U.S. GOVERNMENT PUBLISHING OFFICE

31–255—PDF WASHINGTON : 2018

S. HRG. 115–311 

THE CHILDREN’S HEALTH INSURANCE PROGRAM: 

THE PATH FORWARD 

HEARING 

BEFORE THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

SEPTEMBER 7, 2017 

( 

Printed for the use of the Committee on Finance 

COMMITTEE ON FINANCE 

ORRIN G. HATCH, Utah, Chairman 

CHUCK GRASSLEY, Iowa 

MIKE CRAPO, Idaho 

PAT ROBERTS, Kansas 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

JOHN THUNE, South Dakota 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

ROB PORTMAN, Ohio 

PATRICK J. TOOMEY, Pennsylvania 

DEAN HELLER, Nevada 

TIM SCOTT, South Carolina 

BILL CASSIDY, Louisiana 

RON WYDEN, Oregon 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

BILL NELSON, Florida 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

BENJAMIN L. CARDIN, Maryland 

SHERROD BROWN, Ohio 

MICHAEL F. BENNET, Colorado 

ROBERT P. CASEY, JR., Pennsylvania 

MARK R. WARNER, Virginia 

CLAIRE MCCASKILL, Missouri 

A. JAY KHOSLA, Staff Director 

JOSHUA SHEINKMAN, Democratic Staff Director 

(II) 

(III) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman, Committee on 

Finance .................................................................................................................. 1 

Wyden, Hon. Ron, a U.S. Senator from Oregon .................................................... 3 

Burr, Hon. Richard, a U.S. Senator from North Carolina ................................... 5 

Warner, Hon. Mark R., a U.S. Senator from Virginia .......................................... 6 

WITNESSES 

George, Leanna, mother of a CHIP recipient, Johnston County, NC ................. 6 

Schwartz, Anne L., Ph.D., Executive Director, Medicaid and CHIP Payment 

and Access Commission, Washington, DC ......................................................... 8 

Nablo, Linda, Chief Deputy Director, Virginia Department of Medical Assistance Services, Richmond, VA .............................................................................. 10 

ALPHABETICAL LISTING AND APPENDIX MATERIAL 

Bennet, Hon. Michael F.: 

Letter submitted by #FundCHIPColorado ..................................................... 39 

Brown, Hon. Sherrod: 

Letters submitted by the Ohio Department of Medicaid and the Ohio 

Children’s Hospital Association ................................................................... 42 

Burr, Hon. Richard: 

Opening statement ........................................................................................... 5 

George, Leanna: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 43 

Hatch, Hon. Orrin G.: 

Opening statement ........................................................................................... 1 

Prepared statement .......................................................................................... 45 

Nablo, Linda: 

Testimony .......................................................................................................... 10 

Prepared statement .......................................................................................... 46 

Schwartz, Anne L.: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 49 

Warner, Hon. Mark R.: 

Opening statement ........................................................................................... 6 

Wyden, Hon. Ron: 

Opening statement ........................................................................................... 3 

Prepared statement .......................................................................................... 75 

COMMUNICATIONS

AASA et al. ............................................................................................................... 77 

American Academy of Family Physicians (AAFP) ................................................ 79 

American College of Physicians (ACP) ................................................................... 81 

Asian and Pacific Islander American Health Forum (APIAHF) .......................... 82 

Campaign to End Obesity Action Fund (CEO–AF) ............................................... 83 

Children’s Hospital Association .............................................................................. 86 

The Fed Is Best Foundation ................................................................................... 87 

Healthcare Leadership Council (HLC) ................................................................... 88 

Page

IV 

National Child Health Organizations .................................................................... 89 

Nemours Children’s Health System ....................................................................... 91 

Oral Health America (OHA) ................................................................................... 93 

UnidosUS .................................................................................................................. 94 

(1) 

THE CHILDREN’S HEALTH INSURANCE 

PROGRAM: THE PATH FORWARD 

THURSDAY, SEPTEMBER 7, 2017 

U.S. SENATE, COMMITTEE ON FINANCE, Washington, DC. 

The hearing was convened, pursuant to notice, at 10:03 a.m., in 

room SD–215, Dirksen Senate Office Building, Hon. Orrin G. Hatch 

(chairman of the committee) presiding. 

Present: Senators Grassley, Cornyn, Thune, Burr, Toomey, Heller, Scott, Wyden, Stabenow, Cantwell, Carper, Cardin, Brown, 

Bennet, Casey, Warner, and McCaskill. 

Also present: Republican Staff: Jennifer Kuskowski, Health Policy Director; and Becky Shipp, Health Policy Advisor. Democratic 

Staff: Joshua Sheinkman, Staff Director; Elizabeth Jurinka, Chief 

Health Advisor; and Anne Dwyer, Health-care Counsel. 

OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. 

SENATOR FROM UTAH, CHAIRMAN, COMMITTEE ON FINANCE 

The CHAIRMAN. Let us call the meeting to order. But before we 

begin, I will take just a moment to say that our thoughts and prayers go out to those who have been impacted over the past few days 

by Hurricane Irma. Of course, we continue to keep those suffering 

from the effects of Hurricane Harvey in our thoughts and prayers 

as well. 

These have truly been horrific events, and I hope and pray for 

the safety of everyone involved. I join with my colleagues in the 

commitment to doing all we can to assist our citizens who are in 

need at this extremely difficult time. And we will see what we can 

do to help alleviate some of the pain. 

Now the hearing we are having today will come to order. 

Twenty years ago, Senator Ted Kennedy and I came together to 

create the Children’s Health Insurance Program, or CHIP, in order 

to provide health coverage for vulnerable children in families who 

were too poor to afford private coverage but still did not qualify for 

Medicaid. Twenty years ago, we were at something of a crossroads. 

The year before CHIP was signed into law, a Republican Congress passed and a Democratic President signed a welfare reform 

bill which ended the entitlement to cash welfare. Welfare reform 

sought to replace a culture of dependency with an emphasis on 

work. 

The emphasis was to move families off assistance and toward 

self-sufficiency. CHIP was needed to help many families make that 

transition. So we needed to be forward-thinking, taking into acVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 R:\DOCS\31255.000 TIM
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count the realities at that time with an eye toward future sustainability of the program. 

Senator Kennedy and I worked in good faith for months to craft 

CHIP, and while neither of us got everything we wanted, the result 

was a dedicated funding stream for the program to help low-income 

families get good, reliable health insurance. 

CHIP, from the outset, was a bipartisan program that enjoyed, 

and continues to enjoy, broad bipartisan support throughout the 

country and, I might add, here in Congress. While it is not perfect, 

and while, in my view, some of the subsequent changes to the program have been regrettable, I believe that, overall, people consider 

it to be a success. 

Current law provides Federal CHIP funding through the end of 

fiscal year 2017. According to the Congressional Research Service, 

if Congress does not act to provide additional Federal funding, a 

number of children who would likely be eligible for CHIP will go 

uninsured once Federal funding is exhausted. 

Additionally, inaction by Congress with regard to CHIP would 

cause another layer of unpredictability and anxiety for States that 

have to administer the program. Of course, this anxiety will pale 

in comparison to the uncertainty families who rely on CHIP will be 

faced with if Congress does not act. 

As the committee contemplates the future of the CHIP program, 

there are several thresholds we will need to consider. The basic 

question is, does the committee want to reauthorize or merely extend CHIP? 

Reauthorization would entail more extensive debate and consideration of potential policy changes to the underlying program. And 

as many of you know, in 2015, Congressman Fred Upton—who was 

then chairman of the House Energy and Commerce Committee— 

and I put forward a number of substantive policy recommendations 

for reforming CHIP, most of which were, admittedly, met with a 

mixed reaction from stakeholders. 

While some policy changes are certainly in order for the program, 

some are justifiably concerned that, given the number of issues 

that are already before the committee, there may not be time to 

give full and fair consideration to CHIP reforms prior to the expiration of Federal funding at the end of the fiscal year. With these 

concerns in mind, some have suggested that, instead of reauthorizing the entire program, we simply act to extend CHIP funding. 

Of course, that option comes with its own set of questions. For 

example, we will need to determine the appropriate length for the 

extension and whether to continue with the 23-percent increase in 

Federal matching for CHIP provided under the Affordable Care Act 

and extended in 2015. 

I know some of our members have strong feelings about both of 

these questions. These are not particularly complicated issues, but 

they will require some deliberation among members of the committee. 

Long story short, we have some difficult questions ahead of us. 

Whether we opt to reopen CHIP for reforms or simply provide another extension, the committee will need to invest significant time 

and effort to find answers to these questions. 

3 

Today, we will continue our discussion of these matters as we 

hear from witnesses who will testify to the importance of CHIP and 

the need for it to continue. I hope members will listen carefully to 

these witnesses, confer with their States, and let me know how 

they would prefer to proceed with regard to CHIP. 

I look forward to working on a bipartisan basis with Ranking 

Member Wyden and all the members of the Senate Finance Committee to move forward on a bipartisan CHIP bill. 

With that, let me now turn to my good friend, Senator Wyden, 

for his opening remarks. 

[The prepared statement of Chairman Hatch appears in the appendix.] 

OPENING STATEMENT OF HON. RON WYDEN, 

A U.S. SENATOR FROM OREGON 

Senator WYDEN. Thank you very much, Mr. Chairman. And I 

just want—as we start this extraordinarily important effort, Mr. 

Chairman—to note your history with Senator Kennedy. The fact is, 

it was that bipartisan partnership that got this program off the 

ground and has significantly reduced the number of uninsured kids 

in America. 

We are very appreciative that you set this in motion. I know all 

of the members on our side very much look forward to working 

with you to make sure that we get this reauthorized and done 

quickly. 

The CHAIRMAN. Thank you, Senator. 

Senator WYDEN. Colleagues, the fact is, it would be easy for 

those who are casual observers of political news to get lost right 

now in what is going on in Washington, DC. And there is an awful 

lot of Washington lingo that is just incomprehensible to people. 

There is the continuing resolution, the debt ceiling, CSR payments, which is cost sharing, NDAA, which is the Defense Act, and 

I think all of us could go on and on with others. 

Today we are talking about the Children’s Health Insurance Program. It is CHIP, and it is the only health bill with a time stamp 

on it. The program is going to expire in a few weeks. 

I think our message on this committee needs to be that we see 

our job as putting kids first. And that means that we are going to 

have to swing into action quickly here, because this program is a 

lifeline for almost 9 million vulnerable kids. 

It is a source of profound relief for parents in Oregon and across 

the country. I want to talk about the kind of person who really sees 

this as the lifeline I have described. 

We might be talking about a single mom who works multiple 

jobs, pays the bills, and handles all of what life throws at her all 

by herself. The last thing that single mom needs is a government 

letter stamped ‘‘notice of termination’’ explaining that her sick kids 

are on their own because CHIP funding has run out. 

That single mom is already juggling an awful lot. I think it is 

fair to say she does not read page A17 of the morning newspaper 

every day, because she has too much going on to be able to do that 

and try to decode all of this Washington lingo to determine if the 

Congress is going to act. 

4 

That single mom sits in her kitchen, and if all she has is that 

scary termination letter, we are going to see a lot of single moms 

and families in a huge mess very quickly. That is the prospect families across the country face in a matter of weeks, and it is what 

they do not deserve. 

Kids who desperately need care might not get it. States are going 

to be required to start planning for the worst. That means enrollment freezes, belt tightening, and emergency steps to try to preserve care for kids currently in the program. 

But a vulnerable child not yet enrolled in CHIP might have to, 

in effect, wait until the Congress gets its act together. At best, that 

leaves families with a mountain of stress, anxiety, and heartache. 

At worst, it is a life-and-death proposition for a great many of some 

of the most vulnerable children in our country. 

So today, the Finance Committee is going to discuss the leading 

health-care issue Congress has to address this fall. The Congress 

created CHIP with one goal in mind: that was to make sure that 

no American child falls through the cracks of our health-care system. 

In the coming weeks, we have an opportunity, as Chairman 

Hatch just noted, to put together a strong bipartisan agreement 

that upholds CHIP’s promise to families and gives those kids security for years to come. 

I am beginning this discussion in an optimistic kind of way, because I have discussed this—as I know many of you have—with 

Chairman Hatch, and I know the history. In the decades since 

Chairman Hatch and Senator Kennedy led the Congress to create 

CHIP, the percentage of kids in America living without health coverage has fallen from nearly 14 percent to less than 5 percent. 

So they gave us concrete proof, again, that you can have Senators who can have fierce disagreements on a variety of issues finding common ground when it comes to big challenges. And I submit—I have heard Senator Casey and others talk about this—it 

does not get any bigger than standing up for vulnerable children. 

So it is important for the Congress to act soon. There is no kicking this can down the road with a short-term bill, and it cannot 

wait until December. 

The States run their programs differently. Some are going to run 

out of funding earlier than others. In that time, no family ought 

to face the panic of being unable to get the care their sick child 

needs. 

As I wrap up, one other point is to note how CHIP and Medicaid 

work hand-in-hand for American kids and families, particularly 

those families working hard every day to climb into the middle 

class. CHIP adds a level of security to the health care of that single 

mom and others above and beyond Medicaid. But CHIP can only 

work if Medicaid works. So we have hard work to do, colleagues, 

now, to uphold the Senate’s promise to kids and families. 

We are going to hear from a witness panel that I think it would 

be fair to say knows CHIP from A to Z: a mom whose child counts 

on this program, an official who assures CHIP runs smoothly in 

her State, and an independent expert who knows the program 

inside-out. 

5 

So I see this as an opportunity for all Senators on both sides of 

the aisle to learn about and discuss this critical program and set 

the stage for the work to come. I am confident that in short order 

Congress can pass a strong and bipartisan extension of CHIP that 

will last for many years. And this is exactly what the important 

work of the Finance Committee is all about. 

[The prepared statement of Senator Wyden appears in the appendix.] 

Senator WYDEN [presiding]. Now Chairman Hatch is going to 

have to do some juggling here. So I am going to call an audible, 

and I would like to welcome each of our three witnesses to our 

hearing today. Each of your perspectives is important with respect 

to CHIP. 

First, we are going to hear from Leanna George, who will be introduced by our friend, Senator Burr. 

OPENING STATEMENT OF HON. RICHARD BURR, 

A U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Senator Wyden. 

Welcome, Leanna. Leanna is a proud parent of two children. Is 

that Caleb behind you? 

Ms. GEORGE. Yes, Sir. 

Senator BURR. Caleb, wave at everybody. We are glad to have 

you. 

Leanna’s daughter is eligible for Medicaid because of her disability. Caleb, her son, is insured by the CHIP program. 

Leanna serves as the beneficiary representative on the Medicaid 

and CHIP Payment and Access Commission. She is also a chairperson of the North Carolina Council on Educational Services for 

Exceptional Children and is the secretary of the Consumer Family 

Advocacy Committee for Johnston County Mental Health Center, 

the local management entity that connects Johnston County citizens with mental health, intellectual developmental disabilities, 

and substance abuse services. 

She is not only a mom, she is an advocate in every sense of the 

word at every level. Leanna, we are just honored to have you here 

today. Welcome. 

Senator WYDEN. Thank you very much, Senator Burr. 

Second, we are going to hear from Dr. Anne L. Schwartz, the Executive Director of the Medicaid and CHIP Payment and Access 

Commission, commonly known in Washington lingo as MACPAC. 

MACPAC is the nonpartisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of Health and Human Services, and the States 

on a wide variety of issues affecting Medicaid and the State CHIP 

programs. 

Dr. Schwartz previously served as deputy editor of the journal 

Health Affairs, vice president at Grant Makers in Health, and Special Assistant to the Executive Director and Senior Analyst at the 

Physician Payment Review Commission—another mouthful—a precursor to the Medicare Payment Advisory Commission. Dr. 

Schwartz has also held positions on committee and personal staff 

for the U.S. House of Representatives. 

6 

She holds a doctorate in health policy from the School of Hygiene 

and Public Health at the Johns Hopkins University. 

Finally, we will hear from Ms. Linda Nablo, who is going to be 

introduced by our good friend, Senator Warner. 

OPENING STATEMENT OF HON. MARK R. WARNER, 

A U.S. SENATOR FROM VIRGINIA 

Senator WARNER. Thank you, Senator Wyden. 

I want to echo what both you and Chairman Hatch said about 

the importance of CHIP. It is a critically important program. 

I would like to present to my colleagues my good friend Linda 

Nablo, who is now the Chief Deputy Director for the Commonwealth’s Medicaid agency, the Virginia Department of Medical Assistance Services, or as we call them, Virginia DMAS. 

Linda and I go back to the days when Bob Casey addressed me 

as his excellency, the Governor. Linda, at that point, was Director 

of the Division of Maternal and Child Health Services. 

Our CHIP program back in the early 2000s was, frankly, a 

dreadful disaster. We were literally sending tens of millions of dollars back to the Federal Government because we did not appropriately sign up enough of our eligible children. 

We came in, and with Linda’s great help turned that program 

around, made it a much easier process to get through the sign-up 

process, and turned a multi-page application into a single-page application process. Linda and I traveled the State at clinics and 

other gatherings, and because of her good work and the work of a 

lot of folks at DMAS, we went from one of the bottom of the barrel 

programs to where we signed up 98 percent of our eligible children. 

Kaiser Foundation recognized us as one of the most effective CHIP 

programs in the country. 

Linda went on to serve at CMS and now has come back to 

DMAS. She has a great, great expertise and a great heart for this 

program, and she should be a very valuable witness. 

Thank you, Senator Wyden. 

Senator WYDEN. Thank you, Senator Warner. So now we have 

gotten to the best part, and that is our witnesses. Why don’t we 

begin with you, Ms. George? We will go right down the row. 

It is a tradition in this committee if you could perhaps highlight 

your testimony in 5 minutes. We will make your prepared remarks 

a part of the record in full. 

Please proceed, Ms. George. 

STATEMENT OF LEANNA GEORGE, MOTHER OF A CHIP 

RECIPIENT, JOHNSTON COUNTY, NC 

Ms. GEORGE. Thank you very much. 

Good morning. My name is Leanna George, and as Senator Burr 

indicated, I am from Johnston County, NC. It is a very small rural 

county. 

Thank you for the opportunity to be here today to meet with you 

and to share my family’s experience with the CHIP program and 

how it impacts families like mine throughout our great country. 

I am married to a wonderful man named Jim. He is a Marine 

Corps vet, and he is in his third year of an electrician’s training 

program to become a fully licensed electrician. As mentioned earVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 R:\DOCS\31255.000 TIM
7 

lier, I have two children: Serenity, who lives in a group home, and 

my great son, Caleb, behind me. Both of my children are on the autism spectrum. 

Caleb has ADHD, Attention Deficit Hyperactivity Disorder, as 

well as a genetic neurological condition. And as you know, Serenity 

has Medicaid, and Caleb is insured by CHIP. 

While I am not here to testify on behalf of MACPAC, it was not 

until I was appointed to the Commission that I realized that 

CHIP’s future was so uncertain. As a parent of a child with extensive needs, my focus had been on advocating for home- and 

community-based service support waivers for children with developmental disabilities like my daughter. I was not aware that CHIP 

was in danger and that the children of working-class families like 

mine were in jeopardy of losing their health insurance. 

As the Commission discussed the CHIP program, I began to wonder just how losing CHIP would impact my family. How would it 

affect the monthly premiums we pay for our insurance? Would 

Caleb have access to the services he needs? How much would it 

cost us? 

With the current health insurance plan, there would be no increase to our premium because my husband’s plan only covers employees or family-only coverage. There is no employee and spouseonly coverage. However, it has a very high deductible which already prevents my husband and I from accessing medical care that 

we need. 

This, in short, means that the services that Caleb needs would 

be pretty much out of our financial reach to get for him without 

CHIP. These services include occupational therapy, which addresses fine motor challenges that impact his ability to write and perform basic self-care tasks like tying his shoes. 

He receives periodic MRIs to mark the progression of his neurologic condition which allow us to be proactive in treatment, which 

results in better outcomes for our children. My son takes daily 

medication which helps him be able to focus in school, which impacts his grades and his ability to learn. 

Over the years, the CHIP program has provided all of these services to us for little to no cost. Even in years when we have had 

cost-sharing, CHIP is still a tremendous value for my family. Without CHIP coverage, his access to services would be greatly diminished. 

CHIP also provides families with financial security and moms 

like me with peace of mind. In January, my husband was laid off 

of work. That resulted in an insurance lapse for him and me. We 

worked hard to ensure that he continued his medication that he 

needed, but I was able to feel confident that Caleb had the services 

and supports he needed should he become sick. I am so thankful 

that I have never had to call his pediatrician and say, ‘‘I am going 

to have to cancel our appointment. We do not have insurance.’’ I 

have never had to watch him lying in his bed with a fever and not 

been able to pursue medical intervention for him. 

CHIP has allowed my son to continue to receive the services he 

needs without interruption, despite what challenges my husband 

and I were facing. If CHIP was to go away, families like mine 

would be forced to make many tough decisions for our children. 

8 

Monetary resources are already stretched thin. Families might 

have to ration medical care, which could result in something that 

appears minor right now progressing into a very serious condition. 

Other families may procrastinate on maintenance services on vehicles and housing, which could lead to tragic accidents occurring. If 

we were not able to afford my son’s medication, I know his education would be severely affected. 

Among sacrifices, we have to consider activities that our kids 

participate in. Caleb is a Boy Scout. He has been in scouting since 

he was in the first grade. He earned his Arrow of Light last year 

in Cub Scouts. His uncle and his cousin are both Eagles, and he 

is excited about earning his Eagle one day. And I want to see him 

grow into a young man who exhibits the 12 principles of the Boy 

Scout law. 

While there is a lot of support for these great programs that 

teach leadership and discipline and promote active, physical, 

healthy lifestyles, losing CHIP can really put a hindrance on families being able to continue the support for these activities for their 

kids. 

Some families would have to sacrifice the care they provide for 

others, their children, their parents who live in situations outside 

of the home. My daughter lives 4 hours away from us. I would like 

to go more often than I can, but without CHIP, we would be even 

more limited in our ability to monitor her needs from where we 

live. 

There are 9 million children who receive CHIP. This program 

provides parents and families with peace of mind and financial security. Without CHIP, life would be a lot harder. I do not even 

want to picture or imagine it, but I know the impact is going to 

be on our kids for years to come. 

I ask you today to continue funding CHIP. And I want to thank 

you for your time to determine the future of this great program. 

Thank you very much. 

Senator WYDEN. Thank you, Ms. George. I know you speak for 

a lot of parents. We very much appreciate your being here. 

[The prepared statement of Ms. George appears in the appendix.] 

Senator WYDEN. Dr. Schwartz? 

STATEMENT OF ANNE L. SCHWARTZ, Ph.D., EXECUTIVE DIRECTOR, MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION, WASHINGTON, DC 

Dr. SCHWARTZ. Good morning, Senator Wyden and members of 

the Finance Committee. I am Anne Schwartz, Executive Director of 

MACPAC, the Medicaid and CHIP Payment and Access Commission. 

As Senator Wyden noted, MACPAC is a nonpartisan congressional advisory body charged with analyzing and reviewing Medicaid and CHIP policies and making recommendations to Congress, 

the Secretary of HHS, and the States on issues affecting these programs. Its 17 members, led by chair Penny Thompson and vice 

chair Marsha Gold, are appointed by GAO. 

While my statement builds on the analyses conducted by 

MACPAC staff, it reflects the views of the Commission itself. We 

appreciate the opportunity to share MACPAC’s recommendations 

9 

at a time when there is a pressing need for congressional action 

and the consequences for children and their families are significant. 

Since its enactment with strong bipartisan support in 1997, 

CHIP has played an important role in providing insurance coverage 

and access to health care for millions of children with incomes just 

above Medicaid eligibility levels. Since 1997 to 2015, the share of 

uninsured children in the typical CHIP income range has fallen 

dramatically from 22.8 to 6.7 percent. 

CHIP is State-administered within Federal parameters and jointly financed by the Federal Government and the States. Flexibility 

in program design is one of its hallmarks; some States run CHIP 

as an expansion of their Medicaid programs, and others operate entirely separate programs. 

As you know, without congressional action, States will not receive any new Federal funds for CHIP beyond the end of this 

month. Our latest projection shows that 3 States and the District 

of Columbia will exhaust their CHIP funds by the end of 2017, and 

27 States will do so by the end of the second quarter of fiscal year 

2018. 

In the face of uncertainty, many State administrators are already 

considering the numerous steps they will have to take to either 

freeze enrollment, scale back, or shut down programs. While they 

do not wish to alarm beneficiaries, States report that they cannot 

continue indefinitely with business as usual. 

Mindful of this situation, the Commission issued its recommendations last January after devoting considerable attention over 

several years to CHIP’s role in our health-care system and policy 

approaches for the future. 

