medical Insurance Security Plan — because the process is only just beginning.
“Initially, it’ll be pretty much all staff costs,” she said. “There may well be some payments that have to be made to contractors for IT system changes and those kinds of things, and those will be real hard dollar costs. Most of it at this point is going to be, we’re pulling staff who should be working on other things to work on this, while at the same time we’re hoping that it never actually happens.”
DMAS is a $9 billion agency and operates the largest health insurance program in the state, Nablo said. The staff that is going to be unraveling CHIP and answering questions from families will doubtlessly be pulled from other projects.
“There’s a constant barrage of work to run a program that provides health coverage for over a million people,” she said. “So I can’t tell you specifically that something’s going to not get done, or what those consequences are, because again, we’re just really at the beginning of all this, and we’ll certainly try to do things in a way that minimizes the negative impact. But there are only so many people here.”
But the headache for the state is minor compared to the situation families will face if their children lose health insurance. If Congress fails to act, sick children receiving medical treatment and pregnant women in need of perinatal care will see their health coverage disappear.
“Some of them will surely just end up uninsured,” Nablo said.
Utah has already submitted a plan for suspending its program to the federal government, and officials in Nevada have said the state will freeze enrollment Nov. 1 and end coverage Nov. 30 unless Congress strikes a deal.
Both the House and the Senate contain similar bills that would extend CHIP by five years, but there’s no debate or vote scheduled on either yet.
Nablo said it seems more likely a decision will come — if it comes at all — after Thanksgiving. That means Virginia will be down to the wire, because Nablo’s department plans to send out letters to families on Dec. 1 if the program really will end Jan. 31.
“It’s going to be a balancing act between giving parents too little notice and unnecessarily scaring them,” she said.
Virginia uses its funds from CHIP in two ways: to pay for FAMIS, which insures children from 144 to 200 percent of the federal poverty level, and to partially fund some of the children covered under Medicaid. The state would have to continue paying for the latter group regardless of what happens to CHIP, but that is not the case for FAMIS.
It would cost the state $52.9 million in 2018 and $137.3 million in 2019 to continue covering all of the children who receive CHIP funding, Nablo estimated in a presentation she made to the Senate Finance Committee.
There are few options available to these families should they lose coverage, said Margaret Nimmo Holland, executive director of the advocacy group Voices for Virginia’s Children. They likely cannot get an employer-sponsored insurance plan or sign up for a plan on the federal exchange, on which premiums have been skyrocketing recently.
“These families don’t have other options,” she said.
But to complicate the situation further, she said, many families likely do not know that their children receive CHIP funds. Because family incomes often fluctuate, the state has made the back-and-forth between its different coverage programs for children seamless.
Bennett estimates that about 30 to 40 percent of his patients are on a CHIP product, but even in the billing process, it’s difficult to tell which one.
He said some of his low-income patients move around so often that they may never receive a letter from the state, making it likely that some families will find out their insurance expired at the doctor’s office or in the emergency room.
“Health is the cornerstone to everything,” he said. “How do you blame a child for asthma, diabetes, cancer?”
The common refrain punctuating any discussion of CHIP goes something like, “There’s no way Congress will let it end.”
It’s an appealing mantra and is largely based on history. Since CHIP was enacted in 1997, it has enjoyed bipartisan support.
But evidence is piling up against that optimism. Federal lawmakers missed the first deadline to reauthorize the program by the end of the fiscal year as they grappled with the last attempt to repeal the Affordable Care Act. Congress today is no closer to renewing the program that, in 2016, covered 8.9 million children nationwide.
“I never would have thought we’d be here,” Nablo said.
But Nablo holds onto that history, using it to spur her hope that the program will not end, and the expensive planning for the approaching deadline will end up being useless.
“It’s the history of the program, it’s always been very popular,” she said. “And it’s, I guess, my belief that with all of the difficult and thorny health care decisions they are plagued with, this should not be a tough one.
“And surely, they don’t want to be known as the Congress that ended coverage for millions of children. Surely.”