We reviewed available evidence about the quality and affordability of CHIP compared to other alternatives and focused attention on the implications of various policy approaches on children 

and their families, States, providers, plans, and the Federal Government. Based on this review, and in light of considerable uncertainty now facing health insurance markets, MACPAC recommends 

that Federal funding for CHIP be extended for 5 years. 

If CHIP funding is not renewed, 1.2 million children covered 

under separate CHIP will lose their coverage. While some of these 

children may be eligible for coverage privately, they would have to 

pay considerably more than under CHIP, creating barriers to needed health and developmental services. In addition, they would lose 

access to services covered by CHIP that are not typically covered 

by other payers. Those covered by Medicaid expansion CHIP would 

not lose coverage, but there would be a significant shift in the 

funding obligation to the States. 

The Commission also recommends extension of the current CHIP 

maintenance of effort requirement and the 23 percentage point increase in the Federal CHIP matching rate through fiscal year 2022. 

These linked recommendations reflect the view that extension of 

the MOE—which it judged important to retaining gains in coverage—should be accompanied by an extension in enhanced funding. The higher CHIP matching rate is also thought to have influenced decisions in some States, including Florida, Utah, and Arizona, to expand coverage to previously uninsured children. 

10 

MACPAC’s recommendations also look to a future in which a 

more seamless system of children’s coverage can be created. Such 

a system would provide comprehensive and affordable coverage and 

remove gaps that occur when children transition among different 

sources of publicly and privately financed coverage. 

Recognizing that States will be the drivers of such change, 

MACPAC recommends that demonstration grants be made available to States to develop and test new approaches. 

Our other recommendations call for an extension of other childfocused programs that are typically reauthorized with CHIP. 

CHIP has clearly played an important role in providing access to 

health care for millions of America’s children. In addition, CHIP 

has provided a platform for State innovations to reach eligible but 

uninsured children, remove enrollment barriers, and focus on highquality pediatric care. 

Congress now faces an important decision regarding the future 

of CHIP during a period of great uncertainty affecting other healthcare markets, including both Medicaid and the exchanges. 

MACPAC’s recommendations provide guidance on how to ensure a 

stable source of affordable and comprehensive coverage for low- and 

moderate-income children amid such uncertainty. And the Commission urges Congress to act as soon as possible to extend CHIP, an 

action necessary to prevent children from losing coverage and access to care and to ensure that States have the necessary funds to 

provide people services. 

Senator WYDEN. Dr. Schwartz, thank you very much. 

[The prepared statement of Dr. Schwartz appears in the appendix.] 

Senator WYDEN. Ms. Nablo, welcome. 

STATEMENT OF LINDA NABLO, CHIEF DEPUTY DIRECTOR, 

VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, RICHMOND, VA 

Ms. NABLO. Thank you, Senator Wyden, for allowing me to speak 

to you today on the importance to States of continued funding for 

the Children’s Health Insurance Program. 

And thank you, Senator Warner. I remember well when you were 

Governor and enrolling every eligible child was your top priority. 

I particularly remember how you would ask every Friday—without 

fail—how many more children we had gotten covered that week. 

So before you ask, let me say that in Virginia today there are 

614,100 children covered through Medicaid and CHIP. These programs are the health insurance plan for almost one in three children in the Commonwealth, which is actually slightly below the national average. 

However States have chosen to design their CHIP program, it 

plays a vital role for all of us in ensuring children have access to 

affordable and appropriate health care by building on top of the 

much larger Medicaid program. In fact, CHIP just turned 20. It is 

now a mature program that is woven deep into the fabric of healthcare coverage in all States. 

There are only two points I want to make with you today in my 

few minutes. First is that CHIP is vital to the health of children. 

11 

And second is that there are serious consequences looming if you 

delay reauthorization even for a few months. 

In Virginia, as of September 1st, there are over 58,000 children 

enrolled in Medicaid, but funded by CHIP. There are 65,000-plus 

enrolled in our separate program we call ‘‘FAMIS.’’ We also have 

a CHIP waiver to provide prenatal care to pregnant women, and 

about 1,100 are currently enrolled. 

Virginia receives 88-percent Federal funding for this program. In 

the last two State fiscal years, this money has paid for hundreds 

of thousands of well-child visits and immunizations, over 21,000 

pairs of glasses, and well over 367,000 visits to the dentist. But we 

have also paid for 258 heart surgeries, six brain cancer surgeries, 

two liver transplants, and one heart transplant. We have provided 

services for over 1,100 children diagnosed with cancer, 31 children 

living with HIV, and 32 babies born with neonatal abstinence syndrome. 

Obviously, CHIP helps children lead healthy and normal lives. 

For example, they can play sports. You know you have to have insurance to play sports. They can control their asthma, they can see 

better in school, or get their teeth fixed. 

For other children, CHIP has provided lifesaving treatments. 

This is true in my State and in yours. But without congressional 

action soon—as Senator Wyden clearly explained—States will be 

forced to start preparations to shut these programs down. 

You have heard that most States will not actually run out of 

CHIP dollars until sometime in the second quarter of 2018. Some 

might believe you can safely delay action on CHIP while you deal 

with your very full calendar. But let me explain the reality for 

States. 

According to all estimates, Virginia will run out of Federal CHIP 

dollars sometime in March. However, Virginia like many States, 

covers these children through managed-care plans. We pay those 

health plans a capitated rate retrospectively for the previous 

month’s coverage. So in March, we will not have sufficient funds 

to pay for the month of February. We will, therefore, need to terminate our separate CHIP program at the end of January. 

In order to give the families of those 65,000 children adequate 

notice, we will need to send them letters on or about December 1st. 

Before then, we will need to train eligibility workers, application 

assisters, call center operators, and others so they are able to answer questions and provide whatever assistance they can to these 

frightened families. 

We will also need to inform providers and prepare to deal with 

their questions as well. We will need to expend CHIP funds to reprogram automated eligibility rules and to modify online and paper 

applications and notices. Countless other contracts, from managed 

care plans, prior authorization reviews, auditors, et cetera, will all 

need to be amended. 

I suspect for States without a high degree of managed care, the 

situation will be even more precarious, as their costs are less predictable. And remember, Virginia is not one of the first States to 

run out of money. Please be aware that your State will soon be 

making difficult decisions about if and when to freeze enrollment 

so as to preserve current coverage as long as possible, and what to 

12 

tell families and when to tell them as the end of funding approaches. 

Because we have come so dangerously close to the wire this time, 

States would be grateful for any quick extension of CHIP. But I do 

want to make the point that funding this program in one- or twoyear increments can generate instability, dampen innovation, may 

limit State investment, and freeze programs where they are when 

the future is so uncertain. I hope at some point you are able to consider the recommendation of MACPAC and other organizations of 

reauthorizing and funding the program for at least 5 years. 

Finally, please be aware that, for Virginia alone, if Congress reauthorizes CHIP by September 30th but reduces the Federal match 

rate to previous levels, we will experience over a $57-million shortfall for the current State fiscal year which began in July, and an 

$83-million shortfall in the next. 

Senator Wyden and members of the committee, as you know, 

CHIP has always had strong bipartisan support. With all of the 

very difficult and complex decisions you have to make about health 

care in America, surely whether or not to extend CHIP is not one 

of the hard ones. 

On behalf of States, I am here to ask you to please continue your 

support of children’s health care by straightforward reauthorization 

for continued funding of CHIP at current levels. And please do it 

before we have to send those letters. 

Thank you. 

Senator WYDEN. Thank you, Ms. Nablo. 

[The prepared statement of Ms. Nablo appears in the appendix.] 

Senator WYDEN. Well said. And I also appreciated hearing how 

it was morning in Virginia when Mark Warner was Governor and 

everybody got their daily report on how many kids got covered. 

[Laughter.] 

You all have been an excellent panel. Let me just start with a 

couple of questions. 

Ms. George, I would like to hear what it really means in a parent’s case, in terms of what they would give up if the program expires. For example, I think it would be helpful to know how you 

would pay for Caleb’s medications, because it sounds like those are 

pretty pricey. And you talked to us about a whole variety of circumstances which obviously a parent cares about, but how would 

you pay for Caleb’s medications? 

Ms. GEORGE. Right now, I am not really 100-percent sure. I 

would probably be asking my mother for a lot more help than we 

already get. And right now Caleb and his father take a class called 

Tang Soo Do, a martial arts class that helps my husband with 

some arthritis challenges and helps Caleb immensely. But that 

would be one of the first things we would have to drop. 

Right now we put aside money each month so that we can have 

money when the Boy Scouts go to summer camp, you know—that 

is another area. Because we are looking at $3,600 a year that we 

have to find savings for, for his medications, and that is if they do 

not go up again. 

And that is a third of our—is it a third of our income? No. It is 

not a third of our income. It is about a tenth of our income, actually, though. 

13 

And just trying to find that savings would be a challenge, because we can probably get half of it, as I said, through some of the 

martial arts classes that he takes, but the rest of it, I am not sure 

where it would come from. 

Senator WYDEN. That was my sense. And I appreciate that, because you have described how, basically, every single month you 

are trying to watch how you allocate your dollars, and it is tight, 

but you get along. And you try to do, obviously, right by your kids. 

I just kept looking at Caleb’s medications, and I cannot figure 

out how you would be able to pick those up without some magical 

approach that we have not talked about. So I probably want to ask 

you some more about it. 

Ms. Nablo, a question for you. You really gave us a very concrete 

and specific case about the kind of bedlam that we would see in 

the State of Virginia if this program was delayed. 

Can you tell us—because you are an authority on this subject— 

what would happen in other States? In other words, based on your 

knowledge and your expertise about the program, tell us a little bit 

about whether what Virginia does is representative, and would 

other States have other problems, and just walk us through, if you 

would, some of the other States. 

Ms. NABLO. I would say Virginia is probably somewhat fortunate 

in this situation in that the Federal funding does not run out until 

March, even though the program would have to close. 

Senator WYDEN. So the problems you describe would, essentially, 

be worse elsewhere? 

Ms. NABLO. Absolutely. Obviously, as has already been stated, 

there are several States that will run out of funding before the end 

of this year. They have really got to be thinking about notifying 

those families very soon. 

In addition, I believe there are some States that actually have a 

State law that says if the funding level from the Federal Government is reduced or goes away, they have to shut down their programs. Every State is a little bit different, and every State program 

is constructed a little differently. There are some that I think are 

really kind of reaching the desperation point. Now, I suspect if they 

do not hear something in the matter of a couple of weeks, several 

States will be sending those letters, or being in the paper trying 

to warn parents. 

Senator WYDEN. Your message—and that is particularly helpful—is that anybody who thinks they can wait around until December 15th to get serious about this—— 

Ms. NABLO. Has never shut down a program before. 

Senator WYDEN. Okay. Well said. You are talking about people 

getting a signal in a couple of weeks. And if Congress plays stall 

ball on this, there are going to be real consequences. 

Ms. NABLO. Absolutely. There would be very scared families, and 

our phones would ring off the hook in State offices and local offices. 

Senator WYDEN. Very important to know. 

One other really quick question. Dr. Schwartz, we feel very 

strongly that this program be multi-year, and we are going to push 

for the most generous funding that we can. I mean, obviously, we 

are going to have to have discussions back and forth on that, but 

that is my objective. That is our objective here. 

14 

What, in your view, is the value of a multi-year extension and 

why that is preferable? I mean, my sense is, that gives some certainty and predictability, but you are the expert on this. 

Dr. SCHWARTZ. Certainly. The last time that MACPAC made a 

recommendation in advance of the extension that you passed in 

2015—our recommendation was for 2 years. And at that point, 

there was some hopefulness that some of the uncertainty in healthcare markets that were a feature in the congressional debate at 

that time would be solved. And it is clear that now, if anything, 

things are more uncertain. We are not sure about what sources of 

coverage would be available to kids going forward, with the uncertainty affecting Medicaid and the exchange market as well as privately sponsored coverage. 

So it is the Commission’s view that it is important to put kids 

in a safe space while these other bigger issues are debated and figured out. And that is why the Commission recommended a 5-year 

extension to ensure that families would have stability in insurance 

coverage, that States would not be in a situation where they were 

constantly having to sort of be in a groundhog day situation of 

going through the steps that they would have to take. 

Senator WYDEN. Thank you. My time is expired. 

Senator Heller? 

Senator HELLER. I want to thank the ranking member and the 

chairman for holding this hearing today. It is a critical program, 

and it is a program that helps millions of children. So I want to 

thank Ms. George for being here and sharing your story with us, 

and the other witnesses for your help and support of this particular 

program. 

In Nevada, CHIP provides medical coverage for roughly 25,000 

children who otherwise might not get care. And over the years, this 

program has been responsible for increasing coverage for lowincome children throughout my home State. 

Nevada has made great strides when it comes to improving our 

uninsured rate, making sure that our kids have access to affordable 

health care. And this is something that both Governor Sandoval 

and myself are quite proud of. So it is my hope that Congress will 

act swiftly to reauthorize this program, give families in Nevada 

and across the Nation the certainty that they need when it comes 

to children’s health care. 

So with that, I would like to ask a question or two—specifically 

to you, Ms. Nablo, because of your background, expertise, and what 

you were able to accomplish in Virginia. I said 25,000 Nevada children now are covered. It is estimated that probably 9 million—I 

think, Ms. George, you said that—children across the country benefit from this program. But they also estimate that there are 

roughly 5 million children who remain uninsured today. 

So with your expertise, your background, your knowledge of this 

program, can you share what some of the barriers are that would 

produce what we have today of 5 million uninsured children and 

their inability to get into a program like this? 

Ms. NABLO. Certainly. I would say the first barrier is always 

awareness. It is amazing how many individuals still do not understand that this program actually can cover the children of working 

families, and there are many families who never in their life conVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 R:\DOCS\31255.000 TIM
15 

sidered that they might be eligible for a publicly funded health-care 

program. 

And someone loses their job, or their hours get cut back, and all 

of a sudden they are eligible. They have never paid attention to the 

ads before. So it is a constant need, a constant drumbeat, because 

there is always a new population. A plant closes, whatever, that 

creates a new population. That is one. 

Plus, there are certain populations that have higher uninsurance 

rates that are more difficult to target, but States really need to 

make those efforts. Teenagers are much less insured than young 

children. Hispanics are classically underinsured. 

So it takes special efforts, special outreach. And quite honestly, 

funding for outreach is one of the first things that goes when 

States get strapped. So that is a constant campaign to keep that 

up. 

I think perhaps—and it may be MACPAC that has done some 

analysis of those 5 million children still uninsured—a good percentage of them, I think it is 60-some percent of them, would be eligible 

for CHIP or Medicaid if they would apply, if they were aware and 

took the action to apply. 

Senator HELLER. Dr. Schwartz, could you add anything to that? 

Dr. SCHWARTZ. Yes. I do not have those numbers at my fingertips, although we could get them for you. 

I think, also, it is important that that number of children who 

remain uninsured includes undocumented children who would not 

be eligible for programs in different States. 

Senator HELLER. Do you anticipate that this number is climbing, 

or is it actually getting better at this point? 

Ms. NABLO. I think we have seen a consistent drop in the uninsured number for children going back to 1997, and that was the 

primary motivation for the Commission to recommend extension, 

wanting to secure those gains in coverage and make sure that the 

number of uninsured children does not go back to where it had 

been historically. 

Senator HELLER. Yes. 

Ms. Nablo, based on the barriers that you just spoke about, what 

can we be doing better here in Congress to address some of those 

issues? 

Ms. NABLO. I think there is even a recommendation of MACPAC 

that money that is set aside, specifically targeted for outreach— 

right now States generally take that money out of their admin dollars that are allowable under the CHIP program. Those admin dollars get stretched to all kinds of other things. 

So having a set-aside, if you will, that is meant to help States 

continuously promote this program, I think, would certainly be 

helpful. 

There are some policy changes that could make it easier for people. There are some States that still have a required period of 

uninsurance before a child can become eligible for CHIP. That is 

my least favorite policy in the CHIP program. 

Senator HELLER. Does the law allow any outreach in the CHIP 

program, in the funding the States receive? 

Ms. NABLO. Does it allow it? 

Senator HELLER. Yes. 

16 

Ms. NABLO. Yes. You can take it out of your admin dollars. Every 

State can spend up to 10 percent on admin of what they spend on 

medical care for kids. 

So the bigger your program gets, the bigger your admin budget 

gets too. But that needs to pay for workers and IT systems and all 

of that kind of stuff as well. 

But that is where most States are able to find some dollars for 

outreach. 

Senator HELLER. Thank you very much, Mr. Chairman. 

Senator WYDEN. Thank you, Senator Heller. 

Senator Casey? 

Senator CASEY. Thank you very much. I want to thank the ranking member for his leadership on this issue over many years. And 

of course, I want to thank Chairman Hatch for his work today as 

well as his leadership over many years in a bipartisan fashion. 

This is an issue where we are particularly grateful our witnesses 

are here, but we are also grateful that you are here at this time, 

because we need your voice, we need your expertise, your advocacy, 

to inject a sense of urgency into a place where urgency is often not 

the order of the day. 

I am going to start with Ms. George. We are particularly grateful 

that you are here to bring your own, not only expertise as all three 

members of the panel bring, but you bring a personal dimension. 

Your testimony has—I think in some ways—added value and significance on a day like today. 

I was noting from your testimony all of the, not maybe an exhaustive list, but some of the services that you testify that Caleb 

benefits from. And I am looking at, I guess, the second page of testimony where you talk about weekly occupational therapy to address fine motor challenges that affect Caleb, periodic MRIs and 

ultrasounds to monitor the progression of his neurological condition, and daily medication which helps him stay focused on his 

schoolwork. 

And you say, ‘‘The CHIP program has provided these services for 

little or no cost. CHIP is a tremendous value.’’ And you talk about 

financial security and peace of mind. All of that testimony is critically important to hear from you as a parent and hear from you 

as someone who is deeply concerned about your son. 

I guess my first question would be, if you were to receive a termination of coverage notification, how would that affect your family? 

Ms. GEORGE. Well, the first thing I would be looking for is a way 

to appeal the determination as an applicant. 

Senator CASEY. Right. 

Ms. GEORGE. But it would just be a challenge. I look at Caleb 

and his needs with education. His medication, primarily, is so important, because without his medication for ADHD, he could barely 

complete a half a worksheet in kindergarten. Within a week or two 

of having the medication, he is now completing two worksheets. 

This medication allows him to stay focused. Without being able 

to focus on what you are doing, you cannot do more complex math. 

Right now, we are doing long division. When his meds wear out, 

put that aside, because it is too much involved in long division. 

17 

It is just so important that he keeps getting his medication. So 

that is the first thing. How are we going to pay for the medication? 

How are we going to address his penmanship? 

We started occupational therapy over the summer, and he went 

from not being able to write legibly at all—I could not read it. He 

is homeschooled this year—now he writes fairly well. As long as we 

keep that up—and hopefully we can wean him off of the occupational therapy, but it is just so critical, that it is going to impact 

him not just today, but as he goes into high school, as he goes 

hopefully into college, into being an adult, that if he does not have 

these skills, then he is not going to be able to achieve as well as 

he could achieve. 

That is why I think it is such a tremendous value, intervention. 

But as a family member, it would just be devastating to find out 

that all of these things that we have done to build him up, we are 

no longer going to have access to. 

Senator CASEY. We are grateful for that testimony. I know if you 

just multiply that in just one State like, in my case, Pennsylvania—as of August we had over 176,000 children enrolled. And 

that number goes up and down depending on what day of the 

month it is or what time period, but lots of children benefit, I am 

sure, in the same way that Caleb does. So we are grateful for that 

testimony. 

I am almost out of time, but, Dr. Schwartz, I wanted to ask you, 

has the risk to—I am sorry. I was going to ask Director Nablo this. 

Has the risk to CHIP funding already impacted your State in administering the program? 

Ms. NABLO. I will say no. We have been very cautiously optimistic. And so we have not made any cutbacks. 

I will say we just recently ended an outreach campaign. It ended 

this summer. It was the first media buy we have been able to do 

probably since the days when Senator Warner was Governor. And 

it did boost our enrollment again, but we have let that expire, I 

think, in part, because of funding, but the other part is, are we 

driving people to a program that is going to close soon? 

I think there are other States that have had much more serious 

consequences. There are States that have prepared those notices, 

that are really actively engaged in shutting things down, are ready 

to pull the trigger. 

Senator CASEY. Great. And I will have more. 

Dr. Schwartz, I will send you one in writing. Thanks very much. 

Senator WYDEN. Thank you, Senator Casey. 

Senator Scott? 

Senator SCOTT. Thank you, sir. And thank you to the panel for 

being here with us this morning. 

Ms. George, thank you and your family for your service to the 

country. Your husband’s service as a marine is greatly appreciated. 

I will say that, as many of my colleagues know, I have a passion 

for helping our most vulnerable, our kids, access quality education, 

whether that is through school choice programs or youth apprenticeships. Anyone who has ever set foot in a classroom understands 

and appreciates the importance that health plays in the success of 

the child in the classroom and, by extension, in life. 

18 

For almost 9 million children across the country, including 

80,000 in South Carolina, the CHIP plays a vital role in ensuring 

that our young folks are healthy enough to learn and thrive in 

school and in life. In considering the ways in which CHIP shapes 

education outcomes for many of our students, we need to look no 

further than the issue of asthma. 

Asthma is the most common chronic condition among children, a 

leading cause of disability, and with bronchitis it is the leading 

cause of hospitalization among children in South Carolina. It is 

also one of the leading causes of absenteeism in schools and can 

increase the risk that that child will not reach their full potential 

educationally, and that, in turn, means in life. 

Whether a child is struggling with asthma or another condition 

that impacts their ability to succeed at school, CHIP can help remove some barriers for families who are often up against a lot of 

other challenges. By producing healthier children, we also produce 

children who can be fully present in the classroom, fully invested 

in their studies, and fully prepared for a fruitful educational journey. 

Shortchanging children’s health produces a vicious cycle whereby 

poor health care leads to lower academic achievement, and poor 

academic outcomes, in turn, diminish long-term health. 

Ms. George, first off, I want to say thank you again for the opportunity to listen to your story and to understand and appreciate that 

you are here not only as an advocate, but as a mother. Can you 

please talk with us as the chairperson of the Council on Educational Services for Exceptional Children about how you have seen 

the connection between health services that students with exceptional needs receive and the success that they are able to achieve 

in the classroom? 

Ms. GEORGE. Well, as you know, through IDEA, public students 

have access through public education and their Individualized Education Programs for related services such as occupational therapy, 

physical therapy, speech therapy—the list goes on and on. And 

some of that is funded through public insurances, CHIP and Medicaid. A lot of students receive these services. It is very much beneficial to them. 

Senator SCOTT. Excellent—excellent. 

My second question for you, ma’am, is, as a mother, you have 

come before us, and I wanted to understand and appreciate—we 

certainly have heard Senator Warner and others talk about the importance of CHIP as it relates to your son. Can you perhaps expound upon the services and the way that they impact his academic achievements as well? 

Ms. GEORGE. Well, with the occupational therapy, as I shared a 

little bit earlier, with his penmanship—he was completely illegible. 

We started homeschooling him in the fifth grade year, last year. 

We are in our second year of homeschooling. 

We could not read his handwriting, despite having occupational 

therapy in the public school system. So we were able to get him 

private therapy, and he has made tremendous progress between 

that and constantly redoing it at home. 

If you cannot read somebody’s handwriting—you cannot write a 

letter, you cannot fill out a job application. Even in this technologyVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6633 R:\DOCS\31255.000 TIM
19 

based world, it is still a vital skill. As well as, with him, when 

doing multiplication and long division, when he was trying to line 

up and add his numbers, if he could not read the number he wrote, 

he would come up with the wrong answer. 

Senator SCOTT. Yes, ma’am. 

Ms. GEORGE. And once again, that impacts his education there. 

Yes. 

Senator SCOTT. Thank you very much. 

Senator WYDEN. Thank you, Senator Scott. 

Senator Warner is next. 

Senator WARNER. Thank you, Senator Wyden. Let me, again, 

thank all of our witnesses: Ms. George, Dr. Schwartz; Linda, it is 

great to see you again. 

I am going to direct most of my questions, I hope appropriately, 

to Ms. George and Dr. Schwartz. And I also want to commend—— 

Senator BENNET. By the way, when you refer to the days that 

Mark Warner was Governor, did you mean the dark days for Virginia? [Laughter.] 

Senator WARNER. They were already called the morning in Virginia, as Senator Wyden mentioned. [Laughter.] 

One of the things that I hope, particularly, Ms. George will take 

back is, it is rare to have a program where people on both sides 

of this dais are all saying good things about the program. I hope 

it gives you a little more faith that we can get our act together and 

get this done in a timely way. 

Dr. Schwartz, we appreciate all of the, kind of broader policy 

goals you have looked at, and the extension time you have set. 

Again, I think it is a 5-year extension at least. 

One of the things I would like you to talk about—I do not want 

to be presumptuous and assume we are going to get it done in a 

timely way. But one of the things I recall in the past is, so many 

of these families, their incomes fluctuate so much month-to-month, 

and they may be Medicaid-eligible at one point and then CHIPeligible at another point. On a going forward basis, are there better 

ways for us to make sure that people do not have to constantly reapply, and can we streamline this, so people who fall within these 

eligibilities do not have to spend their time as they bounce from 

one program qualification to another? 

Ms. NABLO. There is an option for States of making the Medicaid 

or the CHIP program for children—you would be continuously eligible for a 12-month period. So even though your income may fluctuate and you may drop down to Medicaid or go up to being not 

eligible for the program, you would not have to report a constantly 

changing income and your child would be covered for 1 year until 

their annual renewal date. 

Not every State by far has adopted that policy. That would be 

wonderful if that was part of the law. 

Senator WARNER. Would you keep that as an optional basis on 

reauthorization? 

Ms. NABLO. Well, if we really truly wanted to address that concern, it would not be optional. It would be the way the program 

was structured. 

In Virginia, we have a version of that. It does say that if your 

income goes up, you have to report that. 

20 

But you are absolutely right. People’s income—there are a lot of 

seasonal workers here, there are a lot of people who get extra jobs 

over Christmas, and their income changes. You know, we have 

school teachers with children on CHIP. 

So it is a constantly moving target and fluctuating environment 

for families. To realistically expect families, every time somebody 

works a few more hours, to report that and ask an eligibility worker to figure out if that makes a change or not is really not the 

smart way to have this coverage. 

Senator WARNER. Right. There could be a retroactive look-back 

after a year or so, but this bouncing between income levels is really, I think, really important. 

Ms. NABLO. Absolutely—absolutely. And in States where the benefits packages between CHIP and Medicaid are very different, that 

alone can cause problems. You may lose a provider. You may still 

be eligible for coverage in Medicaid, but perhaps your provider is 

not a Medicaid provider. 

Senator WARNER. And I think we have heard from Senator Scott 

and others that, in terms of plain old business ROI, making sure 

that child—making sure Caleb—goes to school healthy and prepared is going to make him a better student. 

Ms. NABLO. Sure. 

Senator WARNER. That pays back enormous benefits. 

Ms. NABLO. I think that is what you have to do. Hopefully you 

look at the long road, the long picture, and does it make sense that 

we have programs where families could potentially bounce back 

and forth almost month to month. 

Senator WARNER. Talk to me a little bit about the importance of 

outreach, and particularly rural outreach, since there are so many 

communities. I know we have online signups. But the truth is, 

many families may not feel comfortable doing it online or going to 

a library and putting very personal data into a computer without 

an outreach worker. Talk about outreach, and more specifically, 

rural outreach. 

Ms. NABLO. Certainly. Well, as you know very well, we—the 

State—employ a few outreach workers, and we do try to position 

them around the Commonwealth, but another thing that we do in 

Virginia is, we use some of our CHIP admin dollars to help support 

a project through the Virginia Health Care Foundation, of which 

you are the founding chairman. And that project—they also get a 

Federal grant to do the same. So their reach is more extensive 

across the Commonwealth in trying to help families. 

And we do still, even in this day and age, we still get a healthy 

proportion of our applications on paper, even though the form is 

not particularly friendly. Really, it is shorter than it used to be, but 

you still have to answer all of those questions. So we still get a surprising number of people who submit on paper. 

We have working families, working mothers, who cannot take off 

during their work hours and go to the local social services agency 

and sit across the desk from an eligibility worker to help complete 

that form or to follow it through. That is where the outreach workers come in. They will meet you at McDonalds; they will meet you 

at their home; they will meet you at your home; they will find a 

way to sit with you in a time and a place that works for you and 

21 

help you through that process, help you understand the questions 

and get the information in. 

Then they will do the all-too-important follow-up on your behalf, 

because, as much as we would like to think we are all about helping people, we are still a bureaucracy, and it is not easy to deal 

with the system. So without that handholding, without that personal touch, especially in rural areas for families who have limited 

English capacity, it is absolutely essential, which is why we have 

still several million children who are eligible and not enrolled. 

Senator WARNER. Thank all of you. Particularly, thank you, 

Linda, for your great work in the Commonwealth. 

Senator WYDEN. Thank you, Senator Warner. 

Next, it will be Senator McCaskill, Senator Bennet, and Senator 

Grassley. We will have to see what happens if others come. 

Senator McCaskill? 

Senator MCCASKILL. Thank you. 

Senator Warner briefly talked about outreach. Ms. George, how 

did you find out about CHIP coverage? 

Ms. GEORGE. When Caleb was born, he was qualified for Medicaid, and it was pretty much a seamless transfer over from Medicaid onto the CHIP program in North Carolina—— 

Senator MCCASKILL. Executive Director Schwartz, I am not sure 

you can talk about this countrywide, but I am really curious what 

kind of outreach is going on in these rural communities. Is there 

an aggressive outreach? I do not recall ever seeing anything, but 

maybe it is more targeted, the outreach. So in terms of radio or 

billboards or anything like that, I do not recall ever seeing anything talking about CHIP in my State. 

Is it more targeted through the Medicaid population? But there 

are some children qualified for this in my State who would not 

qualify under Medicaid. 

Dr. SCHWARTZ. As with all things CHIP and Medicaid, it definitely varies from State to State. States can use some of their administrative dollars for outreach and enrollment, as Linda mentioned. The Federal grants allow States to partner with community-based organizations, which could be churches, or a community 

organization, schools, and so it can range tremendously across 

States. 

I do want to echo, obviously, the ad buys are the things that you 

and I would notice. We have heard quite a bit in Medicaid about 

people wanting that personal touch when signing up. Many people 

are very nervous in submitting an application, want to make sure 

everything is correct, and so that last touch with an outreach worker, it really gives them peace of mind that they have done everything properly to ensure that the enrollment goes through properly. 

Senator MCCASKILL. That would be a role similar to the navigators in the ACA? 

Dr. SCHWARTZ. It is very similar, very. 

Senator MCCASKILL. Which, by the way—I would point out they 

have just cut the budget 40 percent for navigators, ACA, and the 

advertising budget by 90 percent, which is a real problem. 

Could the two of you address what impact cuts to the Medicaid 

program would have on your work, assuming that there was success, which we hope there will not be, but if there were success in 

22 

cutting the Medicaid program as has been proposed a couple of different times in the context of an ACA replacement. What impact 

would that have on the CHIP program? 

Dr. SCHWARTZ. Well, CHIP is separately funded from Medicaid, 

but in most States, the two programs work hand-in-hand. 

The Medicaid proposals that have been considered over the past 

few months would put significant constraints on States, particularly going forward, on how they use those dollars. And presumably, if States had to make choices that would reduce eligibility levels in Medicaid, they would have to also reassess their CHIP programs. 

It is very hard to predict how individual States would make 

those choices, but clearly, I think that is very much on the mind 

of State administrators. 

Ms. NABLO. Absolutely. And I will just add Medicaid, obviously, 

takes care of the lower-income children. It also frequently takes 

care of the sicker children, waivers, disability waivers, et cetera. 

Oftentimes a child may well be in the CHIP income range or even 

the private insurance income range, but given medical expenses 

and the extent of their disability, they become eligible for Medicaid. 

If Medicaid is curtailed, if enrollment has to be rolled back because of funding, if those children were to become eligible for the 

State’s CHIP program, I think you would see us running through 

that funding much faster. 

Senator MCCASKILL. So what would happen is, some of the sickest children potentially would be removed from the Medicaid rolls 

and put on the CHIP rolls, which would put incredible pressure on 

the funding levels of CHIP, which would squeeze out, at some 

point, people from coverage under the CHIP program? 

Ms. NABLO. That would be my assumption, yes. 

Senator MCCASKILL. That is the way that I think it has been 

looked at, that you cannot look at Medicaid cuts in isolation and 

assume other parts of the system are not going to be put under 

pressure, and ultimately folks end up in an emergency room uninsured, in the most expensive care possible, and all of those costs 

are passed on to us. 

Thank you very much, Mr. Chairman. 

Senator WYDEN. Thank you, Senator McCaskill. 

The ever-gracious Michael Bennet. 

Senator BENNET. Thank you, Mr. Chairman. And to add to that, 

let me say words that have not been said in the Senate before. My 

questions have been asked. [Laughter.] 

Senator WYDEN. But not everyone has asked them. [Laughter.] 

Senator BENNET. That is true. That is a habit I am trying to 

have us break. 

But I have spent the morning in the HELP Committee, where we 

are trying to work on a bipartisan solution to our health-care issue. 

So I apologize to this very able panel. Your testimony was excellent, and it is really critical that we reauthorize this program. 

CHIP has provided localized health insurance for about 90,000 

kids who did not qualify for Medicaid in Colorado but are still unable to afford private health insurance. Colorado’s working families 

have benefitted from CHIP by increasing coverage for kids, driving 

23 

the percent of uninsured children to an all-time low now of 2.5 percent. 

On both sides of the aisle, everyone in this room certainly can 

agree that our children need to be covered and have access to quality health care, whether it is through CHIP or Medicaid, which covers over 400,000 children in my State of Colorado. CHIP also covers about 600 pregnant women in Colorado, and for these women, 

they have peace of mind knowing that they will have a provider to 

go to for maternity care. 

Without reauthorization—as these witnesses have so ably stated—without reauthorization of the CHIP program this month, Colorado may stop enrolling new children as of October 1st. They 

would have to move forward with an emergency plan, and it would 

be a disaster for us. 

So, Mr. Chairman, all I would like to do is, with your permission, 

submit for the record a letter from the Colorado CHIP Coalition, 

which includes over 70 organizations, asking for reauthorization of 

the program. 

Senator WYDEN. Without objection, so ordered. 

[The letter appears in the appendix on p. 39.] 

Senator BENNET. Thank you, Mr. Chairman. Thank you to the 

panel. 

Senator WYDEN. Thank you, Senator Bennet. 

At this point, it is Senator Stabenow and then Senator Grassley. 

Senator STABENOW. Well, thank you very much, Senator Wyden, 

for your leadership and for the chairman’s leadership. This is an 

issue that has traditionally been bipartisan. I am very hopeful we 

are going to be able to continue with a long-term extension in a bipartisan way and do what children and families across Michigan 

and across the country are counting on us to do. 

We know that before CHIP was created back in August 1997, 

millions of hardworking families could not take their children to 

the doctor and give them the care that they needed. Ms. George, 

thank you for speaking about your family and your experiences. 

I can tell you in Michigan right now, the good news is that 97 

percent of our children can go to the doctor. That is a very big deal. 

It is the highest percentage ever because of changes that we have 

made through the Affordable Care Act and through the Childrens’ 

Health Insurance Plan. We want to make that 100 percent, but 97 

percent is very good. 

Unfortunately, as has been said—and, Ms. Nablo, you have been 

talking about the sense of urgency—we are about to see that health 

care go away. And we do not need a short-term extension. What 

we need is to fully fund the program and give States, and more importantly, families, the peace of mind of knowing that they can continue to take their child to the doctor and give them the certainty 

that they need. 

So we need to act now. We need to act now, and I am hopeful 

that we are going to do that and do it in the right way for families. 

I want to just share one story before asking questions. I have 

talked to so many people in Michigan, so many families who are 

so glad that they have the opportunity to not worry in the middle 

of the night what is going to happen if the kids get sick, but know 

24 

that they are going to have the confidence to be able to take them 

to the doctor and get the care they need. 

One of my constituents, Jan, wrote me a letter saying, ‘‘From the 

time my daughter, Susie, was young, we knew she was going to 

need extra help. She was diagnosed in second grade with ADHD, 

and we proceeded to try a medical solution to her attention problems. 

‘‘As she got older, she was diagnosed as being bipolar and required a different approach to control her mood swings. Without 

having access to quality health care, we would have been lost. And 

thanks to MIChild, the Michigan CHIP program, with a premium 

of only $10 a month, we were able to afford the help she so desperately needed. 

‘‘She is now a high school graduate with a goal of attending community college. And we are so grateful that we have been able to 

get the help necessary to help her get to this point.’’ 

So today’s hearing is not about numbers. It is about people. It 

is about Susie. And I want to thank you, again, Ms. George, for 

coming today. 

I want to take a moment—because my questions on the cost of 

prescription drugs were ably asked and answered by Senator Wyden’s question, because that is such an important part of health 

care today and the drivers of health care. 

But there is another piece that Senator Grassley and I have been 

working on that I think would be wonderful to add to CHIP in 

terms of quality measures for prenatal care and for making sure 

that we are providing, through CHIP and Medicaid, a set of maternity and infant quality measures that have not been there. And we 

have been working on this for some time together. 

There is a broad coalition of organizations supporting this. There 

are so many that it is hard to know who to thank, but I want to 

thank the March of Dimes, in particular, for incredible advocacy on 

this. 

But I want to ask, Dr. Schwartz, if you could speak to the desire, 

the need to have a set of measures as it relates to quality standards. I know that MACPAC recommended a 5-year extension of the 

Pediatric Quality Measures Program, which we are building off of. 

So I wonder if you might indicate whether or not you agree there 

are gaps in the measures right now for labor and delivery, and 

could you discuss some potential quality measures and how they 

would benefit moms and babies? 

Dr. SCHWARTZ. Certainly. I am not an expert on quality measurement for maternity. I would note that the Pediatric Quality Measures Program is intended to help fill gaps, and also to work with 

users of measures to make sure that measures are not some academic exercise but can actually work in terms of reporting and in 

their usefulness in providing feedback to plans and providers about 

the experience of care. 

That work informs the inclusion of measures in the adult and 

child core set that CMS uses, and there are measures related to 

labor and delivery and prenatal care in both the adult and child 

core set. That is, obviously, a dynamic process, and over time measures have been introduced into the core set and taken out of the 

core set as our understanding increases. 

25 

I do think it is important. We talk about value to the beneficiary 

and value to the taxpayer of these programs, and certainly the 

availability of valid and reliable measures is an important part of 

that value equation. 

Senator STABENOW. Senator Wyden, I want to thank you and the 

chairman for supporting our effort to report out of committee the 

Quality Care for Moms and Babies Act last year. It is strongly bipartisan. It is noncontroversial and would add to the strength and 

the quality of what is before us now, and I am hopeful we can include it in the final bill. 

Senator WYDEN. I very much appreciate what Senator Stabenow 

and Senator Grassley are trying to do here. It has been supported 

in the committee, and I look forward to working with both of my 

colleagues. 

Now at this point, the also-gracious Senator Cardin has said 

that, while he is next, it would be fine if Senator Grassley went. 

We appreciate Senator Cardin’s courtesy, and I think Senator 

Grassley has—I think—a relatively short set of questions. But go 

ahead. 

Senator GRASSLEY. And I appreciate Senator Cardin’s—— 

Senator WYDEN. Everybody appreciates everybody. [Laughter.] 

Senator GRASSLEY. I think I have a fairly easy question for Dr. 

Schwartz, but before I do that, I want to say that we have this program that is a CHIP program for my State of Iowa. It is called 

hawk-i, not exactly spelled the same way as the Hawkeye football 

team. It is the Healthy And Well Kids in Iowa program. 

We had 83,400 Iowa children covered by hawk-i. It provides 

health insurance through commercial health insurance plans to 

kids of low-income Iowa households, up to 302 percent of FPL. 

Because of this program, children can receive lifesaving vaccines, 

medicines, doctor visits. In addition, children are checked to make 

sure that they are developing appropriately. 

This is a program that I have supported in the past, and I look 

forward to its reauthorization. 

So to Dr. Schwartz, I want to ask you about children’s access to 

care. As you may know, I have introduced S. 428, the Advancing 

Care for Exceptional Kids Act. We call that the ACE Kids for short. 

And I have introduced that with Senator Bennet, who has already 

spoken here. 

The goal of this legislation is to ensure that sick kids have access 

to the very best care. However, there are some statutory and regulatory barriers which can require children’s hospitals and specialized pediatric doctors additional work in order to care for these 

children. 

My two questions: has your organization, MACPAC, done work 

on this issue, and are there potential solutions that maintain or 

even strengthen the program integrity but make caring for these 

children more streamlined? 

Dr. SCHWARTZ. It is my understanding that the ACE Kids Act 

has evolved over a number of months, or perhaps maybe even 

longer than a year, in terms of its scope and size. We have not 

looked at it recently. It is something that we would be very willing 

to do, both at the staff level and the commission level, and would 

stand ready to provide any advice and feedback on that for you. 

26 

Senator GRASSLEY. Yes. Well what about just generally? Have 

you solutions that would strengthen program integrity and make 

caring for these children more streamlined, without looking at the 

bill I asked about? 

Dr. SCHWARTZ. It is my understanding that the ACE Kids Act focuses on children who are extremely sick and tend to have quite 

a number of hospitalizations. It is a very small population that 

needs specialized care and often needs care outside of their community and maybe even in another State. 

So that does create potential challenges for States that are very 

scrupulous in program integrity and knowledgeable about the providers in their State. So certainly that is a challenge when you 

have a kid who needs to have care across State lines. And as I said, 

we would be happy to look at any specific provisions and provide 

any guidance. 

Senator GRASSLEY. Okay. 

Well, is there any advice you can give about the bill—but also 

any consideration you can give, even without the legislation, would 

be very much appreciated. 

I thank you and thank Senator Cardin. 

Senator WYDEN. Thank you, Senator Grassley. 

And now, the patient Senator Cardin. 

Senator CARDIN. Thank you, Mr. Chairman. Everybody is thanking everyone else. I heard your opening statement, and I just identify with it and thank you for your leadership on the CHIP program. 

Senator WYDEN. Thank you. 

Senator CARDIN. I just really first want to underscore how important it is for us to timely reauthorize the CHIP program. There are 

143,000 Marylanders who are covered under the CHIP program. 

In this fiscal year, the cost is about $275 million. Now, $275 million is the total cost of the program. The Federal share is about 

$241 million. 

The Board of Public Works in Maryland just approved a budget 

cut mid-term because of budget deficits in our State. There is no 

conceivable, possible way that the State of Maryland can fill the 

gap under the CHIP program if it is not reauthorized in a timely 

way. So, if we do not reauthorize in a timely way, there are 

143,000 Maryland children who are at risk. And I just really wanted to underscore that. 

I was proud that in the 2009 reauthorization, an amendment I 

offered to include mandatory dental coverage was included under 

the CHIP program. 

Now, Mr. Chairman, many of you have heard me talk about this 

before. This was as a result of a tragedy that took place in Maryland in 2007, 2 years before the reauthorization was enacted into 

law. And it occurred about 7 miles from here in Maryland. Deamonte Driver, a 12-year-old, died because he could not get access 

to dental care. 

He had an abscessed tooth, needed to find a dentist who would 

provide about $80 worth of dental care, and could not be seen. He 

ended up becoming abscess-infected in his brain. A couple of operations later, a quarter of a million dollars, and he lost his life. 

27 

That motivated the Congress to take action, and I was pleased 

that we did. And we recognized that tooth decay is the number one 

disease affecting children in this country, and it is preventable. 

I went to many schools in Maryland and saw children and talked 

to teachers, learned exactly what oral health meant for the success 

of students in our schools. You cannot really learn if you have tooth 

problems and pain. 

So we have made tremendous advancements in dealing with pediatric dental care as a result of coverage within the Children’s 

Health Insurance Program. And I am proud of the progress that we 

made. 

After we included dental under the CHIP program, we also included pediatric dental under the Affordable Care Act. So one 

might think, well, now if CHIP is not reauthorized, will we not still 

be protected under the Affordable Care Act? The answer is ‘‘yes,’’ 

but not to the same extent that we have under the Children’s 

Health Insurance Program because of the match, cost sharing, and 

the fact that States can put in caps, et cetera. So there is a significant difference for oral health for children if we do not timely reauthorize. 

So I would just like to get the view of our distinguished panel 

of witnesses as to how important the CHIP program is for our children’s dental care and what changes we have seen occur nationwide as a result of the coverage for dental care within the CHIP 

program. 

Dr. Schwartz, would you—— 

Dr. SCHWARTZ. One of the areas for the Commission’s analysis 

and consideration in thinking about the future for children’s coverage was the availability of different types of benefits for children 

in CHIP versus other sources. And as you pointed out, pediatric 

dental is an essential health benefit, but the way the exchanges 

cover dental, it is often not included in a comprehensive package; 

it can be purchased separately, but the way the cost sharing works 

out, it is in fact more expensive. 

So we did not find a tremendous number of differences between 

CHIP and exchange coverage, but audiology and dental were the 

two benefits that we called out just as you say. 

Senator CARDIN. I would point out that I was proud of Maryland 

in that all of our carriers included pediatric dental within the 

prime contracts. We did not have to have a separate policy. But 

there are places in the country where you have to get a separate 

policy, and then you run into the cost sharings and the caps that 

can be different, which causes problems. 

Ms. Nablo, would you want to comment? 

Ms. NABLO. What occurred to me first, as you were speaking, 

was that we are always very cognizant when we do outreach for 

the CHIP program of highlighting that it involves dental care. That 

is extremely valuable to parents. And it is—I suspect it is—for parents who do not have a particularly sick child at this point, it is 

one of the big drivers that brings them to our door to apply for 

CHIP coverage, because it is not common with private insurance or 

exchange coverage for those children to have access to dental care. 

Senator CARDIN. I would just point out, Mr. Chairman, in closing 

that one of the side benefits of the CHIP program and oral health 

28 

for children is that we now have dentist access in communities that 

did not have that access before. So it is not just coverage, it is also 

that providers are now in communities that they were not in before 

as a result of the CHIP program. 

Thank you, Mr. Chairman. 

Senator WYDEN. Thank you, Senator Cardin, and thank you for 

again highlighting the importance of dental care. 

Now here is where we are in the order: Senator Thune, in order 

of appearance is next, Senator Cantwell, and then our friend from 

Delaware, if that is all right with colleagues. 

Senator Thune? 

Senator THUNE. Thank you, Mr. Chairman, for holding the hearing on the path forward for the Children’s Health Insurance Program. Of course, I want to thank all of our witnesses for joining 

us as well, especially Ms. George, who has shared her family’s personal experience with the CHIP program. 

In my home State of South Dakota, CHIP serves more than 

50,000 kids in a given month. And like many States, we run a combination program. And our State projects that if CHIP expires, 

nearly 12,000 kids would be shifted to Medicaid and more than 

3,500 could lose coverage altogether. 

I think we can all agree that this program has enjoyed broad bipartisan support over the years, and it is critical that we work together to ensure that kids across the country continue to have access to uninterrupted coverage. 

And it sounds like this ground has been plowed a little bit already, but I want to—for purposes of my State’s interest—ask the 

question of Ms. Nablo. 

The administrators of CHIP in South Dakota have talked with 

us about the importance of maintaining State flexibility—which I 

think you have addressed on some level already—to determine benefit structure moving forward. You mentioned that in your testimony as well. From a State perspective, are there other areas 

where greater flexibility might be needed so that States can best 

meet the needs of their populations? 

Ms. NABLO. I would say that the Virginia experience is one of 

continual change and continual improvement of the program to 

best meet the needs of families in our State. Certainly some flexibility in the benefit structure is helpful. 

For example, Virginia just added a very robust package of substance use disorder benefits to help address the opioid epidemic. 

We added those for children in our CHIP program and for the pregnant women in our CHIP waiver. 

So the ability to be able to do that was very helpful. The story 

in Virginia is, we started out with a very restrictive program. We 

had some of the most restrictive policies in the country. 

For example, we started out with a 12-month forced period of 

uninsurance before a child could be found eligible for CHIP. That 

later went to 6 months, then went down to 4 months, and we have 

since abolished it. But that is within the ability of the State, given 

where the legislature is, what people learn as they go along with 

the program about what is needed and as they become more educated about families’ needs. There is a constant and continual improvement to the program. 

29 

I think States probably appreciate the flexibility in CHIP a great 

deal. It is one of the most attractive features, probably originally, 

for States taking up this offer in the first place, and I think they 

would be very concerned if that flexibility went away. 

Senator THUNE. Okay. 

Dr. Schwartz, South Dakota also raised the importance of States’ 

continued ability to carry over funds. You raised this issue in the 

context of how long States will be able to continue to run CHIP 

programs and also raised operational considerations associated 

with extending the program. 

How quickly can States respond to congressional action? And I 

would also, I guess, direct the question to Ms. Nablo, if you would 

care to comment on how quickly you would expect Virginia to be 

able to respond. 

Dr. Schwartz? 

Dr. SCHWARTZ. When MACPAC made its recommendations, we 

set ourselves a deadline of having our recommendations available 

at the beginning of this Congress so that you could act quickly, to 

allow States to take the time to plan for the next fiscal year. Obviously, many months have elapsed since then. States have held off 

making changes to their programs, not wanting to alarm beneficiaries unduly and also to not cause disruption for the plans and 

providers. 

I think that the clock really is very close to having run out. 

The other point I want to make clear is that, while MACPAC has 

put out these figures noting when States will run out of money, 

that is not meant to say that Congress can wait until that deadline 

to make a decision. 

It is really important for States to have the certainty right now 

so that they can plan appropriately so that these programs are run 

in a deliberate and professional manner. 

Senator THUNE. Okay. Thank you. 

Ms. Nablo, any response in terms of Virginia’s—— 

Ms. NABLO. I would say the challenge is not so much how fast 

we can respond to any changes you would choose to make. I would 

say the challenge is much more, how long can we wait until you 

tell us with certainty that there will be funding for this program 

and what level it will be? 

I think for some States we are weeks, a few weeks, maybe a couple of weeks away from having to take proactive measures to start 

shutting down. For Virginia, as I said earlier, I have a long ‘‘to do’’ 

list—I actually have it in my briefcase today—of things that will 

need to happen. And that ‘‘to do’’ list starts in October for us, with 

beginning to do the training, and the system changes, and all the 

things that will need to happen. 

If the CHIP is authorized but the funding is reduced, that causes 

immediate budgetary problems in the State of Virginia. We have 

an immediate $57-million shortfall in this State fiscal year. Our 

legislature comes to town on January 10th, and I guess that would 

be one of the very first problems they would have to face, what do 

we do with that kind of a hole in the budget, and it grows the next 

year. 

So it is really more a matter of, we are waiting with bated breath 

to hear from Congress. 

30 

Senator THUNE. Okay. Thank you. 

Thank you, Mr. Chairman. 

Senator WYDEN. Thank you, Senator Thune. 

We started, actually, a couple of hours ago with that question. 

And now as we move towards the end, I am glad you have highlighted that, because this is not something, where in the traditional 

Washington situation, you can have the amendment, the amendment to the amendment, and maybe it happens, and maybe it does 

not. Your question, again—Ms. Nablo highlighted that this morning—shows this has real consequences if there is delay. And I appreciate your bringing it up as we get to wrapping up. 

Senator Cantwell? 

Senator CANTWELL. Well that is definitely the line—thank you, 

Mr. Chairman—that I want to follow as well, because I am from 

Washington, and we like efficiency in our health-care delivery system no matter, whether it is talking about CHIP, adults, or what 

have you. 

I do want to say, Ms. George, I so appreciate your testimony 

today. Being here, you really highlighted what this issue is all 

about, and it is about giving families the ability to take care of the 

needs of their families by making sure that they have coverage. 

And I so appreciate that your son, Caleb, is here as well. 

And I wondered if we could just—I was so touched by your story 

about his Scouting awards. Is it okay if we give him a round of applause for his achievements? 

[Applause.] 

Senator CANTWELL. So I do not think we can ever forget the people who are affected by this program and what it means. And when 

I think about Ms. George and her family, what she has been able 

to accomplish, I think about the modernization of CHIP. 

So in our State, we cover children up to 211 percent of poverty. 

And we cover up to 312 percent through CHIP, and yet we have 

families at a different level. 

One thing that we have seen in New York, with the advent of 

the basic health plan, is a front door that allowed families in CHIP, 

no matter whatever the entry way was, to then get coverage. It 

also has driven down costs. It has driven down costs for everybody. 

It has driven down cost for the State. It has driven down cost for 

the Federal Government. It has made the program streamlined and 

efficient. 

Do you think there is more to do, Dr. Schwartz or Ms. Nablo, in 

streamlining this program, thinking about both children and 

adults, making sure that there is coverage and cost savings in the 

administration side of this? 

Dr. SCHWARTZ. There is certainly always work to do. One of the 

things that the Commission recommended was demonstration 

grants to States to try to think about how to better coordinate different sources of coverage. We know that the answer may be different in different States and wanted to provide an opportunity for 

States to experiment in how to smooth these transitions across coverage so you do not have situations where families lose coverage 

due to change in their life circumstances and lose continuity of care 

and have gaps in coverage. 

31 

So there is certainly more work to be done. MACPAC is meeting 

next week, and one of the things that we are taking up is a broader 

inquiry around Medicaid to assess where we are with streamlining 

eligibility, enrollment, and renewal processes to be able to see what 

we have accomplished and what more work needs to be done. 

Ms. NABLO. I would agree with Dr. Schwartz. Both within the 

health-care arena and also just other Federal programs like SNAP 

and TANF, et cetera, there is a great deal of difficulty, disparity, 

differences in how those are administered and how you count income, et cetera, that is extremely confusing for families and very 

difficult to administer. 

And even if you are successful in, for example, the health-care 

arena, moving from CHIP to Medicaid or back or if your family 

gets coverage on the exchange or whatever, the benefits can be 

very different. The doctors can be very different. The copayments 

and deductibles can be extremely different, and it just creates an 

extremely confusing atmosphere. 

Senator CANTWELL. Well, I think it probably creates costs too. 

Ms. NABLO. And costs. 

Senator CANTWELL. And to me, streamlining that so there is a 

front door where families are covered and doing so in the most 

cost-effective way, considering they are likely getting coverage—it 

is just not in a uniformed way. 

I, Mr. Chairman, regret that we—we identified this when we 

were doing the Affordable Care Act, but some of our colleagues 

were thinking more about CHIP at the time, less about this confluence that was going to happen. But I wish that then we would 

have offered some innovation to streamline, because I think we 

could have reduced costs, and I think we could have given more 

certainty to those families. 

So I certainly hope we will take a look at that now, because I 

do think it is one of the keys to making this more affordable for 

everybody. 

Thank you. 

Senator WYDEN. Thank you, Senator Cantwell. And Oregon has 

always seen itself in a partnership with Washington State on these 

efficiencies. 

And I think the point you made is extraordinarily important, because inefficiency wastes money. And if you waste money, you are 

not dealing with the scarce services, for example, that you talked 

about with respect to Caleb and the real consequences for people. 

So I thank my colleague. 

Senator Carper? 

Senator CARPER. I am not sure if Senator Brown was in line before me. 

Senator WYDEN. You were here first. 

Senator CARPER. Okay. Thanks. 

To our colleagues here—the four Senators who are here in the 

room right now are all Democrats. I would just note that our chairman, one of his most important—he has a lot of important accomplishments in the time that he served here, but maybe none more 

important than his work, I think, with Senator Kennedy on the 

Children’s Health Insurance Program. 

32 

I look forward to working with my colleagues who are here, but 

certainly with Senator Hatch, to extend funding to ensure that millions of kids, including about 18,000 in Delaware, continue receiving health insurance coverage under this program. 

I was actually—as chairman of the National Governor’s Association—in the White House with President Clinton and Hillary Clinton on the day that this was rolled out at the White House. So this 

is one that has special meaning for me and for the people I am 

privileged to represent. 

I have a couple of questions I would like to ask of our witnesses. 

Thank you so much for being here. Are you from Virginia? You 

work for the Governor there? 

Ms. NABLO. Yes, I do. 

Senator CARPER. Tell him a guy who grew up in Danville and Roanoke sends his best, please. 

And they are building a ship in Newport News, VA today, a submarine called the U.S.S. Delaware, and we look forward to being 

back down there with Terry and to launching that with Joe Biden 

in several months. 

CHIP serves millions of people in our country, some 18,000 kids 

in Delaware. Our neighboring State—I think Senator Cardin, when 

he was here, just said a few minutes ago about 143,000 kids in 

Maryland are covered. 

But if we allow CHIP to expire at the end of this month, many 

of the children in our State, on Delmarva, and across the country 

are going to either become uninsured or maybe underinsured. 

I am going to ask Dr. Schwartz, can you speak to whether other 

insurance coverage options for kids, including private insurance, 

would be able to provide for these children if CHIP expires, and 

how do these options compare in terms of cost sharing protections, 

in terms of pediatric benefits and pediatric networks, to CHIP? 

Dr. SCHWARTZ. Certainly. Our analysis shows that if CHIP funding comes to an end, there are two different scenarios depending 

upon whether a child is covered under separate CHIP or a Medicaid expansion CHIP. 

Separate CHIP funding programs would end. And we estimate 

that 1.2 million of those children would become uninsured. 

All of those children would be eligible for either subsidized exchange coverage or employer-sponsored coverage, but for most of 

them, the cost of those, cost sharing, would be prohibitive, and that 

is why they would become uninsured. 

For those who do enroll in exchange coverage and those who do 

enroll in employer-sponsored coverage, they would experience much 

higher cost sharing than they currently experience under CHIP. 

And as I noted earlier, there would be some differences in benefits, most notably audiology and dental were the ones that we 

pointed out, and I think it is very likely as well that they would 

experience a change in provider in moving to a different plan. 

Senator CARPER. Okay. Thanks. 

Ms. Nablo, you mentioned the importance of CHIP for access to 

mental health services, for substance abuse treatments, for immunizations, basic health care, to help children be able to live a normal life. Could you describe for us the role that CHIP plays in 

treating mental health conditions as well as combating the opioid 

33 

epidemic and the improvements in public health that Virginia has 

experienced because of the CHIP program? 

Ms. NABLO. CHIP in Virginia was originally designed based on 

the State employee health plan. Over the years, additional benefits 

have been added, bringing it much closer to the Medicaid package 

of benefits, but not the full range of Medicaid. For example, we do 

not cover EPSDT or we do not cover residential care in CHIP. 

But it has become a very robust child-centered benefit package. 

So it includes many mental health benefits. 

But in reaction to the—I will not say recent, but in the last several years—awareness of the opioid epidemic, Virginia has, under 

the leadership of Governor McAuliffe, taken a very aggressive 

stance to try to combat that epidemic. A big part of that initiative 

is to add addiction treatments that are evidence-based and recognized by national associations as being effective, to both Medicaid 

and to CHIP and to our pregnant women coverage in both of those 

programs as well. 

We have just done that. Most of those benefits became effective 

April 1st. We just added another one as of July 1st. So it is, I 

think, a little too early to talk about the effect on individuals. 

What we have seen—because along with adding those benefits, 

we also increased provider rates. So we have seen a significant 

growth in providers offering these evidence-based practices into the 

southwest of Virginia, Roanoke, and beyond. We are very excited 

about the growth in the provider network and believe that will 

carry over into improvement in outcomes. 

Senator CARPER. Thank you. 

Thanks so much. Thanks to each of you for the work you do. God 

bless. 

Senator WYDEN. Thank you, Senator Carper. 

Senator Brown? 

Senator BROWN. Thank you, Mr. Chairman. 

Today, first a ‘‘thank you’’ to the witnesses. I appreciate your 

being here and speaking out for one of the most important things 

that we should do this fall. 

I would like to submit for the record two letters: one from Ohio’s 

Department of Medicaid Services Director, Barbara Sears; and one 

from the Ohio Children’s Hospital Association. 

Senator WYDEN. Without objection, so ordered. 

[The letters appear in the appendix beginning on p. 42.] 

Senator BROWN. Thank you, Mr. Chairman. 

I would add that Ohio has, I believe, still more free-standing children’s hospitals than any State in the country. I know that when 

my friend, the Senator from Oregon, was in Ohio, he met some of 

the people who work in some of these hospitals. 

I would like to ask each of you about the importance of extending 

CHIP funding for more than 2 years. Dr. Schwartz, many advocates have written in support of a longer period, as much as 5 or 

more years. 

When Secretary Price testified—Secretary-Designee Price—I 

asked him about the question of longer extension. I suggested 8 

years. He concurred and said 8 years could make sense. MACPAC 

recommended we extend funding through fiscal year 2022. 

34 

Dr. Schwartz, explain briefly—and I need briefly, and I apologize. 

And you are probably tired of these questions anyway. So explain 

briefly why MACPAC recommends a 5-year extension? 

Dr. SCHWARTZ. Yes, MACPAC’s primary reason for the 5-year extension is the tremendous uncertainty in health insurance markets 

generally at this point, whether that relates to Medicaid or the exchange market, and certainly volatility of private coverage. And 

really it is important to secure the gains in coverage that CHIP has 

brought and to put kids in a place that is safe, where coverage is 

going to be available to them while all of these other problems are 

sorted out. 

We have had quite long extensions of CHIP in the past. The first 

one was for 10 years. CHIPRA was from 2009 to 2013. So certainly 

there is a track record in the Congress for long-term extensions. 

Senator BROWN. Thank you, Dr. Schwartz. 

Ms. George, thank you for coming today. I understand your son, 

Caleb, is here, and he is aiming to become an Eagle Scout. I am 

an Eagle Scout, and I know the work that he will do to become an 

Eagle. I assume that his mother having the peace of mind knowing 

that CHIP will be there to raise her healthy young future Eagle 

Scout will be important. Talk to me about what extension means 

for peace of mind, what that means for a mother of a young man 

like Caleb. 

Ms. GEORGE. Well, probably for me the biggest thing is knowing 

that he is covered. Right now, we had an insurance lapse a couple 

of months ago because of changing employers. He was not affected 

by that because he had CHIP. 

Just that peace of mind knowing that no matter what happens 

to you, what happens to your loved ones, your child has the coverage that they need to be healthy, to have everything they need 

for school, for developing into the young man that they can become, 

is just tremendous. That is why it is so important for us. 

Senator BROWN. Good luck. 

Let me know when his court of honor is in ‘‘X’’ number of years. 

Ms. GEORGE. Thank you. I sure will. 

Senator BROWN. Ms. Nablo, my home State of Ohio has been a 

leader in innovating within CHIP and Medicaid. It is to lower costs 

and to improve outcomes—we still are embarrassingly awful in 

terms of infant mortality and some other indices. But CHIP has 

helped us be more than marginally better. 

The Kasich administration tells me it is difficult to innovate 

when the future of the program is uncertain. Talk about what certainty means, in terms of stability, in terms of running a department, in terms of making this all work, especially in terms of innovation. 

Ms. NABLO. Well, when you are looking at—we have come extremely close to the wire this time. So what does that mean for the 

future? 

If there is a 1-year extension or a 2-year extension, what that is 

saying, I think, to States is, we are going to potentially be right 

back here 2 years from now, up against the wire again. 

So the question you have to ask yourself, I think, as a State is, 

what kind of an investment are you going to make in this program? 

How much outreach are you going to do to drive children to this 

35 

program when it may not be there 2 years from now because it has 

come so close this time? 

There is a feature in CHIP called a Health Services Initiative, 

HIS, where States that have sufficient admin funding can actually 

help support other programs like poison control centers. I understand there is one State that is now using some funding to help 

supply those kits that help somebody immediately recover from an 

overdose, to help pay for some of that for children. 

So do you as a State begin to invest in something like that when 

by the time you get all of the paperwork done and the money flowing—— 

Senator BROWN. So it needs to be at least—it needs to be more 

than 2 years? 

Ms. NABLO. I will take anything at this point. 

Senator BROWN. Of course, of course. 

Ms. NABLO. But I absolutely—— 

Senator BROWN. But I do not want you to have to come in here 

every year or two and say, I will take anything. I want you to—— 

Ms. NABLO. But absolutely, 5 years or longer would be a very 

welcome thing for States. 

Senator BROWN. I will continue—and I know the chairman, I 

know Senator Wyden agrees with this. We will continue, at least 

many of us who care about this program, we will continue to advocate for at least 5 years. 

So thank you all. 

Senator WYDEN. Thank you, Senator Brown. 

I want to just wrap up with a couple of thoughts, picking up on 

Senator Brown’s really thoughtful case for how important a longterm extension is. And, Ms. Nablo, you have done an extraordinary 

job this morning laying this case out. 

I have agreed with every single thought, save that one at the end 

about you will take anything. [Laughter.] 

I want to leave this hearing saying that I think we all understand—and you did not mean it that way, of course—that kids deserve the very best. 

I want to kind of recap a little bit on where we are on this issue. 

The Children’s Health Insurance Program did not come about by 

osmosis. It did not just kind of magically show up in America and 

everybody said, hey, we are going to cut the rate of uninsured kids 

in America. 

It happened because two very strong-willed United States Senators, the late Senator Kennedy and the chairman of this committee, acknowledged that they had plenty of differences on plenty 

of issues, but both said, we have got to do right by kids. We have 

got to step up. 

And the reality is that without the two of them doing it, I do not 

see how it would have happened. So what we are talking about 

today is asking United States Senators to pick up on that extraordinary legacy of Chairman Hatch and Senator Kennedy and step 

up. 

And you are going to hear a lot this fall about how there are all 

kinds of priorities on the Senate calendar. I listed some of them, 

and I am sure Caleb was not paying attention to all of the government lingo and all of the acronyms and all the initials. 

36 

But the real question behind our job going forward is to make 

sure that CHIP is way, way, way up that priority list so it does not 

get short shrift, it does not put us in a situation, as Ms. Nablo described very eloquently about this kind of parade of horribles—I do 

not know any other way to describe it—that kicks in if somehow 

everybody says, oh, we have other things to do and that sort of 

thing. And it starts to happen pretty darn soon if it does not get 

the attention that it is deserving. 

Now, the last point I want to make is that I am sure we are 

going to have a discussion about costs. America has a lot of challenges in terms of the budget. 

But I just hope what we say is, when people say, can we afford 

a generous funding package for CHIP, I hope that we say—on the 

basis of the really thoughtful comments that you all have made, 

and for Caleb sitting behind his mom—I hope we say America cannot afford not to cover CHIP in a generous kind of way, because 

we heard testimony about what it really means to be able to afford 

these skyrocketing medication prices. 

I noticed your comment was, well, you know, we probably could 

figure out a way to do this. You said that as a mom. But you know, 

that is not considering all of the prospective price hikes. 

So what we know is that, if you do not get there early for these 

children, you end up playing catchup for years and years to come. 

So we either get there for kids like Caleb and ensure that they can 

afford medications and spend a modest amount of money in order 

to get that coverage, or you basically say, oh, we are not going to 

do it, and we will pay, and pay, and pay some more in the years 

ahead as a result of that short-sighted thinking. 

So we have a lot to do to talk about how we cannot afford not 

to do this. We have a lot to do to make sure that this gets up the 

priority list. We have a lot to do to show that this did not just come 

about by accident. It came about because of the extraordinary leadership of our chairman and the late Senator Kennedy. 

The three of you have really given us sort of a road map on how 

the Congress ought to come together, and why it ought to come together. Each one of you brought a unique experience. 

I have sat in on a fair number of hearings on this committee and 

have tried to specialize in health care since the days when I was 

director of the Gray Panthers back at home in Oregon. This has 

been one of the best health hearings that we have had in the Finance Committee. It is because the three of you laid the case out 

so well. 

You could see the great interest among members on both sides 

of the aisle, and we are walking out of here today knowing that the 

job is going to be tough in the days ahead, but you have given us 

a path for the important work that has to be done. 

I have one bit of business on behalf of the chairman. I wanted 

to make sure everybody understood he appreciates their attendance 

and that he feels that this is a very important conversation. He 

wants Senators to meet with him to talk through their ideas and 

suggestions. He believes that we are confident that we can get a 

meaningful and bipartisan solution. 

And the last request of the chairman is that he would like to 

make clear that, for any members of the committee who have writVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 R:\DOCS\31255.000 TIM
37 

ten questions for the record, the chairman would request that those 

written questions be submitted by the close of business on September 14th. 

With that, the Senate Finance Committee is adjourned. 

[Whereupon, at 12 p.m., the hearing was concluded.] 

(39) 

1 Roughly 90,000 kids and pregnant women had coverage in Colorado’s CHIP program (CHP+) 

sometime during the 2015–2016 fiscal year. This number is slightly higher than HCPF’s reported monthly caseload numbers, which use point-in-time estimates. Since some clients lose eligibility and others gain eligibility throughout the year, the number here is higher than the number of children being served during any one month during the year. 

A P P E N D I X 

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

LETTER SUBMITTED BY HON. MICHAEL F. BENNET, A U.S. SENATOR FROM COLORADO

#FUNDCHIPCOLORADO

The Honorable Michael Bennet The Honorable Ken Buck 

U.S. Senate U.S. House of Representatives 

The Honorable Cory Gardner The Honorable Doug Lamborn 

U.S. Senate U.S. House of Representatives 

The Honorable Diana DeGette The Honorable Mike Coffman 

U.S. House of Representatives U.S. House of Representatives 

The Honorable Jared Polis The Honorable Ed Perlmutter 

U.S. House of Representatives U.S. House of Representatives 

The Honorable Scott Tipton 

U.S. House of Representatives 

Dear members of the Colorado congressional delegation: 

We write to you today with an urgent issue to which we hope you will give your 

immediate attention and unwavering support. The Children’s Health Insurance Program (CHIP) funding is set to expire on September 30, 2017. We urge you in the 

strongest terms to renew funding for this important program through 2022 at the 

currently established levels that enable Colorado to implement a successful program. 

Our organizations represent a broad and diverse coalition of child health advocates, 

family doctors, pediatricians, community clinics, large and small hospitals and many 

others who have seen first-hand that CHIP, or CHP+ as Colorado’s program is 

called, has made a genuine impact on thousands of Colorado kids and their families 

as well as the pregnant women the program serves. By bridging the gap for working 

families who wouldn’t otherwise be able to afford private health insurance for their 

children, this program represents the difference between a healthy start and a childhood plagued with no preventive care, poor health, and poor performance in school. 

CHIP has benefited Colorado’s working families by ensuring their kids get the 

healthy start they need to reach their full potential. A failure to extend Federal 

funding for the program would jeopardize coverage for about 90,000 kids and pregnant women in Colorado.1 Nationally, about 8.9 million kids and their families use 

CHIP for their health insurance. If financing is not extended, coverage losses will 

start in early 2018 according to the Colorado Department of Health Care Policy and 

Financing (HCPF). CHIP has been an integral part of Colorado’s efforts to get kids 

covered, as well as national coverage gains, since its inception 20 years ago. A loss 

of the program would wipe out much of this progress Colorado and other States 

have achieved. CHIP, partnered with Medicaid, has given Colorado the two-pronged 

40 

approach it needed to help increase coverage for kids, driving the percent of uninsured Colorado kids to an all-time low of only 2.5 percent. 

Simply switching to private insurance isn’t a solution for families who use this program. For example, the maximum annual enrollment fee for a family on CHIP is 

$75 or about $6.25 per month. The cheapest catastrophic health plan in Denver for 

a child is $103 monthly—a 1,500 percent increase. That increase climbs to at least 

$144 a month—a 2,200 percent jump—if you live in rural Chaffee County. And 

these catastrophic health plans would still expose families to very high out-of-pocket 

costs including large deductibles. In addition, recent studies have shown that outof-pocket maximums for the working families using the program would skyrocket if 

the program goes away, jumping from an average of $789 to as much as $4,500 annually for a family of three living on $32,484 a year. 

Like all States that use the program, Colorado has set the rules for how it operates. 

Here, families buy into the program through an annual fee and pay co-pays for services, much like private insurance. Colorado has worked to ensure that the provider 

network for the program is pediatric-focused, which puts kids’ health first and provides lower cost-sharing options than in private plans. The program includes important benefits, such as dental, that aren’t often found in other plans. This attention 

to a pediatric-focused benefits package is particularly important to kids with chronic 

issues who often require specialty care. For kids with chronic illnesses and disabilities, CHIP is critical because it provides more benefits than private insurance. 

We know that for all kids, their family’s ability to access insurance for them matters. Kids with CHIP coverage are more likely to have a doctor that they see for 

regular care and less likely to be hospitalized for a condition that could have been 

treated at a primary care doctor visit. Kids with health coverage are less likely to 

drop out of high school, and more likely to graduate from college and have higher 

incomes as adults. An overwhelming amount of research tells us that healthy kids 

are better learners in school, have fewer absences from their educational experience 

and are better prepared when they enter adulthood. 

From a Colorado budget perspective, our State stands to lose $254 million annually 

in Federal funding if the program is ended. That’s a hole in the State budget that 

Colorado won’t be able to close due to constitutionally imposed tax and spending 

limitations. CHIP funding in Colorado provides support for both kids and pregnant 

women in Colorado’s CHP+ program as well as certain kids enrolled in Medicaid. 

Colorado’s budget for 2017–2018 is already set and includes Federal CHIP funding 

at current rates. Abruptly stopping the program does not allow State lawmakers to 

appropriately plan for dramatic changes to anticipated Federal revenue streams, 

does not give our State government time to implement thoughtful transitions, and 

does not give families the time they need to plan ahead. Extending funding for 

CHIP through 2022 will provide budget predictability as Colorado plans for the next 

fiscal year and beyond. 

Across its nearly 20-year history, CHIP has enjoyed bi-partisan support because it 

increases health insurance for children and helps working families while operating 

more like a private insurance plan through membership fees and co-pays. Even in 

our current, deeply divisive political environment, there is no reason CHIP should 

not continue to enjoy this kind of support. It’s a strong program with a track record 

that has proved its value to our country, our State, Colorado’s working families and, 

most importantly, the children and pregnant women it serves. It deserves your attention and support. 

Sincerely, 

9to5 Colorado 

AFT Colorado 

All Families Deserve a Chance Coalition 

American Academy of Pediatrics—Colorado Chapter 

American Heart Association—Colorado 

American Liver Foundation, Rocky Mountain Division 

Boulder County Commissioners 

Boulder County Department of Housing and Human Services 

Bruce Doenecke, MD 

Center for Health Progress 

Children’s Hospital Colorado 

Chronic Care Collaborative 

Colorado Academy of Family Physicians 

Colorado Access 

41 

Colorado Center on Law and Policy 

Colorado Chapter of the National Hemophilia Foundation 

Colorado Children’s Healthcare Access Program 

Colorado Children’s Campaign 

Colorado Coalition for the Homeless 

Colorado Community Health Network 

Colorado Consumer Health Initiative 

Colorado Covering Kids and Families 

Colorado Cross-Disability Coalition 

Colorado Dental Association 

Colorado Dental Hygienists’ Association 

Colorado Fiscal Institute 

Colorado Gerontological Society 

Colorado Hospital Association 

Colorado Organization for Latina Opportunity and Reproductive Rights 

Colorado Public Health Association 

Colorado’s Community Safety Net Clinics 

Delta Dental of Colorado 

Denver Health and Hospital Authority 

Early Milestones Colorado 

Epilepsy Foundation of Colorado 

Family Voices Colorado 

Farley Health Policy Center, University of Colorado School of Medicine 

Focus Points Family Resource Center 

Healthier Colorado 

Huerfano-Las Animas Counties Early Childhood Advisory Council 

Joanne Sprouse, Director, Division of Human Services, Summit County 

La Plata County Board of County Commissioners 

La Plata Family Centers Coalition 

Larimer County Department of Human Services 

Las Animas County Department of Human Services 

Leland Johnston, MD 

Mara S. Baer, Founder and President, AgoHealth, LLC 

Mental Health Colorado 

National Association of Social Workers, Colorado Chapter 

National Council of Jewish Women, Colorado Section 

National Stroke Association 

Nurse Advocate 

Oral Health Colorado 

Parkinson Association of the Rockies 

Peak Vista Community Health Centers 

Peter Dawson, MD, MPH 

Pitkin County Human Services 

Planned Parenthood of the Rocky Mountains 

ProgressNow Colorado 

Pueblo County Department of Social Services 

Rocky Mountain Health Plans 

Rural Communities Resource Center 

Senior Mobile Dental 

Stahlman Disability Consulting, LLC 

Steve Clifton, Director Fremont County Department of Human Services 

Steve Johnson, Larimer County Commissioner 

Sunrise Community Health 

Support Jeffco Kids 

The Arc Arapahoe and Douglas Counties 

The Bell Policy Center 

The Consortium 

Together Colorado 

Tri County Health Department 

Wendy Zerin, MD, FAAP 

Women’s Lobby of Colorado 

Yondorf and Associates 

Young Invincibles 

CC: Governor John Hickenlooper 

Sue Birch, Executive Director of the Department of Health Care Policy and 

Financing 

Gretchen Hammer, Medicaid Director 

42 

Senator Kent Lambert 

Senator Kevin Lundberg 

Senator Dominick Moreno 

Representative Bob Rankin 

Representative Millie Hamner 

Representative Dave Young 

LETTERS SUBMITTED BY HON. SHERROD BROWN, A U.S. SENATOR FROM OHIO

OHIO DEPARTMENT OF MEDICAID

50 W. Town Street, Suite 400 

Columbus, Ohio 43215 

http://medicaid.ohio.gov/ 

John R. Kasich, Governor 

Barbara R. Sears, Director 

September 6, 2017 

The Honorable Rob Portman The Honorable Sherrod Brown 

448 Russell Senate Office Building 713 Hart Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

The Honorable Bob Latta The Honorable Bill Johnson 

2448 Rayburn House Office Building 1710 Longworth House Office Building 

Washington, DC 20515 Washington, DC 20515 

Re: CHIP Reauthorization 

Dear Senators Portman and Brown and Congressmen Latta and Johnson: 

I am writing today to urge your support of reauthorizing funding for the Children’s 

Health Insurance Program (CHIP), which currently supports coverage for nearly 

219,000 Ohio children as part of the Ohio Medicaid program. Retaining CHIP funding for services at its present 23-point enhanced match rate will provide Ohio with 

much needed stability as it faces challenges brought about by an already challenging State biennial budget. 

Unless funding for CHIP is reauthorized, Ohio stands to exhaust CHIP funding by 

the close of calendar year 2017. Ohio provides CHIP coverage as an extension of its 

Medicaid program. Thus, as required by the Affordable Care Act’s maintenance of 

effort provisions, Ohio will be compelled to continue coverage for these children at 

its regular Federal match rate, at an estimated cost of more than $200 million over 

the next 2 years. 

The Ohio Medicaid program is already successfully navigating an appropriations 

gap in the State’s current budget. However, elimination of over $200 million in 

CHIP funding would be a severe additional blow to the program and would likely 

require cuts in other services in order to support continued access to necessary 

health care for Ohio’s Medicaid-eligible children. 

For all of these reasons, I strongly urge your support for a measure that would reauthorize CHIP for at least the next 2 years. That said, a longer reauthorization period (5 to 10 years) would provide additional stability and avoid the cyclical uncertainty that has plagued this valuable resource over the last several years. 

Thank you for your continued support for Ohio’s most vulnerable citizens. If you 

need further information, please do not hesitate to contact me. 

Sincerely, 

Barbara R. Sears 

Director 

CC: Hon. Orrin G. Hatch, Chairman, Committee on Finance 

Hon. Ron Wyden, Ranking Member, Committee on Finance 

Hon. Greg Walden, Chairman, Energy and Commerce Committee 

Hon. Frank Pallone, Ranking Member, Energy and Commerce Committee 

43 

OHIO CHILDREN’S HOSPITAL ASSOCIATION

September 6, 2017 

The Honorable Orrin G. Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Committee on Finance Committee on Finance 

U.S. Senate U.S. Senate 

219 Dirksen Senate Office Building 219 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

Re: Children’s Health Insurance Program 

Dear Chairman Hatch and Ranking Member Wyden: 

On behalf of the 6 members of the Ohio Children’s Hospital Association and the 1.3 

million children who rely on Medicaid and CHIP in Ohio for their health insurance, 

we respectfully and strongly urge you to act quickly to provide a 5-year extension 

of funding for the Children’s Health Insurance Program (CHIP), at the current enhanced match, to ensure kids continue to have access to quality health care. 

As you know, CHIP provides coverage for children who fall above Medicaid eligibility levels but lack access to other options. CHIP covers children whose families 

earn too much to qualify for Medicaid, but who do not have access to adequate 

health insurance options. The parents of these families have jobs. In fact, 85 percent 

of the children in CHIP households have at least one parent working 50 weeks per 

year, according to numbers from the Medicaid and CHIP Payment and Access Commission. 

CHIP was designed specifically for children and includes child-appropriate benefits, 

access to pediatric providers and cost sharing limits to protect vulnerable youth. In 

Ohio, the program extends as a complement to Medicaid, designed within the State’s 

Department of Medicaid, and serves on average more than 200,000 children annually. Many of the children served by CHIP in Ohio also cycle back and forth between 

traditional Medicaid and CHIP. 

Here in Ohio, Medicaid and CHIP serve the State’s most vulnerable children, including 100% of all youth in foster care—many of whom are displaced due to the 

opioid epidemic. These programs also serve more than half of Ohio’s newborns. Children need access to stable and predictable health care if they are to have an opportunity to grow and thrive. 

With strong bipartisan support, an overwhelming majority of the U.S. Congress 

have consistently reauthorized this important program. Current Federal funding for 

CHIP expires at the end of Federal FY 2017. Because this program has not yet been 

reauthorized, State budgets have now been built on the assumption that CHIP dollars will be forthcoming. If Congress does not act before September 30, 2017, States 

will be forced to take action to fill those budget gaps by either disenrolling children, 

imposing lock-outs and waiting periods, winding down their programs altogether or 

cutting providers, in effort to recoup costs not covered with budgeted Federal dollars. 

As always, we appreciate your commitment to support children and encourage your 

formal backing of a clean extension of CHIP. We look forward to working with you 

to ensure all Ohio children have access to the health care they need when they need 

it. 

Sincerely, 

Nick Lashutka 

President and CEO 

Ohio Children’s Hospital Association 

PREPARED STATEMENT OF LEANNA GEORGE, MOTHER OF A CHIP RECIPIENT

Good morning. My name is Leanna George, and I live in Benson, NC. Thank you 

for the opportunity to meet with you and share my family’s experience with the 

CHIP program and why this program is so important to working families. My husband and I have been married 16 years. We met when he was stationed at Marine 

Corps Base Camp LeJeune. After 7 years of service in the Marines, about a year 

after our daughter was born, he was honorably discharged. Currently he has completed 2 years of a 4 year apprenticeship training program to become a licensed elecVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00047 Fmt 6601 Sfmt 6621 R:\DOCS\31255.000 TIM
44 

trician. Together, we have 2 children: Serenity who is 15 years old and has severe 

Autism, Intellectual Disability, and resides in a group home; and 11-year old Caleb 

who has Autism, ADHD, and a genetic neurological condition. While Serenity has 

Medicaid, Caleb is insured by CHIP. 

Although I’m not here testifying on behalf of MACPAC, it wasn’t until I was appointed to the Commission that I realized that CHIP’s future was so uncertain. As 

a parent of a child with extensive needs; the focus of my advocacy had been on increasing the availability of Medicaid waivers that provide home and community 

based supports for people like my daughter. While there is a need for that, I wasn’t 

aware that basic coverage for children of the working poor was in jeopardy. As the 

Commission discussed the CHIP program, I began to wonder just how much losing 

CHIP would impact my family. How much would our premium cost if we added 

Caleb to our insurance? How would the change impact the services he’s been receiving? How would we pay for it? 

With our current health insurance plan, the monthly premiums would not increase if we added Caleb to our coverage as my husband’s company only offers Employee Only or Family coverage levels. However, our insurance plan has a high deductible of $6,000 which currently prevents my husband and me from accessing 

medical care. This deductible would put almost all of all of the services Caleb currently receives out of our financial reach. These services include weekly occupational 

therapy to address fine motor challenges that impact Caleb’s ability to write legibly 

and perform basic self-care tasks such as tying his shoes. He receives periodic MRIs 

and ultrasounds to monitor the progression of his neurologic condition, which allow 

us to be proactive in treatment which results in better outcomes. My son also takes 

daily medication which helps him stay focused on his schoolwork; this medicine 

costs in excess of $300 a month and requires at least biannual office visits for medication management. Over the years, the CHIP program has provided these services 

to us for little to no cost. Even with the cost sharing we’ve had in the past, CHIP 

is a tremendous value. Without CHIP coverage, Caleb’s access to services would be 

greatly diminished and that would directly affect his ability to be successful in 

school. CHIP supports kids as they learn and grow; enabling them to be healthy and 

able to succeed at school which builds them as citizens and leaders for America’s 

future. 

CHIP also provides families with financial security and moms, like me, with peace 

of mind. In January of 2017, my husband was laid off. Thankfully he found employment a few weeks later. However, this short period of unemployment resulted in an 

insurance lapse for my husband and me. While we struggled to pay for my husband’s medication, I was able to live my life with confidence knowing Caleb had access to care that he may need if he became sick or injured. I have never had to call 

the pediatrician and cancel a visit because of lack of insurance. I have never had 

to feel helpless and scared while watching him fight off illness without the benefit 

of medical intervention. CHIP has meant that my son has continued to receive the 

services and medical care he needs without interruption, despite the uncertainty his 

father and I have faced. 

If the CHIP program was to go away, many families like mine would be forced 

to make tough choices between the immediate health of our children and the longterm well-being of the family unit. Monetary resources are already stretched for 

many families like mine. Families may have to ration medical care which could result in something that appears to be a minor medical issue going untreated and progressing into a more serious condition. Other families may procrastinate spending 

on maintenance services for vehicles or houses which can contribute to a tragic accident or expose the family to environmental health risks. If we were not able to find 

a way to afford my son’s medication, his education would be severely impacted and 

that could impact his life well into adulthood. 

Among the sacrifices families may consider are activities such as sports leagues, 

dance classes, and Scouting. These programs teach our young people so much in 

terms of teamwork, perseverance, discipline, and leadership while promoting physical activity and healthy lifestyles. Caleb has been active in Scouts ever since he 

was in the first grade. As a Cub Scout, he earned his Arrow of Light. He recently 

made Scout, the first rank in Boy Scouts. His uncle and cousin are both Eagle 

Scouts, and he aspires to earn his. I’m looking forward to seeing him enjoy similar 

experiences that I saw my brother participate in and to watch him grow into a 

young man who exhibits the 12 principles in the Boy Scout Law. While there is a 

lot of support for these excellent youth programs, they still require incredible investment of time and resources from the families of these youth. Losing CHIP coverage 

45 

can affect the availability of these family resources and limit the ability of children 

to participate in these life enriching programs. 

Some families may even have to sacrifice some of the care and oversight they provide for loved ones like parents, siblings, or even their children who, because of 

their unique needs, may live in group homes, nursing homes, or are aging in place 

with support staff. My daughter lives in a group home that is more than a 4-hour 

drive from my home. While I wish I could travel to visit her monthly, the best I 

have been able to do is about bimonthly and sometimes it stretches to quarterly visits. The increased financial burdens my family will experience if CHIP is not funded 

will impact our ability to participate in our daughter’s life and insure that her needs 

are being appropriately met. 

There are approximately 9 million children who receive CHIP. This program provides parents with the security of knowing their children have high quality and reliable insurance coverage, no matter what challenges they face with their own health 

or employment. Losing CHIP would jeopardize the health of America’s current workforce and the well-being of its future leaders. I ask you to extend funding for CHIP 

with the enhanced match rate for the next 5 years. Funding CHIP will contribute 

to the financial security of working middle class families like mine and ensure our 

children will continue to have access to exceptional medical care which impacts their 

quality of life well into adulthood. Thank you for the time you are investing in determining the future of the CHIP program. 

PREPARED STATEMENT OF HON. ORRIN G. HATCH, 

A U.S. SENATOR FROM UTAH

WASHINGTON—Senate Finance Committee Chairman Orrin Hatch (R–Utah) today 

delivered the following opening statement at a hearing entitled ‘‘The Children’s 

Health Insurance Program: the Path Forward’’: 

Twenty years ago, Senator Ted Kennedy and I came together to create the Children’s Health Insurance Program, or CHIP, in order to provide health coverage for 

vulnerable children in families who were too poor to afford private coverage but still 

didn’t qualify for Medicaid. 

Twenty years ago, we were at something of a crossroads. 

The year before CHIP was signed into law, a Republican Congress passed and a 

Democratic President signed a welfare reform bill which ended the entitlement to 

cash welfare. Welfare reform sought to replace a culture of dependency with an emphasis on work. The emphasis was to move families off assistance and toward selfsufficiency. CHIP was needed to help many families make that transition. 

So we needed to be forward-thinking, taking into account the realities at that 

time with an eye toward future sustainability of the program. 

Senator Kennedy and I worked in good faith for months to craft CHIP, and while 

neither of us got everything we wanted, the result was a dedicated funding stream 

for the program to help low-income families get good, reliable health insurance. 

CHIP, from the outset, was a bipartisan program that enjoyed, and continues to 

enjoy, broad support throughout the country and here in Congress. While it isn’t 

perfect, and while, in my view, some of the subsequent changes to the program have 

been regrettable, I believe that, overall, people consider it to be a success. 

Current law provides Federal CHIP funding through the end of fiscal year 2017. 

According to the Congressional Research Service, if Congress doesn’t act to provide 

additional Federal funding, a number of children who would likely be eligible for 

CHIP will go uninsured once Federal funding is exhausted. 

Additionally, inaction by Congress with regard to CHIP would cause another layer 

of unpredictability and anxiety for States that have to administer the program. Of 

course, this anxiety will pale in comparison to the uncertainty families who rely on 

CHIP will be faced with if Congress doesn’t act. 

As the committee contemplates the future of the CHIP program, there are several 

thresholds we’ll need to consider. 

The basic question is, does the committee want to reauthorize or merely extend 

CHIP? 

46 

Reauthorization would entail more extensive debate and the consideration of potential policy changes to the underlying program. As many of you know, in 2015, 

Congressman Fred Upton—who was then chairman of the House Energy and Commerce Committee—and I put forward a number of substantive policy recommendations for reforming CHIP, most of which were, admittedly, met with a mixed reaction from stakeholders. 

While some policy changes are certainly in order for the program, some are justifiably concerned that, given the number of issues that are already before the committee, there may not be time to give full and fair consideration to CHIP reforms 

prior to the expiration of Federal funding at the end of the fiscal year. With these 

concerns in mind, some have suggested that, instead of reauthorizing the entire program, we simply act to extend CHIP funding. 

Of course, that option comes with its own set of questions. 

For example, we’ll need to determine the appropriate length for the extension and 

whether to continue with the 23-percent increase in Federal matching for CHIP provided under the Affordable Care Act and extended in 2015. 

I know some of our members have strong feelings about both of these questions. 

These are not particularly complicated issues, but they will require some deliberation among members of the committee. 

Long story short, we have some difficult questions ahead of us. Whether we opt 

to reopen CHIP for reforms or simply provide another extension, the committee will 

need to invest significant time and effort to find answers to those questions. 

Today, we will continue our discussion of these matters as we hear from witnesses 

who will testify to the importance of CHIP and the need for it to continue. 

I hope members will listen carefully to these witnesses, confer with their States, 

and let me know how they would prefer to proceed with regard to CHIP. I look forward to working on a bipartisan basis with Ranking Member Wyden and all the 

members of the Senate Finance Committee to move forward on a bipartisan CHIP 

bill. 

PREPARED STATEMENT OF LINDA NABLO, CHIEF DEPUTY DIRECTOR, 

VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chairman Hatch, Ranking Member Wyden, and members of the committee, thank 

you for allowing me to speak to you today on the importance to States of continued 

funding for the Children’s Health Insurance Program. 

And thank you, Senator Warner—I remember well when you were Governor and 

I was hired as the CHIP Director to help you improve Virginia’s program and enroll 

every eligible child. I particularly remember how you would ask every Friday, without fail, how many more children we had gotten covered that week. So before you 

go there, I will say that Virginia currently has 614,100 children covered through 

Medicaid and CHIP. These programs are the health insurance plan for almost one 

in three children in the Commonwealth, or slightly less than the national average. 

I was invited here today to give the State perspective on the importance of continued funding for CHIP. As Dr. Schwartz has explained, the authorizing CHIP legislation provided certain flexibilities to States in how to design their programs so there 

are differences across the country. Virginia, like most States has a combination program with some children enrolled in Medicaid but supported by CHIP funding and 

others covered in a separate program. But however States have chosen to administer this program, it plays a vital role for all of us in ensuring children have access 

to affordable and appropriate health-care coverage by building on top of the much 

larger Medicaid program. In fact, CHIP just turned 20—it is now a mature program 

that is woven deep into the fabric of health-care coverage in all States and is a key 

program protecting the health of children for all of us. 

There are only two points I want to make in my 5 minutes today. First, that 

CHIP is vital to the health of children in Virginia and in each of the States you 

represent. By my quick calculation over 4 million children are covered by CHIP in 

just your States alone. Second, I want to make sure you understand that there are 

serious consequences looming if you delay reauthorization—even for a few months. 

In Virginia, as of September 1st, there are 123,256 children receiving their health 

care through CHIP. Over 58,000 of them are enrolled in Medicaid and the other 

47 

65,000+ are enrolled in the separate program initially modeled after the State employee health plan. We call the separate program ‘‘FAMIS’’ and we call the Medicaid 

program for children ‘‘FAMIS Plus’’; the plus is because Medicaid provides additional benefits. 

In Virginia we cover children up to 200% of the poverty level. We do not charge 

premiums but we do charge modest co-payments for services and children are required to be served through one of our six managed care plans at an average per 

child monthly cost of $160. 

Virginia also has a CHIP waiver to provide prenatal care to pregnant women with 

incomes above the Medicaid limit up to 200% of the poverty level, and about 1,100 

pregnant women are currently enrolled. We also have a small premium assistance 

program whereby families can choose to enroll their child in an employer’s health 

plan and we will help them cover the cost of the children’s coverage, as long as it 

is cost-effective to do so and certain benefits are included. 

The separate CHIP benefit package is strong, and most recently, we have added 

new substance use treatments for CHIP children and pregnant women as part of 

Virginia’s effort to address the opioid epidemic. 

Virginia receives 88% Federal funding for this program and to emphasize just how 

important this is to Virginia children, in the last 2 fiscal years this funding has paid 

for: • 218,190 immunizations and 221,309 well-child checkups, • 21,430 glasses/contact lenses, and • 326,567 dental visits. 

In addition to this more routine and preventive care, CHIP has covered: 

• 258 heart surgeries, • 6 brain cancer surgeries, • 2 liver transplants, and • 1 heart transplant. 

We have provided services for: 

• 1,118 children diagnosed with cancer, • 31 children living with HIV, and • 32 children born with neonatal abstinence syndrome. 

You have heard today from Ms. George about the difference CHIP has made in 

her child’s life. There are thousands of stories in each of your States that would deliver the same message. In Virginia I could tell you stories of children who simply 

get to lead more normal lives because of CHIP; they can play sports (you know you 

need to have insurance to play sports), control their asthma, see better in school, 

or get their teeth fixed; and their families breathe easier. Some even avoid falling 

into poverty because they have ready access to good quality health care for their 

children. Or I could tell you stories of children with very serious illnesses that have 

received lifesaving treatments because of this program. I could talk about James 

who learned he needed heart surgery days before he was to turn 18. Everyone 

worked together to expedite his eligibility and schedule his surgery so it would be 

covered before he aged out of CHIP. We couldn’t pay for his considerable follow-up 

treatments but we could help fix his heart. 

Or Nathan, a 15-year-old without health insurance who showed sudden symptoms 

of diabetes and was rushed to the local emergency room. On the cusp of entering 

a diabetic coma the staff transferred him to a nearby hospital better able to treat 

his health crisis. His mother was fortunate to connect with a Virginia Health Care 

Foundation outreach worker, an organization Senator Warner is very familiar with 

as he is the founding chairman, and that we help support with CHIP administrative 

dollars. The outreach worker quickly assessed that Nathan would be eligible for 

FAMIS and personally engaged the local department of social services to expedite 

his application and ensure receipt of life-saving care without delay. Like so many 

others, Nathan’s mother was amazed to find out that CHIP is designed to meet the 

needs of working families. 

I hope you understand that CHIP is vital to the health of our children and therefore our Nation and it works. But without congressional action soon we will be 

forced to start preparations to shut it down, throwing families of over 60,000 children in Virginia, and millions across the country into a panic. 

You have heard that most States will not actually run out of Federal CHIP dollars 

until sometime in the second quarter of FY 2018. Some might naively believe this 

48 

means you can safely delay any action on CHIP while you deal with your very full 

calendar. But let me explain how problematic that would be for States and how devastating for families. 

The analysis from CMS and the MACPAC data shows that with some redistributed funds, Virginia will run out of Federal CHIP dollars sometime in March—and 

we agree. However, what that analysis does not take into account is that Virginia, 

like many States, covers these children through managed care plans. We pay those 

health plans a capitated rate retrospectively for the previous month’s coverage. So 

in February 2018 we will pay the six health plans for the month of January—but 

in March we will not have sufficient funds to pay for the month of February. We 

will therefore need to terminate FAMIS coverage at the end of January. 

In order to give families adequate notice, we will need to send them letters informing them of this alarming news at the end of November. To address the inevitable turmoil this will cause, in Virginia we will first need to train Eligibility Workers, advocates, application assistors, call center operators, and others before families 

receive those letters so they are able to answer questions and provide whatever assistance they can offer. In essence, we will need to mount a reverse outreach campaign. We will also need to inform providers along the same time frame and prepare 

to deal with their questions as well. 

We will need to expend funds to modify IT systems as eligibility rules are now 

embedded into such systems across the country and to change online and paper applications and notices. Countless other contracts for managed care, prior authorization reviews, auditors, etc. will also need to be amended. 

I suspect for States without a high degree of managed care the situation will be 

even more precarious. They will have to try and predict what CHIP claims will come 

in, and when, in order to shut down the program in time to cover unknown costs. 

This will be further complicated as parents who get that letter telling them their 

child’s coverage will end soon will very likely rush their child to the doctor, dentist 

and eye doctor and fill any prescriptions to the maximum; thus driving up utilization and expending remaining dollars faster than anticipated. 

Even if some States were able to continue a reduced level of coverage for a time— 

or move children in a separate program into Medicaid, it would take months to develop and implement new policies and change systems. In Virginia our legislators 

begin their regular session on January 10th, too late to begin any legislative debate 

of how to continue some form of coverage. 

If the future of CHIP remains uncertain, States will soon need to make decisions 

about policies such as freezing enrollment so as to preserve current coverage as long 

as possible, and what to say to families and when to say it, as the end of funding 

approaches. I have a long ‘‘To Do’’ list of what will need to happen in Virginia and 

that list starts in October if CHIP is not reauthorized by September 30th. 

While we have come so close to the wire this time that States would be grateful 

for any quick reauthorization, I do want to make the point that funding this program in 1- or 2-year increments breeds instability. It dampens innovation and probably limits State investment when the future is so uncertain. I absolutely endorse 

the MACPAC recommendation of reauthorizing and funding the program for 5 

years. 

Finally, I want to talk about the enhanced Federal match rate for CHIP. I understand there is some question of whether or not it will continue at the current rate 

or be reduced. Please be aware that for Virginia alone, we know that if Congress 

reauthorizes CHIP but reduces the Federal match rate to previous levels (65% for 

Virginia) we will experience an immediate $56 million dollar shortfall in the current 

State fiscal year (July–June) and an $83 million shortfall in the next. Virginia, like 

almost all States, has built the current biennial budget on current law with the 

higher CHIP match. 

As the chairman knows better than anyone, CHIP has always had strong bipartisan support, and that is true at the State level as well. With all the very difficult 

and complex decisions you have to make about health care in America, surely 

whether or not to reauthorize CHIP is not one of them. On behalf of States I am 

here to ask you to please continue your strong support of children’s health care with 

passage of a straightforward authorization for continued funding of CHIP, at current levels. 

Thank you. 

49 

PREPARED STATEMENT OF ANNE L. SCHWARTZ, PH.D., EXECUTIVE DIRECTOR, MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION

Summary 

Since its enactment with strong bipartisan support in 1997, CHIP has played an 

important role in providing insurance coverage and access to health care for tens 

of millions of low- and moderate-income children with incomes just above Medicaid 

eligibility levels. Under current law, CHIP is funded through fiscal year (FY) 2017. 

The Commission urges Congress to act as soon as possible to avoid disruption for 

families, plans, providers, and States, and to ensure that children continue to have 

access to needed health-care services. Without congressional action, States will not 

receive new Federal funds for CHIP beyond the end of this month, and States will 

rapidly deplete available funding. MACPAC projects that four States will exhaust 

available Federal funds in the first quarter of FY 2018; another 27 will do so in the 

second quarter. 

In January 2017, MACPAC recommended that Congress extend Federal CHIP 

funding for a transition period of 5 years, as well as extend the CHIP maintenance 

of effort requirement and 23 percentage point increase in the CHIP matching rate 

though FY 2022. The Commission’s priority in making these recommendations was 

to ensure the stability of children’s health coverage during a period of uncertainty 

as Congress debates the future of Medicaid and subsidized exchange markets. 

In coming to these recommendations, the Commission considered what would happen if no CHIP allotments were available to States after FY 2017. Our most recent 

estimates are that, if CHIP funding is not renewed, 1.2 million children covered 

under separate CHIP will become uninsured. While others may transition to 

employer-sponsored or exchange coverage, it would cost considerably more, potentially creating barriers to obtaining needed health and developmental services. In 

addition they could lose access to needed services that these sources are less likely 

to cover, such as dental care or audiology services. 

When the Commission made these recommendations, it noted that coverage under 

separate CHIP authority should not be maintained indefinitely but that more time 

is needed to address concerns related to the affordability and comprehensiveness of 

other sources of children’s coverage. Health insurance markets may face substantial 

changes over the next few years; unless renewed, Federal funding for CHIP will be 

exhausted long before any such changes can be fully realized. 

Although States can continue to use FY 2017 funds into FY 2018, they cannot do 

so indefinitely. Moreover, they have legal obligations to notify families, plans, and 

providers about future plans, which may include freezing enrollment, transitioning 

children to other sources of coverage, and making eligibility and enrollment systems 

changes. In some States (e.g., Arizona and West Virginia), State law requires termination of CHIP if Federal funding is not available. 

In the long term, a more seamless system of children’s coverage needs to be developed. That is why the Commission made a number of recommendations for a more 

seamless system of children’s coverage to accompany its recommendations for Federal CHIP funding. Such a system would provide comprehensive and affordable coverage to low- and moderate-income children and remove the potential gaps in coverage children may experience as they transition between publicly and privately financed health insurance. 

Good morning, Chairman Hatch, Ranking Member Wyden, and members of the 

committee. I am Anne Schwartz, Executive Director of the Medicaid and CHIP Payment and Access Commission (MACPAC). As you know, MACPAC is a congressional 

advisory body charged with analyzing and reviewing Medicaid and CHIP policies 

and making recommendations to Congress, the Secretary of the U.S. Department of 

Health and Human Services (HHS), and the States on issues affecting these programs. Its 17 members, including Chair Penny Thompson and Vice Chair Marsha 

Gold, are appointed by the U.S. Government Accountability Office (GAO). While the 

insights and information I will share this morning build on the analyses conducted 

by MACPAC’s staff, they are in fact the views of the Commission itself. We appreciate the opportunity to share MACPAC’s recommendations and work as this committee considers the future of the State Children’s Health Insurance Program 

(CHIP). 

50 

OVERVIEW OF CHIP

Since its enactment with strong bipartisan support in 1997, CHIP, a joint 

Federal-State program, has played an important role in providing insurance coverage and access to health care for millions of low-income children with incomes just 

above Medicaid eligibility levels. Over this period, the share of uninsured children 

in the typical CHIP income range (those with family income above 100 percent but 

below 200 percent of the Federal poverty level (FPL)) has fallen dramatically—from 

22.8 percent in 1997 to 6.7 percent in 2015 (MACPAC 2017a). In contrast, during 

the same period, which included two recessions, private coverage for children in this 

income range declined substantially—from 55 percent in 1997 to 29.8 percent in 

2015 (Martinez et al. 2017). 

In fiscal year 2016, 8.9 million children were enrolled in CHIP-funded coverage 

(CMS 2017a). States have flexibility in designing CHIP. States can operate these 

programs either as an expansion of Medicaid, an entirely separate program, or a 

combination of both approaches. States with Medicaid-expansion CHIP must provide 

the full Medicaid benefit package, including early and periodic screening, diagnostic, 

and treatment services, and must follow Medicaid cost-sharing rules. States with 

separate CHIP provide comprehensive health-care services subject to the approval 

of the Secretary of the U.S. Department of Health and Human Services (the Secretary) or based on a benchmark benefit package. In separate CHIP, States may require premiums and cost sharing, such as copayments and deductibles (although not 

for preventive services), with a combined limit of 5 percent of income. States receive 

an enhanced Federal match for CHIP, subject to the cap on their allotments, and 

must contribute a State share to receive their Federal funding allotments. 

BASIS FOR MACPAC RECOMMENDATIONS

Under current law, CHIP is funded through FY 2017, and without congressional 

action, States will not receive any new Federal funds for CHIP beyond September 

30, 2017. Mindful of this date, the Commission devoted considerable attention over 

the past several years to CHIP’s role in our health-care system and policy approaches for the future. We reviewed available evidence about the quality and affordability of CHIP compared to other alternatives, and focused attention on the implications of various policy approaches for children and their families, States, providers, health plans, and the Federal Government. 

Based on this review, the Commission issued a report this past January recommending that Federal funding for CHIP be extended for 5 years. If CHIP funding 

is not renewed, many of the children covered under separate CHIP will lose their 

health coverage. While some of these children may be eligible for private coverage, 

their families would have to pay considerably more than under CHIP, potentially 

creating barriers to needed health and developmental services. In addition, they 

would lose access to services covered by CHIP that are not typically covered by 

other payers. Those covered by Medicaid-expansion CHIP would not lose coverage 

but there would be a significant shift in the funding obligation for their coverage 

to the States. 

MACPAC has always looked at CHIP in its context, a relatively small public 

health coverage program in an evolving array of sources of coverage for children 

that includes Medicaid, publicly subsidized exchange coverage established by the 

Patient Protection and Affordable Care Act (ACA, Pub. L. 111–148, as amended), 

and employer-sponsored coverage. In the long term, the development of a more 

seamless system of children’s coverage is needed. Such a system would provide comprehensive and affordable coverage to low- and moderate-income children, removing 

the potential gaps in coverage and care that can affect children as they transition 

among different sources of publicly and privately financed health insurance. 

Moreover, the future of publicly financed health coverage markets currently is uncertain. Over the past few months, Congress has been debating reforms to both 

Medicaid and federally subsidized exchange coverage that would affect the available 

alternatives for children in the absence of CHIP. This uncertainty heightens the 

need for congressional action to extend CHIP. 

In my testimony today, I will present the rationale behind the Commission’s recommendations on the future of CHIP funding and children’s coverage, as well as the 

evidence it considered in making its recommendations. I also will address CHIP financing; in particular, how States will be affected if Federal CHIP funding ends. 

MACPAC’s most recent analyses focus on when States are projected to run out of 

CHIP funds and how the requirement that States maintain coverage for children 

51 

through fiscal year (FY) 2019 will affect States differentially based on their decisions to run CHIP as a Medicaid expansion or a separate program. 

MACPAC’s Recommendations on the Future of CHIP and Children’s Coverage 

In a January 2017 special report (made available in print in our March 2017 Report to Congress on Medicaid and CHIP), MACPAC made nine recommendations to 

Congress to fund and stabilize CHIP, and to move toward a more seamless system 

of affordable and comprehensive children coverage (Box 1). 

STABILIZING CHILDREN’S HEALTH COVERAGE

In making its recommendations for CHIP funding, a key priority for the Commission was to ensure the stability of children’s health coverage during this period of 

uncertainty about other sources of coverage. The Commission recommends that Congress extend Federal CHIP funding for a transitional period of 5 years through FY 

2022. It also recommends extension of the current CHIP maintenance of effort 

(MOE) requirement and the 23 percentage point increase in the Federal CHIP 

matching rate through FY 2022. 

Rationale. Extending CHIP for a transition period would ensure that low- and 

moderate-income children would retain access to affordable insurance coverage during a time of uncertainty for coverage markets. The transition period of 5 years 

would also provide time to address concerns with affordability and benefits of other 

coverage sources, which are described in greater detail below. In addition, this period would provide Federal and State policymakers time to plan and implement 

comprehensive children’s coverage demonstrations, which the Commission also is 

recommending. 

BOX 1. MACPAC Recommendations for the Future of CHIP and Children’s Coverage 

Recommendation 1.1 

Congress should extend Federal CHIP funding for a transition period that would 

maintain a stable source of children’s coverage and provide time to develop and test 

approaches for a more coordinated and seamless system of comprehensive, affordable coverage for children. 

Recommendation 1.2 

Congress should extend Federal CHIP funding for 5 years, through fiscal year 

2022, to give Federal and State policymakers time to develop policies for, and to implement and test coverage approaches that promote seamlessness of coverage, affordability, and adequacy of covered benefits for low- and moderate-income children. 

Recommendation 1.3 

In order to provide a stable source of children’s coverage while approaches and 

policies for a system of seamless children’s coverage are being developed and tested, 

and to align key dates in CHIP with the period of the program’s funding, Congress 

should extend the current CHIP maintenance of effort and the 23 percentage point 

increase in the Federal CHIP matching rate, currently in effect through FY 2019, 

for 3 additional years, through fiscal year 2022. 

Recommendation 1.4 

To reduce complexity and to promote continuity of coverage for children, Congress 

should eliminate waiting periods for CHIP. 

Recommendation 1.5 

In order to align premium policies in separate CHIP with premium policies in 

Medicaid, Congress should provide that children with family incomes below 150 percent of the Federal poverty level not be subject to CHIP premiums. 

Recommendation 1.6 

Congress should create and fund a children’s coverage demonstration grant program, including planning and implementation grants, to support State efforts to develop, test, and implement approaches to providing, for CHIP-eligible children, 

seamless health coverage that is as comprehensive and affordable as CHIP. 

Recommendation 1.7 

Congress should permanently extend the authority for States to use Express Lane 

Eligibility for children in Medicaid and CHIP. 

52 

1The definition of targeted low-income child at section 2110(b) created a CHIP upper incomeeligibility limit of no greater than 50 points above the State pre-CHIP Medicaid income levels. 

Recommendation 1.8 

The Secretary of Health and Human Services, in consultation with the Secretaries 

of Agriculture and Education, should not later than September 30, 2018, submit a 

report to Congress on the legislative and regulatory modifications needed to permit 

States to use Medicaid and CHIP eligibility determination information to determine 

eligibility for other designated programs serving children and families. 

Recommendation 1.9 

Congress should extend funding for 5 years for grants to support outreach and 

enrollment of Medicaid- and CHIP-eligible children, the Childhood Obesity Research 

Demonstration projects, and the Pediatric Quality Measures program, through fiscal 

year 2022. 

To further stabilize children’s coverage and prevent States from rolling back eligibility, the Commission recommends extending the CHIP MOE through FY 2022. 

The current MOE, which requires States to maintain the CHIP eligibility levels in 

place on March 23, 2010 through FY 2019, was established by the ACA (Appendix 

A). The MOE also prohibits States from adopting eligibility and enrollment standards or methodologies that are more restrictive than those in place prior to the enactment of the ACA (§ 2105(d)(3) of the Act). 

MACPAC also recommends extending the 23 percentage point increase to the 

CHIP enhanced matching rate through FY 2022. This increase was enacted in the 

ACA for FYs 2016–2019. In the current fiscal year, 11 States and the District of 

Columbia have a CHIP matching rate of 100 percent meaning that the Federal Government pays for 100 percent of the cost of providing CHIP coverage to children 

(Appendix B). An additional 22 States have CHIP matching rates ranging from 90 

percent to 99 percent (MACPAC 2017a). 

The Commission’s recommendation reflects the view that an extension to the 

MOE, which it judged important to retaining gains in coverage, should be accompanied by an extension of enhanced funding. The increase to the CHIP matching 

rate is also thought to have influenced decisions in 2016 in some States to expand 

children’s coverage, within permissible limits.1 For example, Florida and Utah expanded Medicaid and CHIP coverage to lawfully residing immigrant children. In 

July 2016, Arizona reinstated CHIP, which it had previously closed. 

The Commission has long held that coverage under separate CHIP authority 

should not be maintained indefinitely (MACPAC 2014a). The Commission also has 

stated that children’s coverage should be affordable and comprehensive, and State 

flexibility in program design must be maintained. In the Commission’s view, other 

current sources of coverage do not meet these standards. In addition, over the 

course of the Commission’s deliberation, two additional facts became clear. First, 

more time is needed for assessing, planning, and implementing changes to address 

concerns of other coverage sources for children. Second, given the expectation that 

health insurance markets may face substantial changes over the next few years, 

Federal funding for CHIP would be exhausted before these changes would be fully 

realized. 

IMPLICATIONS IF FEDERAL CHIP FUNDING IS NOT RENEWED

If CHIP funding ends and States exhaust available Federal funds, the implications for States depend on whether they operate CHIP as a Medicaid expansion or 

a separate program. As of January 1, 2016, 10 States (including the District of Columbia) ran CHIP as a Medicaid expansion, 2 States had separate CHIP, and 39 

operated combination programs (MACPAC 2017a). In the absence of CHIP, children 

leaving separate CHIP and gaining other coverage likely would face higher cost 

sharing, different benefits, and enrollment in plans with different provider networks. 

Increase in uninsurance. Although the MOE generally requires States to maintain their children’s coverage eligibility levels in place when the ACA was enacted, 

States face different scenarios for separate CHIP and Medicaid-expansion if Federal 

CHIP funds run out. States with Medicaid-expansion CHIP must continue that coverage for children, but instead of receiving the enhanced CHIP match, States will 

receive the lower Medicaid matching rate. Of the 8.4 million children enrolled in 

53 

2 Urban Institute analysis for MACPAC of Health Insurance Policy Simulation ModelAmerican Community Survey (HIPSM–ACS), August 2017. 3Premiums and cost sharing are permitted for children in separate CHIP (capped at 5 percent 

of family income), but they generally are prohibited for children in Medicaid. 

CHIP-funded coverage in 2015, 4.7 million were in Medicaid-expansion CHIP 

(MACPAC 2017a). 

States with separate CHIP are permitted to terminate that coverage if Federal 

CHIP funds run out. In this case, the ACA requires States to develop procedures 

to automatically transition children from separate CHIP to exchange coverage that 

has been certified as ‘‘at least comparable to’’ CHIP programs with respect to benefits and cost sharing (§ 2105(d)(3)(B) of the Social Security Act (the Act)). If the Secretary finds that no exchange plans are comparable to CHIP, States are not required to facilitate the transition to exchange coverage, although families may obtain subsidized exchange coverage on their own. In November 2015, the Secretary 

of the U.S. Department of Health and Human Services (the Secretary) did not certify any exchange plan as comparable to CHIP coverage (CMS 2015). 

We recently updated our analysis of how an end to separate CHIP would affect 

children’s coverage, finding that in the absence of CHIP, 1.2 million children enrolled in separate CHIP would become uninsured because the cost of other sources 

of coverage would be unaffordable.2 We estimate that 1.1 million would enroll in 

employer-sponsored coverage, and almost 700,000 would enroll in subsidized exchange coverage. 

This analysis also found that of the children losing separate CHIP and who would 

become uninsured: 

• Forty-four percent will be eligible for exchange subsidies; 

• Forty percent are eligible for exchange subsidies because their parents do not 

have an offer of employer coverage or the available employer-sponsored coverage excludes dependent coverage; and 

• Fifty-six percent will have an offer of employer-sponsored coverage in the household. 

However, the average additional premium to obtain family coverage would be 8 

percent of income, making the total cost of family coverage equal to 11 percent of 

family income. 

We also previously noted that the majority of separate CHIP-enrolled children 

who would become uninsured if CHIP funding is exhausted have family income 

below 200 percent FPL (61.3 percent) and are non-white (53.9 percent). In addition, 

89.6 percent have a full-time worker in the family (MACPAC 2015). 

Affordability of coverage. For children in the CHIP income-eligibility range, 

CHIP coverage is considerably less costly to families with respect to both premiums 

and out-of-pocket cost sharing than exchange or employer-sponsored coverage 

(MACPAC 2016, 2015).3 In 2015, the combined premiums and cost sharing of separate CHIP in 36 States averaged $158 per year per child, $127 for premium and 

$31 for cost sharing. On average in these 36 States, the effective actuarial value 

of CHIP coverage was 98 percent. In other words, the plans covered 98 percent of 

the cost of covered medical benefits and enrollees 2 percent. 

If these same children were enrolled in employer-sponsored insurance, they would 

have faced an estimated $891 per year per child in average annual out-of-pocket 

spending ($603 for premiums and $288 in cost sharing), and if enrolled in the second lowest cost silver exchange plan, they would have faced an estimated $1,073 

per year per child ($806 for premiums and $266 in cost sharing). The effective actuarial value averaged 81 percent in employer sponsored insurance plans and 82 percent in second lowest cost silver exchange plans, with families responsible for the 

remaining 18 percent to 19 percent through cost sharing (MACPAC 2016). 

Adequacy of benefits. MACPAC’s comparison of benefits in separate CHIP, 

Medicaid (including Medicaid-expansion CHIP), exchange plans, and employersponsored insurance found that covered benefits vary within each source—between 

States for Medicaid and CHIP, and among plans for employer-sponsored insurance 

and exchange plans (MACPAC 2015). Most separate CHIP, Medicaid, exchange, and 

employer-sponsored insurance plans cover major medical benefits, such as inpatient 

and outpatient care, physician services, and prescription drugs. Children enrolled in 

Medicaid-expansion CHIP are entitled to all Medicaid services, including early and 

54 

4MACPAC projects that the Federal CHIP funding that States have received through their 

FY 2017 allotments and the redistribution funding that is available from prior year allotments 

will be adequate to cover projected State spending in FY 2017 (MACPAC 2017b). Four States 

and the District of Columbia are projected to have CHIP spending that exceeds their FY 2017 

allotment, but these States are expected to receive redistribution funds in FY 2017 sufficient 

to cover their projected CHIP funding shortfall. Approximately $3 billion in redistribution funding is available in FY 2017 (MACPAC 2017b). 5States experiencing CHIP funding shortfalls can also receive contingency fund payments if 

their CHIP enrollment exceeds target levels specified in section 2105(n) of the Act. However, 

contingency fund payments are not available for FY 2018 and subsequent years. 6The projected FY 2018 Federal CHIP spending of $17.4 billion includes States and territories. 

periodic screening, diagnostic, and treatment (EPSDT) services that exchange and 

employer-sponsored plans often do not cover. 

Differences are pronounced for dental care, an EPSDT service. Like Medicaid, separate CHIP covers pediatric dental services. However in most exchanges and employer-sponsored coverage, dental benefits are offered as a separate, stand-alone insurance product for which families pay separate premiums and cover cost sharing 

expenses. More than half of all employer-sponsored plans (54 percent) do not include 

pediatric dental coverage. Of the employers that offer separate dental coverage, 

many require an additional premium. 

CHIP also covers many services important to children’s healthy development that 

are not always available in exchange plans. For example, all separate CHIP and 

Medicaid programs cover audiology exams, and 95 percent of separate CHIP programs cover hearing aids. However, only 37 percent of exchange plan essential 

health benefit benchmarks cover audiology exams, and only 54 percent cover hearing aids (MACPAC 2015). Among employer-sponsored health plans, 34 percent cover 

pediatric audiology exams and 43 percent cover hearing aids (MACPAC 2015). 

Provider networks. The Commission also looked at how CHIP provider networks compare to those of other sources of coverage. Under Federal law, CHIP managed care is subject to the same Federal provisions that establish standards for 

Medicaid managed care (§ 2103(f)(3) of the Act). These provisions require States to 

establish ‘‘standards for access to care so that covered services are available within 

reasonable time frames and in a manner that ensures continuity of care and adequate primary care and specialized services capacity’’ (§ 1932(c)(1)(A)(i) of the Act). 

CHIP regulations also specify that a State must ensure ‘‘access to out-of-network 

providers when the network is not adequate for the enrollee’s medical condition’’ (42 

CFR 457.495). 

Advocates have suggested that separate CHIP networks are better than Medicaid 

or exchange plan networks because they are similar to private plan networks or because they are designed specifically for pediatric needs (Hensley-Quinn and Hess 

2013, Hoag et al. 2011). However, we found little empirical evidence to either support or refute this assertion. 

IMPLICATIONS FOR STATES

MACPAC has also considered the financial and operational implications for States 

if CHIP funding were to end, which are described below. Unless funding for CHIP 

is renewed, States will begin running out of available Federal funds during the first 

quarter of FY 2018, which begins in just a few weeks. All States will exhaust their 

funds before the end of fiscal year 2018. 

Exhaustion of Federal funds. Federal funding for CHIP is capped and allotted 

to States annually. States have 2 years to spend their allotments, and unspent allotments are available for redistribution to other States experiencing CHIP funding 

shortfalls.4 Under current law, new CHIP allotments are not available after FY 

2017 and unspent FY 2017 CHIP allotments that remain available for expenditures 

in FY 2018 are reduced by one-third (§ 2104(m)(2)(B)(iv) of the Act).5

Under current law, in FY 2018, States may continue to spend unspent FY 2017 

allotments and redistribution funds from prior years (an estimated $4.2 billion in 

total), however these funds are expected to be insufficient to cover expected State 

CHIP expenses in FY 2018 (an estimated $17.4 billion).6 Based on State spending 

estimates submitted to CMS, MACPAC projects that three States and the District 

of Columbia will exhaust available Federal CHIP funds sometime in the first quarter of the fiscal year, and 27 States will do so in the second quarter (Table 1 and 

Appendix C). 

55 

Table 1. Projected Exhaustion of Federal CHIP Funds in Fiscal Year 2018 

Quarter of fiscal year Number of 

States States 

First quarter 

(October–December 2017) 

4 Arizona, District of Columbia, Minnesota, and North 

Carolina 

Second quarter 

(January–March 2018) 

27 Alaska, Arkansas, California, Colorado, Connecticut, 

Delaware, Florida, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nevada, New York, Ohio, Oregon, 

Pennsylvania, Rhode Island, South Dakota, Utah, 

Vermont, Virginia, and Washington 

Third quarter 

(April–June 2018) 

19 Alabama, Georgia, Illinois, Indiana, Iowa, Maine, 

Maryland, Michigan, Nebraska, New Hampshire, 

New Jersey, New Mexico, North Dakota, Oklahoma, South Carolina, Tennessee, Texas, West 

Virginia, and Wisconsin 

Fourth quarter 

(July–September 2018) 

1 Wyoming 

Note: CHIP is the State Children’s Health Insurance Program. 

Source: MACPAC 2017 analysis using June 2017 Medicaid and CHIP Budget and Expenditure System data 

from the Centers for Medicare and Medicaid Services, including quarterly projections provided by States in 

May 2017. 

State policies may also affect when States exhaust their Federal CHIP funding. 

For example, while the ACA’s maintenance of effort (MOE) requirement generally 

prohibits reducing children’s eligibility for CHIP, States are permitted to impose enrollment limits ‘‘in order to limit expenditures . . . to those for which Federal financial participation is available’’ (§ 2105(d)(3)(A)(iii) of the Act). States may also take 

other actions to reduce CHIP spending such as allowing CHIP waivers to expire and 

cutting payments to plans and providers. 

State budgets. Most States have fiscal years that begin July 1; thus they have 

already set their budgets for the State fiscal year 2018. Despite the uncertainty of 

Federal CHIP funding, 33 out of 40 States responding to a survey about the future 

of CHIP funding indicated that their State budget assumed that CHIP funding 

would continue; 21 States have assumed that the 23 percentage point increase in 

the CHIP match continues as well (NASHP 2017). Absent congressional action, 

these States will likely experience shortfalls and may have to close their separate 

CHIP programs or provide coverage to children enrolled in Medicaid-expansion 

CHIP with substantially fewer Federal funds than anticipated. 

Operational considerations and timelines. Although States can continue to 

use FY 2017 funds into FY 2018, they cannot do so indefinitely. Moreover, they have 

legal obligations to notify families, plans, and providers about future plans, which 

may include freezing enrollment, transitioning children to other sources of coverage, 

and making eligibility and enrollment systems changes (NASHP 2017). In some 

States (e.g., Arizona and West Virginia), State law requires termination of CHIP if 

Federal funding is not available. 

Although we are hearing from State officials that they do not wish to unnecessarily alarm beneficiaries and other stakeholders, others are planning to send notices this month with freezes beginning in October and November. 

Companion Recommendations to Promote Seamless Children’s Coverage 

In addition to the recommendations pertaining to Federal CHIP funding, the 

Commission made a number of companion recommendations for moving toward a 

more seamless system of children’s coverage. These recommendations include: 

• Creating and funding a children’s coverage demonstration grant program to 

support State efforts to develop, test, and implement approaches to providing 

CHIP-eligible children with seamless health coverage that is as comprehensive 

and affordable as CHIP; 

• Eliminating waiting periods in CHIP, aligning separate CHIP premium policies 

with those of Medicaid, and permanently extending authority for States to use 

Express Lane Eligibility; and 

56 

7Savings were the result of reduced staff time to complete eligibility determinations due to 

simplified enrollment processes, according to State reports (OIG 2016). 8 As of January 1, 2016, eight States use ELE for children at Medicaid enrollment, five States 

use ELE for CHIP enrollment, seven States use ELE for children at Medicaid renewal, and 

three States use ELE for CHIP renewal (KFF 2016). 

• Extending funding to support outreach and enrollment of Medicaid-and CHIPeligible children, the Childhood Obesity Research Demonstration projects, and 

the Pediatric Quality Measures Program. 

Demonstration grants. State innovation will be a key driver in improving the 

system of coverage for low- and moderate-income children; Federal support of such 

efforts would ease financial barriers to States that aspire to transform their children’s coverage systems. 

To encourage and support child-focused efforts, the Commission recommends providing planning and implementation demonstration grants to develop and test models for transforming coverage systems for children. Such models could be developed 

using existing State plan and waiver authorities, such as those available under sections 1115 and 1332 of the Act. Developing options for a seamless system of affordable and comprehensive coverage for children across available coverage sources will 

require resources for research and analysis of markets, needs assessments, stakeholder and expert engagement, as well as legal, regulatory, policy, and cost analyses. These activities are typically not eligible for Federal match under State plan 

authority, and in past efforts to develop and implement health delivery system 

changes, States have used waiver authority or other grant funding such as the Real 

Choice Systems Change grant program to finance these planning activities. Historically, State demonstrations have been an effective way to gain experience from 

which learning and strategies can be gleaned for broader take up by States. 

Eliminate CHIP waiting periods and premiums for children under 150 

percent FPL. While CHIP has been enormously successful in reducing uninsurance, steps can be taken to promote greater continuity and seamlessness of coverage within the existing program. MACPAC initially recommended such steps relating to CHIP waiting periods and premiums in order to achieve these goals in 

March 2014, and continues to recommend them in 2017. There is little evidence 

showing that waiting periods have deterred crowd-out of private coverage; eliminating them would promote more stable coverage for children, simplify and make 

CHIP policy more consistent with Medicaid and other publicly finance coverage programs, and reduce administrative complexity and burden for families, States, health 

plans, and providers (MACPAC 2014b). Eliminating CHIP premiums for families 

with incomes under 150 percent FPL would reduce uninsurance and align CHIP 

premium policies with Medicaid policies for lower-income children. Compared to 

higher-income enrollees, families with incomes below 150 percent FPL are more 

price sensitive and less likely to take up CHIP coverage for their children when a 

premium is required (MACPAC 2017). 

Express Lane Eligibility. The Commission recommends that Congress permanently extend Express Lane Eligibility (ELE) authority as an option States can 

adopt to simplify enrollment processes and promote continuity of coverage. ELE, 

currently authorized through September 30, 2017, permits States to rely on findings 

from another program designated as an Express Lane agency (e.g., Supplemental 

Nutrition Assistance Program, the National School Lunch Program, and Head Start) 

when making Medicaid and CHIP eligibility determinations (including renewals of 

eligibility). 

ELE processes are associated with positive enrollment gains (both new enrollment 

and renewals), and administrative savings in some States (OIG 2016, Hoag et al. 

2013). A Federal evaluation indicated that, as of December 2013, nearly 1.4 million 

children enrolled in Medicaid or CHIP and retained coverage through ELE processes. Federal evaluations have found that some States reported that implementing 

ELE resulted in administrative savings. For example, one State reportedly saved 

$7.3 million between 2011 and 2014, and another State reported that the Medicaid 

agency saved $25.77 per initial enrollment and $5.15 per renewal (OIG 2016).7

Without an extension, States that have implemented this option would be likely to 

incur additional costs in reverting to legacy eligibility processes. Should authority 

for the ELE option expire, the States that have implemented this option could only 

continue to do so under a section 1115 waiver.8

The Commission also recommends that the HHS Secretary, in consultation with 

the Secretaries of the U.S. Department of Agriculture and the U.S. Department of 

57 

9Specifically, the report should describe the legislative and regulatory changes necessary to 

allow designated programs to use publicly subsidized health program findings to determine eligibility for other programs. The report should also assess the operational challenges and technical 

feasibility of this policy, and evaluate the implications of broadening ELE authority. 

Education, assess and report to Congress on the legislative and regulatory modifications needed to permit States to use Medicaid and CHIP eligibility determination 

information to determine eligibility for other designated programs serving children 

and families. Given the efficiencies and favorable enrollment gains associated with 

ELE as currently implemented, the Commission seeks information on changes necessary to modify ELE authority so that designated programs can use Medicaid or 

CHIP eligibility determination information, and the potential for reducing administrative burden for families and States.9

Renewal of other programs. The Commission recommends extending funding 

for three programs that focus on improving aspects of coverage or care for children 

enrolled in Medicaid or CHIP for 5 years through FY 2022: Medicaid and CHIP outreach and enrollment grants, the Childhood Obesity Research Demonstration 

(CORD) projects, and the Pediatric Quality Measures Program. In past years, funding for these programs has been renewed alongside CHIP funding. 

• Outreach and enrollment grants created in 2009 have helped to support States, 

tribes, and community-based organizations in a variety of proactive outreach 

and enrollment activities. Funds have also supported a national outreach and 

enrollment campaign (CMS 2016). These grants are needed to maintain the historic successes in finding and enrolling eligible children and in helping them retain coverage at renewal. Absent such grants, State spending on outreach and 

enrollment would be limited by Federal law to the 10 percent cap on CHIP administrative spending. CHIPRA established this program, appropriating $100 

million for FYs 2009–2013. Funding was most recently renewed under the 

Medicare Access and CHIP Reauthorization Act (MACRA, Pub. L. 114–10) at 

$40 million for FYs 2016–2017. 

• CHIPRA also established the Childhood Obesity Research Demonstration 

(CORD) to identify and evaluate health care and community strategies to combat childhood obesity in children age 2–12 enrolled in or eligible for Medicaid 

or CHIP (Dooyema et al. 2013). CORD project grantees are evaluating whether 

multi-level, multi-setting approaches that integrate primary care with public 

health strategies can improve health behaviors and reduce childhood obesity. 

The second phase of CORD grants focuses on preventive services to individual 

children and families in Arizona and Massachusetts. Evaluation results which 

became available in July 2017 from some of the Phase I demonstrations, show 

a statistically significant reduction in child body mass index and increase in 

parent satisfaction with obesity related care. Providers who participated in one 

demonstration showed improved confidence in determining child overweight or 

obesity status, providing counseling, and setting behavioral goals with families. 

Most recently, MACRA extended funding for this effort, at $10 million for FYs 

2016–2017. Continued Federal funding is important to efforts to develop and 

test strategies to reduce childhood obesity, as well as disseminating results. 

• In 2009, the Centers for Medicare and Medicaid Services (CMS) developed a 

core set of children’s health care quality measures for children in Medicaid and 

CHIP, the first focused effort to measure the quality of publicly funded children’s health care in a consistent way on a national level. Since 2010, State participation in reporting the voluntary core set of child health measures has increased; by FY 2014, all 50 States and the District of Columbia reported at least 

one measure (CMS 2016b, CMS 2011). In its initial phase, the Pediatric Quality 

Measures Program (PQMP) worked to improve and strengthen the initial child 

core set by bringing together experts, to develop and improve pediatric quality 

measures (AHRQ 2016, Sebelius 2014). Current PQMP grantees are assessing 

the feasibility and usability of the measures at the State, health plan, and provider levels (AHRQ 2016). MACRA extended funding of $20 million over FYs 

2016 and 2017. 

An extension of PQMP funding will allow the Secretary to continue to develop, 

test, validate, and disseminate new child health quality measures, and to continue 

revising existing measures for children enrolled in Medicaid and CHIP. In a November 2014 letter to Congress, MACPAC stated that the needed investments in quality 

measurement are relatively small, but that they are important, not only for those 

whose care is financed by Medicaid and CHIP but also for taxpayers (MACPAC 

58 

10The Congressional Budget Office (CBO) makes unique assumptions regarding the future of 

CHIP, which will affect the projected Federal cost of legislative proposals it examines. CBO is 

required to assume that CHIP and certain other expiring programs continue in perpetuity at 

the last appropriated level (2 U.S.C. 907(b)(2)(A)(i)). However, in order to reduce the long-term 

Federal spending projected by CBO under these assumptions, the Children’s Health Insurance 

Program Reauthorization Act (CHIPRA) was worded so that the last appropriated level for 

CBO’s purposes was $5.7 billion in FY 2013 rather than the $17.4 billion actually appropriated 

for FY 2013. In extending Federal CHIP funding by 2 years, the ACA continued the use of this 

language so that the last appropriated level for CBO’s purposes for CHIP past FY 2015 is $5.7 

billion rather than $21.1 billion. 

2014b). In the letter, MACPAC noted several key areas in which ongoing work can 

build on progress to date, including strengthening CMS’s capacity to calculate quality measures for States, improving quality measures for individuals with disabilities, and expanding the use of core quality measures in State quality improvement 

efforts. Continuation of the PQMP could also support efforts to measure and improve care provided to children with special health care needs enrolled in Medicaid 

and CHIP coverage. 

FEDERAL BUDGET IMPLICATIONS

The Congressional Budget Office (CBO) estimates that these recommendations 

would increase net Federal spending by about $18.7 billion above the agency’s current law baseline over a 10-year period of FYs 2017–2026. CBO’s estimate also reflects congressional budget rules that require the agency to assume in its current 

law spending baseline that Federal CHIP funding continues beyond FY 2015 at $5.7 

billion each year.10

CONCLUSION

CHIP has clearly played an important role in providing access to health-care coverage to low- to moderate-income children who otherwise would have been uninsured. In addition, CHIP has provided a platform for State innovations to improve 

take-up of public coverage among eligible but uninsured children, remove enrollment barriers, and focus on the quality of children’s care. For example, outreach and 

enrollment techniques that often began as experiments in CHIP in individual States 

were subsequently identified as best practices and, in some cases, are now required 

in all States for both CHIP and Medicaid. 

Congress now faces an important decision regarding the future of CHIP and its 

approach to providing a stable, affordable, and adequate source of coverage to millions of low- and moderate income children. MACPAC’s recommendations provide 

advice on how to ensure a stable source of affordable and comprehensive coverage 

for low- and moderate-income children during a period of uncertainty affecting other 

health care markets. 

When the Commission made its recommendations in January, it noted the urgent 

need for congressional action. With the end of the fiscal year in sight, the Commission must underscore the need for Congress to act as soon as possible to extend 

CHIP so that States do not respond to uncertainty around CHIP’s future by implementing policies that reduce children’s access to needed health-care services. 

The Commission’s longer-term vision looks to State innovations that would create 

a more seamless system of children’s coverage, provide comprehensive and affordable coverage for low- and moderate-income children, and remove the potential for 

gaps in coverage and care as children transition between different sources of publicly and privately financed health insurance. Such a system would promote greater 

alignment between Medicaid, CHIP, and other insurance sources and would smooth 

out transitions between them. The recommendations of the Commission reflect these 

goals and take steps to provide States and their Federal partners the tools to transform children’s coverage. 

Thank you, members of the committee. I would be happy to answer any questions 

you may have. 

References 

Agency for Healthcare Research and Quality (AHRQ). 2016. Pediatric Quality Measures Program. Rockville, MD: AHRQ. http://www.ahrq.gov/policymakers/chipra/ 

pqmp.html. 

59 

Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and 

Human Services. 2017a. 2016 number of children ever enrolled. 2017. https:// 

www.medicaid.gov/chip/downloads/fy-2016-childrens-enrollment-report.pdf. 

Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and 

Human Services. 2017b. Key dates for calendar year 2017: Qualified health plan certification in the federally-facilitated exchanges; rate review; risk adjustment, reinsurance and risk corridors, revised April 2017. https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-Revised-Key-Dates-for-Calend 

ar-Year-2017-4-13-17.pdf. 

Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and 

Humans Services. 2016. Connecting kids to coverage outreach and enrollment funding history. Baltimore, MD: CMS. https://www.insurekidsnow.gov/initiatives/connecting-kids/funding/history/index.html. 

Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and 

Human Services. 2016b. 2015 Annual Report on the quality of care for Children in 

Medicaid and CHIP. Baltimore, MD: CMS. https://www.medicaid.gov/medicaid/ 

quality-of-care/downloads/2015-child-sec-rept.pdf. 

Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and 

Human Services. 2015. Certification of comparability of pediatric coverage offered by 

qualified health plans. November 25, 2015. https://www.medicaid.gov/chip/ 

downloads/certification-of-comparability-of-pediatric-coverage-offered-by-qualifiedhealth-plans.pdf. 

Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and 

Human Services. 2011. Children’s Health Insurance Program Reauthorization Act 

2011 annual report on the quality of care for children in Medicaid and CHIP. Baltimore, MD: CMS. https://www.medicaid.gov/medicaid/quality-of-care/downloads/ 

2011_statereporttocongress.pdf. 

Dooyema, C., B. Belay, J. Foltz, et al. 2013. ‘‘The Childhood Obesity Research Demonstration Project: A comprehensive community approach to reduce childhood obesity.’’ Childhood Obesity 9, no. 5: 454–459. 

Hensley-Quinn, M. and C. Hess. 2013. How CHIP can help meet child specific requirements and needs in the exchange: Considerations for policymakers. Washington, 

DC: National Academy for State Health Policy. https://nashp.org/?s=How+CHIP 

+can+help+meet+child+specific+requirements&category_name=. 

Hoag, S., M. Harrington, C. Orfield, et al. 2011. Children’s Health Insurance Program: An evaluation (1997–2010). Interim report to Congress. Ann Arbor, MI: 

Mathematica Policy Research. http://aspe.hhs.gov/health/reports/2012/chiprairtc/index.pdf. 

Kaiser Family Foundation (KFF). 2016. State adoption of Express Lane Eligibility 

for children’s Medicaid and CHIP at enrollment and renewal. http://kff.org/healthreform/state-indicator/state-adoption-of-express-lane-eligibility-for-childrens-medicaid-and-chip-at-enrollment-and-renewal/?currentTimeframe=0&sortModel=%7B 

%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 

Martinez, M.E, E.P Zammitti, and R.A. Cohen. 2017. Health insurance coverage: 

Early release of estimates from the National Health Interview Survey, January– 

September 2016. Hyattsville, MD: National Center for Health Statistics. https:// 

www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2017a. Report to 

the Congress on Medicaid and CHIP. March 2017. Washington, DC: MACPAC. 

https://www.macpac.gov/publication/march-2017-report-to-congress-on-medicaidand-chip/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2017b. Federal 

CHIP Funding: When Will States Exhaust Allotments? March 2017. Washington, 

DC: MACPAC. https://www.macpac.gov/publication/federal-chip-funding-whenwill-states-exhaust-allotments/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2016. ‘‘Chapter 

5: Design considerations for the future of children’s coverage: Focus on affordability.’’ In Report to Congress on Medicaid and CHIP. March 2016. Washington, 

DC: MACPAC. https://www.macpac.gov/publication/design-considerations-for-thefuture-of-childrens-coverage-focus-on-affordability-2/. 

60 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2015. Report to 

the Congress on Medicaid and CHIP. March 2015. Washington, DC: MACPAC. 

https://www.macpac.gov/publication/march-2015-report-to-congress-on-medicaidand-chip/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2014a. Report to 

the Congress on Medicaid and CHIP. June 2014. Washington, DC: MACPAC. 

https://www.macpac.gov/publication/ch-1-chip-and-the-new-coverage-landscape/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2014b. Report to 

the Congress on Medicaid and CHIP. March 2014. Washington, DC: MACPAC. 

https://www.macpac.gov/publication/report-to-the-congress-on-medicaid-and-chip314/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2014c. Letter to 

Secretary of the U.S. Department of Health and Human Services and Congress regarding ‘‘Adult and Children’s Health Care Quality Reports to the Congress,’’ November 2014. Washington, DC: MACPAC. https://www.macpac.gov/wp-content/ 

uploads/2015/01/MACPAC-comments-on-HHS-quality-reports-to-Congress.pdf. 

National Academy for State Health Policy (NASHP). 2017. 2017 CHIP directors survey results. February 2017. Washington, DC: NASHP. http://nashp.org/wp-content/ 

uploads/2017/02/2017-CHIP-Survey-Results.pdf. 

Office of the Inspector General (OIG), U.S. Department of Health and Human Services. 2016. State use of Express Lane Eligibility for Medicaid and CHIP enrollment. 

Washington, DC: OIG. https://oig.hhs.gov/oei/reports/oei-06-15-00410.pdf. 

Sebelius, K. 2014. HHS Secretary’s efforts to improve children’s health care quality 

in Medicaid and CHIP. Washington, DC: U.S. Department of Health and Human 

Services. https://www.medicaid.gov/medicaid/quality-of-care/downloads/2014- 

childrens-report-to-congress.pdf. 

61 

APPENDIX A: ELIGIBILITY AND ENROLLMENT 

Table A–1. CHIP Eligibility Levels (2016) and Enrollment (FY 2015) by State 

State Program type 1 (as of July 1, 2016) 

Children in Medicaid-Expansion CHIP 1 Children in separate CHIP 

Total CHIPfunded child 

enrollment 4 Infants <1 (% FPL) Age 1–5 (% FPL) Age 6–18 (% FPL) Enrollment 

Separate CHIP: Age 0–18 2 Separate CHIP: Unborn Total separate CHIP 

enrollment Infants <1 (% FPL) Age 1–5 (% FPL) Age 6–18 (% FPL) Enrollment Eligibility 3 Enrollment 

Total – – – – 4,702,185 – – – 3,362,642 – 327,175 3,689,817 8,397,651 Alabama Combination – – 107–141 45,697 142–312 142–312 142–312 87,346 – – 87,346 133,043 Alaska Medicaid expansion 159–203 159–203 124–203 10,182 – – – – – – – 10,182 Arizona 5 Combination – – 104–133 37,412 148–200 142–200 134–200 1,399 – – 1,399 38,811 Arkansas Combination – – 107–142 108,706 143–211 143–211 143–211 – 6 209 3,365 3,365 112,071 California 7, 8 Combination 208–261 142–261 108–261 1,787,470 262–317 262–317 262–317 2,461 317 122,197 124,658 1,912,128 Colorado Combination – – 108–142 23,687 143–260 143–260 143–260 62,446 – – 62,446 86,133 Connecticut Separate – – – – 197–318 197–318 197–318 24,884 – – 24,884 24,884 Delaware Combination 194–212 – 110–133 238 – 9 143–212 9 134–212 9 16,141 – – 16,141 16,379 District of Columbia Medicaid expansion 206–319 146–319 112–319 10,676 – – – – – – – 10,676 Florida Combination 192–206 – 112–133 134,708 – 9 141–210 9 134–210 9 293,386 – – 293,386 428,094 Georgia Combination – – 113–133 53,906 206–247 150–247 134–247 176,909 – – 176,909 230,815 Hawaii Medicaid expansion 191–308 139–308 105–308 27,239 – – – – – – – 27,239 Idaho Combination – – 107–133 8,937 143–185 143–185 134–185 25,576 – – 25,576 34,513 Illinois Combination – – 108–142 113,105 143–313 143–313 143–313 191,328 208 26,138 217,466 330,571 

62 

APPENDIX A: ELIGIBILITY AND ENROLLMENT—Continued 

Table A–1. CHIP Eligibility Levels (2016) and Enrollment (FY 2015) by State 

State Program type 1 (as of July 1, 2016) 

Children in Medicaid-Expansion CHIP 1 Children in separate CHIP 

Total CHIPfunded child 

enrollment 4 Infants <1 (% FPL) Age 1–5 (% FPL) Age 6–18 (% FPL) Enrollment 

Separate CHIP: Age 0–18 2 Separate CHIP: Unborn Total separate CHIP 

enrollment Infants <1 (% FPL) Age 1–5 (% FPL) Age 6–18 (% FPL) Enrollment Eligibility 3 Enrollment 

Indiana Combination 157–208 141–158 106–158 69,462 209–250 159–250 159–250 31,098 – – 31,098 100,560 Iowa Combination 240–375 – 122–167 21,777 – 9 168–302 9 168–302 9 60,880 – – 60,880 82,657 Kansas Combination – – 113–133 54 167–238 150–238 134–238 77,085 – – 77,085 77,139 Kentucky Combination – 142–159 109–159 50,926 196–213 160–213 160–213 36,050 – – 36,050 86,976 Louisiana Combination 142–212 142–212 108–212 122,878 213–250 213–250 213–250 3,498 209 9,238 12,736 135,614 Maine Combination – 140–157 132–157 13,440 192–208 158–208 158–208 8,870 – – 8,870 22,310 Maryland Medicaid expansion 194–317 138–317 109–317 142,327 – – – – – – – 142,327 Massachusetts 10 Combination 185–200 133–150 114–150 79,299 201–300 151–300 151–300 76,519 200 13,123 89,642 168,941 Michigan 11 Combination 195–212 143–212 109–212 29,226 – – – 85,302 195 5,171 90,473 119,699 Minnesota Combination 275–283 12 – – 474 – – – – 278 3,361 3,361 3,835 Mississippi Combination – – 107–133 30,819 205–209 144–209 134–209 56,286 – – 56,286 87,105 Missouri Combination – 148–150 110–150 38,600 197–300 151–300 151–300 39,744 300 – 13 39,744 78,344 Montana Combination – – 109–143 16,008 144–261 144–261 144–261 29,253 – – 29,253 45,261 Nebraska Combination 162–213 145–213 109–213 55,515 – – – 4,613 14 197 2,090 6,703 62,218 Nevada Combination – – 122–133 17,763 161–200 161–200 134–200 44,145 – – 44,145 61,908 

63 

New Hampshire Medicaid expansion 196–318 196–318 196–318 16,651 – – – – – – – 16,651 New Jersey Combination – – 107–142 100,826 195–350 143–350 143–350 114,365 – – 114,365 215,191 New Mexico Medicaid expansion 200–300 200–300 138–240 17,155 – – – 40 14 – – 40 17,195 New York Combination – – 110–149 235,945 219–400 150–400 150–400 394,787 – – 394,787 630,732 North Carolina Combination 194–210 141–210 107–133 134,413 – – 138–211 100,237 – 4 15 100,241 234,654 North Dakota Combination – – 111–133 – 148–170 148–170 134–170 4,955 – – 4,955 4,955 Ohio Medicaid expansion 141–206 141–206 107–206 181,100 – – – – – – – 181,100 Oklahoma Combination 169–205 151–205 115–205 174,167 – – – 208 16 205 16,483 16,691 190,858 Oregon 17 Combination 133–185 – 100–133 – 186–300 134–300 134–300 115,726 185 6,143 121,869 121,869 Pennsylvania Combination – – 119–133 64,638 216–314 158–314 134–314 229,704 – – 229,704 294,342 Rhode Island Combination 190–261 142–261 109–261 29,948 – – – 1,376 14 253 – 18 1,376 31,324 South Carolina Medicaid expansion 194–208 143–208 107–208 98,336 – – – – – – – 98,336 South Dakota Combination 177–182 177–182 124–182 12,441 183–204 183–204 183–204 3,775 – – 3,775 16,216 Tennessee 19 Combination – – 109–133 17,971 196–250 143–250 134–250 78,731 250 9,513 88,244 106,215 Texas Combination – – 109–133 336,769 199–201 145–201 133–201 614,417 202 98,437 712,854 1,049,623 Utah Combination – – 105–133 27,762 145–200 145–200 139–200 27,523 – – 27,523 55,285 Vermont Medicaid expansion 237–312 237–312 237–312 4,766 – – – – – – – 4,766 Virginia Combination – – 109–143 86,551 144–200 144–200 144–200 102,815 – – 102,815 189,366 Washington Separate – – – – 211–312 211–312 211–312 37,883 193 8,154 46,037 46,037 West Virginia 20 Combination – – 108–133 15,242 159–300 142–300 134–300 33,036 – – 33,036 48,278 

64 

APPENDIX A: ELIGIBILITY AND ENROLLMENT—Continued 

Table A–1. CHIP Eligibility Levels (2016) and Enrollment (FY 2015) by State 

State Program type 1 (as of July 1, 2016) 

Children in Medicaid-Expansion CHIP 1 Children in separate CHIP 

Total CHIPfunded child 

enrollment 4 Infants <1 (% FPL) Age 1–5 (% FPL) Age 6–18 (% FPL) Enrollment 

Separate CHIP: Age 0–18 2 Separate CHIP: Unborn Total separate CHIP 

enrollment Infants <1 (% FPL) Age 1–5 (% FPL) Age 6–18 (% FPL) Enrollment Eligibility 3 Enrollment 

Wisconsin Combination – – 101–151 96,973 – 9 187–301 9 152–301 9 67,845 301 3,758 71,603 168,576 Wyoming 21 Combination – – 119–133 – 22 155–200 155–200 134–200 – 22 – – – 22 5,649 

Notes: FY is fiscal year. FPL is Federal poverty level. Enrollment numbers generally include individuals ever enrolled during the year, even if for a single month; however, in the event individuals were in multiple categories during the year 

(for example, in Medicaid for the first half of the year but separate CHIP for the second half), the individual would only be counted in the most recent category. Enrollment data shown in the table are as of July 2016, the most current enrollment data available; States may subsequently revise their current or historical data. 

–99Dash indicates that State does not use this eligibility pathway. 

1 Under CHIP, States have the option to use an expansion of Medicaid, separate CHIP, or a combination of both approaches. Ten States (including the District of Columbia) are Medicaid expansions and two States are separate CHIP only 

(Connecticut and Washington). There are combination programs in 39 States; among those, 11 consider themselves to have separate programs but are technically combinations due to the transition of children below 133 percent FPL from separate CHIP to Medicaid (Alabama, Arizona, Georgia, Kansas, Mississippi, Oregon, Pennsylvania, Texas, Utah, West Virginia, Wyoming). Medicaid-expansion CHIP eligibility ranges of 5 percentage points attributable to the mandatory 5 percent disregard are not shown. For States that have different CHIP-funded eligibility levels for children age 6–13 and age 14–18, this table shows only the levels for children age 6–13. For example, Oklahoma offers CHIP-funded Medicaid coverage to children age 6–14 with family income 115–205 percent FPL, and to 14- to 18-year-olds with family income 65–205 percent FPL. Tennessee offers CHIP-funded Medicaid coverage to children age 6–14 with family income from 109–133 percent FPL and 14–19 year olds with family income 29–133 percent FPL. 2 CHIP eligibility levels as of July 2016. 

3 Separate CHIP eligibility for children birth through age 18 generally begins where Medicaid coverage ends (as shown in the previous columns). For unborn children, there is no lower bound for income eligibility if the mother is not eligible 

for Medicaid. 4 Total exceeds the sum of Medicaid expansion and separate CHIP columns due to only total CHIP enrollment being reported for Wyoming. 5 Arizona closed separate CHIP (KidsCare) to new enrollment in January 2010. The State reinstated the program on September 1, 2016. 6 Although Arkansas transitioned its Medicaid-expansion CHIP to separate CHIP effective January 1, 2015, the State continued to report enrollment for children age 0–18 years under Medicaid-expansion CHIP. 7 California has separate CHIP in three counties only that covers children up to 317 percent FPL. 

8 Due to reporting system updates, California CHIP enrollment totals are estimates as a result of the exclusion of certain unborn CHIP enrollees in reporting. 9 Separate CHIP in Delaware, Florida, Iowa, and Wisconsin covers children age 1–18. 10 Certain enrollees who should have been assigned to CHIP were assigned to Medicaid beginning in the second quarter of 2014, making FY 2015 totals artificially low. 11 CHIP-funded Medicaid Michigan enrollees are included in Medicaid enrollment counts rather than in CHIP for FY 2015. Therefore, the CHIP enrollment totals are artificially low and the Medicaid enrollment totals are artificially high. 

Michigan transitioned its separate CHIP into Medicaid-expansion CHIP effective January 1, 2016. 

12 In Minnesota, only infants (defined by the State as being under age two) are eligible for Medicaid-expansion CHIP up to 283 percent FPL. 13Missouri began covering unborn children effective January 1, 2016, however the State has not reported enrollment for this coverage group. 14 Separate CHIP enrollment figures in Nebraska, New Mexico, and Rhode Island are for the States’ § 2101(f) coverage group under the Patient Protection and Affordable Care Act. Section 2101(f) required that States provide separate CHIP 

coverage to children to who lost Medicaid eligibility (including through Medicaid-expansion CHIP) due to the elimination of income disregards under the modified adjusted gross income (MAGI) based methodologies. Children covered under § 2101(f) remained eligible for such coverage until their next scheduled renewal or their 19th birthday, or until they moved out of State, requested removal from the program, or were deceased. Coverage under § 2101(f) has now been phased out. 

15 North Carolina does not provide unborn children separate CHIP coverage. Errors in enrollment data reported are likely due to data quality issues. 16 Separate CHIP enrollment in Oklahoma is for children enrolled in the State’s premium assistance program. 17 Certain Oregon enrollees who should have been assigned to CHIP were assigned to Medicaid-funded coverage for FY 2014 and FY 2015. 18 Lack of enrollment for separate CHIP unborn coverage in Rhode Island is likely due to data quality issues. 19While Tennessee covers children with CHIP-funded Medicaid, enrollment is currently capped, except for children who roll over from traditional Medicaid. 20West Virginia’s enrollment totals are artificially high because children who transitioned between CHIP and Medicaid are reported in both programs, rather than the program they were last enrolled. 21 CMS’s FY 2015 children’s enrollment report considers these values to be estimates. 

65 

22 Due to inconsistencies between the Statistical Enrollment Data System data and the Centers for Medicare and Medicaid Services’ FY 2015 children’s enrollment report, we do not report enrollment for Medicaid expansion and separate 

CHIP. We only report total CHIP enrollment as provided in CMS’s FY 2015 children’s enrollment report. 

Sources: Personal communication with CMS staff on December 2, 2016 and December 9, 2016. For numbers of children: MACPAC, 2016, analysis of CHIP Statistical Enrollment Data System from Centers for Medicare and Medicaid Service 

as of July 1, 2016; MACPAC, 2016, MACStats: Medicaid and CHIP Data Book, December 2016, Washington, DC: MACPAC, https://www.macpac.gov/publication/child-enrollment-in-chip-and-medicaid-bystate/. For eligibility levels: MACPAC, 2016, MACStats: Medicaid and CHIP Data Book, December 2016, Washington, DC: MACPAC, https://www.macpac.gov/publication/medicaid-and-chip-income-eligibility-levels-as-apercentage-of-the-federal-poverty-level-for-children-and-pregnant-women-by-state/. 

66 

APPENDIX B: CHIP ENHANCED FEDERAL MEDICAL ASSISTANCE PERCENTAGES 

Table B–1. CHIP Enhanced Federal Medical Assistance Percentages by State, FYs 2013–2017 

State 

E–FMAPs for CHIP 

FY 2015 1 FY 2016 2 FY 2017 2

All States (median) 70.8% 93.8% 94.0% 

Alabama 78.3 100.0 100.0 

Alaska 65.0 88.0 88.0 

Arizona 77.9 100.0 100.0 

Arkansas 79.6 100.0 100.0 

California 65.0 88.0 88.0 

Colorado 65.7 88.5 88.0 

Connecticut 65.0 88.0 88.0 

Delaware 67.5 91.4 90.9 

District of Columbia 79.0 100.0 100.0 

Florida 71.8 95.5 95.8 

Georgia 76.9 100.0 100.0 

Hawaii 66.6 90.8 91.5 

Idaho 80.2 100.0 100.0 

Illinois 65.5 88.6 88.9 

Indiana 76.6 99.6 99.7 

Iowa 68.9 91.4 92.7 

Kansas 69.6 92.2 92.4 

Kentucky 79.0 100.0 100.0 

Louisiana 73.4 96.6 96.6 

Maine 73.3 96.9 98.1 

Maryland 65.0 88.0 88.0 

Massachusetts 65.0 88.0 88.0 

Michigan 75.9 98.9 98.6 

Minnesota 65.0 88.0 88.0 

Mississippi 81.5 100.0 100.0 

Missouri 74.4 97.3 97.3 

Montana 76.1 98.7 98.9 

Nebraska 67.3 88.8 89.3 

Nevada 75.1 98.5 98.3 

New Hampshire 65.0 88.0 88.0 

67 

APPENDIX B: CHIP ENHANCED FEDERAL MEDICAL ASSISTANCE PERCENTAGES—Continued 

Table B–1. CHIP Enhanced Federal Medical Assistance Percentages by State, FYs 2013–2017 

State 

E–FMAPs for CHIP 

FY 2015 1 FY 2016 2 FY 2017 2

New Jersey 65.0 88.0 88.0 

New Mexico 78.8 100.0 100.0 

New York 65.0 88.0 88.0 

North Carolina 76.1 99.4 99.8 

North Dakota 65.0 88.0 88.0 

Ohio 73.9 96.7 96.6 

Oklahoma 73.6 95.7 95.0 

Oregon 74.8 98.1 98.1 

Pennsylvania 66.3 89.4 89.3 

Rhode Island 65.0 88.3 88.7 

South Carolina 79.5 100.0 100.0 

South Dakota 66.2 89.1 91.5 

Tennessee 75.5 98.5 98.5 

Texas 70.6 93.0 92.3 

Utah 79.4 100.0 100.0 

Vermont 67.8 90.7 91.1 

Virginia 65.0 88.0 88.0 

Washington 65.0 88.0 88.0 

West Virginia 80.0 100.0 100.0 

Wisconsin 70.8 93.8 94.0 

Wyoming 65.0 88.0 88.0 

Notes: FY is fiscal year. FMAP is Federal medical assistance percentage. E–FMAP is enhanced FMAP. ACA 

is the Patient Protection and Affordable Care Act (ACA, Pub. L. 111–148, as amended). The E–FMAP determines the Federal share of both service and administrative costs for CHIP, subject to the availability of funds 

from a State’s Federal allotments for CHIP. 

Enhanced FMAPs for CHIP are calculated by reducing the State share under regular FMAPs for Medicaid 

by 30 percent. In FYs 2016 through 2019, the E–FMAPs are increased by 23 percentage points. For additional 

information on Medicaid FMAPs, see https://www.macpac.gov/subtopic/matching-rates/. 

E–FMAPs for the territories are not included. In FY 2015, all territories had an E–FMAP of 68.5 percent, 

and in FY 2016 and 2017, 91.5 percent. 

1 In FY 2015, States received the traditional CHIP E–FMAP. 

2 Under the ACA, beginning on October 1, 2015, and ending on September 30, 2019, the enhanced FMAPs 

are increased by 23 percentage points, not to exceed 100 percent, for all States. 

Sources: Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human 

Services, ASPE FMAP reports for 2015, 2016, and 2017, https://aspe.hhs.gov/basic-report/fy2017-federal-medical-assistance-percentages (for FY 2017), http://aspe.hhs.gov/health/reports/2015/FMAP2016/fmap16.cfm (for 

FY 2016), http://aspe.hhs.gov/health/reports/2014/FMAP2015/fmap15.pdf (for FY 2015). 

68 

1States report their anticipated expenditures for both Medicaid and CHIP to the Centers for 

Medicare and Medicaid Services on a quarterly basis. The data used for this issue brief reflect 

quarterly projections provided by States in May 2017. MACPAC previously issued this data in 

March 2017 using States’ budget projections submitted in February 2017. 

APPENDIX C: FEDERAL CHIP FUNDING: WHEN WILL STATES EXHAUST ALLOTMENTS?

Issue Brief 

July 2017 Advising Congress on Medicaid and CHIP Policy 

FEDERAL CHIP FUNDING: WHEN WILL STATES EXHAUST ALLOTMENTS?

Under current law, Federal funds for the State Children’s Health Insurance Program (CHIP) are only provided through fiscal year (FY) 2017. Unless CHIP funding 

is extended, all States are expected to exhaust their Federal CHIP funds during FY 

2018; this includes unspent CHIP funding from prior years. Three States and the 

District of Columbia are projected to exhaust their funds by December 2017. Most 

States (31 States and the District of Columbia) are projected to exhaust Federal 

CHIP funds by March 2018. These estimates are based on States’ projections of 

their CHIP spending for FYs 2017 and 2018.1 How quickly States deplete CHIP 

funds could change if actual CHIP spending is above or below projections. 

This issue brief updates data on the exhaustion of CHIP funds presented in a 

March 2017 issue brief and with MACPAC’s January 2017 Recommendations for the 

Future of CHIP and Children’s Coverage. With the end of FY 2017 approaching, congressional action to renew CHIP funding is urgent to ensure the stability of children’s coverage during a time in which health insurance markets are expected to 

face substantial changes, and to provide budgetary certainty for States. If CHIP 

funding is not renewed, States will need to make decisions including whether to end 

separate CHIP, how to finance Medicaid-expansion CHIP with reduced Federal 

spending, and how to provide information to families, providers, and plans (HensleyQuinn and King 2016). 

FEDERAL CHIP FUNDING AND ITS EXHAUSTION UNDER CURRENT LAW

Federal CHIP funds are allotted to States annually based on each State’s recent 

CHIP spending, increased by a growth factor. States have 2 years to spend their 

allotments, and unspent allotments are available for redistribution to other States 

experiencing CHIP funding shortfalls. Under current law, new CHIP allotments are 

not available after FY 2017 and unspent FY 2017 CHIP allotments that remain 

available for expenditures in FY 2018 are reduced by one-third (§ 2104(m)(2)(B)(iv) 

of the Social Security Act (the Act)). 

States experiencing CHIP funding shortfalls can also receive contingency fund 

payments if their CHIP enrollment exceeds target levels specified in section 2105(n) 

of the Act. However, contingency fund payments are not available for FY 2018 and 

subsequent years. 

CHIP funding in FY 2017 

The Federal CHIP funding that States have received for FY 2017 and the redistribution funding that is available from prior year allotments is projected to be adequate to cover projected spending in FY 2017. Two States (Arizona and Minnesota) 

are projected to have CHIP spending that exceeds their FY 2017 allotment, but 

these States are expected to receive redistribution funds in FY 2017 sufficient to 

cover their projected CHIP funding shortfall. Approximately $3 billion in redistribution funding is available in FY 2017 (CMS 2017). 

CHIP funding in FY 2018 

Under current law, in FY 2018, States may continue to spend unspent FY 2017 

allotments and redistribution funds from prior years. These funds will cover some 

but not all expected State CHIP expenses in FY 2018. By the second quarter of FY 

2018, more than half of States are projected to exhaust all available Federal CHIP 

funding, including redistribution funds (Table 1). 

69 

Table 1. Projected Exhaustion of Federal CHIP Funds in Fiscal Year 2018 

Quarter of fiscal year Number of 

States States 

First quarter 

(October–December 2017) 

4 Arizona, District of Columbia, Minnesota, and North 

Carolina 

Second quarter 

(January–March 2018) 

27 Alaska, Arkansas, California, Colorado, Connecticut, 

Delaware, Florida, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nevada, New York, Ohio, Oregon, 

Pennsylvania, Rhode Island, South Dakota, Utah, 

Vermont, Virginia, and Washington 

Third quarter 

(April–June 2018) 

19 Alabama, Georgia, Illinois, Indiana, Iowa, Maine, 

Michigan, Maryland, Nebraska, New Hampshire, 

New Jersey, New Mexico, North Dakota, Oklahoma, South Carolina, Tennessee, Texas, West 

Virginia, and Wisconsin 

Fourth quarter 

(July–September 2018) 

1 Wyoming 

Note: CHIP is the State Children’s Health Insurance Program. 

Source: MACPAC 2017 analysis using June 2017 Medicaid and CHIP Budget and Expenditure System data 

from the Centers for Medicare and Medicaid Services, including quarterly projections provided by States in 

May 2017. 

An estimated $4.2 billion in unspent FY 2017 allotments will be available for 

spending in FY 2018. Total projected FY 2018 Federal CHIP spending for States 

and territories is $17.4 billion. States will exhaust their Federal CHIP funds at different points during FY 2018 depending on their rollover balances from prior year 

allotments and projected spending (Table 2). 

Table 2. Projected Federal CHIP Funding and Spending in FY 2018, by State (millions) 

State 

Estimated 

unspent 

FY 2017 

allotments 

A 

Unspent 

FY 2017 

allotments 

available in 

FY 2018 

B = A × .67 

FY 2018 

projected 

redistribution 

funding from 

prior year 

allotments 

C 

Total FY 2018 

projected 

CHIP funding 

D = B + C 

FY 2018 

projected 

Federal CHIP 

spending 

E 

Month projected to 

exhaust CHIP 

funding 

F 

Total $6,346.2 $4,230.8 $2,949.4 $7,180.2 $17,372.4 N/A 

Alabama 176.9 118.0 37.4 155.3 284.4 April 2018 

Alaska 17.8 11.8 5.4 17.2 35.7 March 2018 

Arizona 0.0 0.0 60.1 60.1 267.9 December 2017 

Arkansas 96.3 64.2 28.7 92.9 191.9 March 2018 

California 192.2 128.1 710.0 838.1 3,291.4 January 2018 

Colorado 87.5 58.3 55.1 113.4 303.7 February 2018 

Connecticut 24.3 16.2 14.3 30.5 79.9 February 2018 

Delaware 10.6 7.1 6.3 13.4 35.2 February 2018 

District of Columbia 1.6 1.1 10.9 11.9 49.4 December 2017 

Florida 135.7 90.5 204.6 295.1 1,002.2 January 2018 

Georgia 220.6 147.1 56.6 203.6 399.1 April 2018 

Hawaii 17.4 11.6 8.2 19.8 48.1 February 2018 

70 

Table 2. Projected Federal CHIP Funding and Spending in FY 2018, by State (millions)— 

Continued 

State 

Estimated 

unspent 

FY 2017 

allotments 

A 

Unspent 

FY 2017 

allotments 

available in 

FY 2018 

B = A × .67 

FY 2018 

projected 

redistribution 

funding from 

prior year 

allotments 

C 

Total FY 2018 

projected 

CHIP funding 

D = B + C 

FY 2018 

projected 

Federal CHIP 

spending 

E 

Month projected to 

exhaust CHIP 

funding 

F 

Idaho 22.2 14.8 15.4 30.2 83.4 February 2018 

Illinois 349.1 232.7 36.6 269.3 395.7 June 2018 

Indiana 144.8 96.5 19.9 116.4 185.2 May 2018 

Iowa 75.8 50.6 19.4 70.0 137.2 April 2018 

Kansas 47.7 31.8 15.9 47.7 102.8 March 2018 

Kentucky 87.7 58.4 40.7 99.2 240.0 February 2018 

Louisiana 134.1 89.4 58.5 147.9 350.0 March 2018 

Maine 29.3 19.5 3.3 22.8 34.1 June 2018 

Maryland 187.6 125.1 35.0 160.1 281.0 April 2018 

Massachusetts 168.4 112.3 117.0 229.3 633.7 February 2018 

Michigan 264.8 176.5 31.3 207.9 316.2 May 2018 

Minnesota 0.0 0.0 38.8 38.8 172.9 December 2017 

Mississippi 147.7 98.5 41.3 139.8 282.5 March 2018 

Missouri 118.6 79.1 32.8 111.8 225.0 March 2018 

Montana 31.8 21.2 18.4 39.6 103.2 February 2018 

Nebraska 61.1 40.7 6.8 47.5 70.9 June 2018 

Nevada 16.5 11.0 15.2 26.2 78.6 January 2018 

New Hampshire 19.9 13.3 4.5 17.8 33.4 April 2018 

New Jersey 337.1 224.7 59.7 284.4 490.7 April 2018 

New Mexico 95.7 63.8 10.8 74.6 112.0 May 2018 

New York 527.3 351.6 197.1 548.6 1,229.8 March 2018 

North Carolina 12.2 8.2 182.9 191.1 823.2 December 2017 

North Dakota 16.6 11.1 2.3 13.3 21.2 May 2018 

Ohio 200.1 133.4 70.1 203.5 445.6 March 2018 

Oklahoma 127.5 85.0 30.4 115.4 220.6 April 2018 

Oregon 48.6 32.4 52.5 84.9 266.3 January 2018 

Pennsylvania 193.6 129.1 114.1 243.2 637.6 February 2018 

Rhode Island 11.1 7.4 15.4 22.8 76.1 January 2018 

South Carolina 127.5 85.0 15.5 100.5 154.2 May 2018 

71 

2States have the flexibility to structure CHIP as an expansion of Medicaid, as a program entirely separate from Medicaid, or as a combination of both approaches. 3 If CHIP funding were exhausted, unborn children enrolled through separate CHIP in 15 

States could not be moved into Medicaid under current law and regulations. 

Table 2. Projected Federal CHIP Funding and Spending in FY 2018, by State (millions)— 

Continued 

State 

Estimated 

unspent 

FY 2017 

allotments A 

Unspent 

FY 2017 

allotments 

available in 

FY 2018 

B = A × .67 

FY 2018 

projected 

redistribution 

funding from 

prior year 

allotments C 

Total FY 2018 

projected 

CHIP funding 

D = B + C 

FY 2018 

projected 

Federal CHIP 

spending E 

Month projected to exhaust CHIP funding F 

South Dakota 16.2 10.8 4.5 15.3 30.9 March 2018 

Tennessee 202.2 134.8 30.1 164.9 268.8 May 2018 

Texas 1,074.5 716.4 204.6 921.0 1,628.0 April 2018 

Utah 30.0 20.0 28.2 48.2 145.6 January 2018 

Vermont 5.6 3.7 5.5 9.2 28.1 January 2018 

Virginia 127.5 85.0 51.0 136.0 312.3 March 2018 

Washington 42.1 28.0 49.0 77.1 246.6 January 2018 

West Virginia 43.8 29.2 8.9 38.0 68.6 April 2018 

Wisconsin 127.3 84.9 31.8 116.7 226.7 April 2018 

Wyoming 12.2 8.1 0.8 8.9 11.5 July 2018 

Notes: FY is fiscal year. CHIP is the State Children’s Health Insurance Program. Total dollars include territories. Under current law, available unspent FY 2017 CHIP allotments are reduced by one-third in FY 2018. Projected redistribution funding is distributed proportionally 

among States based on their projected CHIP funding shortfalls for FY 2018 and the amount of unspent CHIP funding available from prior 

years. 

Source: MACPAC 2017 analysis as of June 2017 of Medicaid and CHIP Budget Expenditure System data from the Centers for Medicare and 

Medicaid Services, including quarterly projections provided by States in May 2017. 

IMPLICATIONS

The exhaustion of CHIP funding in FY 2018 will affect State budgets and will require States to make decisions about children’s coverage depending on the type of 

CHIP program States had in place in March 2010.2 Under the maintenance of effort 

requirement in the Patient Protection and Affordable Care Act (Pub. L. 111–148, as 

amended), States must maintain 2010 Medicaid and CHIP eligibility levels for children through FY 2019. 

States with separate CHIP are permitted to terminate that coverage if Federal 

CHIP funding runs out; States with Medicaid-expansion CHIP must continue that 

coverage for children at the lower Federal Medicaid matching rate. As of January 

2016, 10 States (including the District of Columbia) ran CHIP as a Medicaid expansion, 2 States had separate CHIP, and 39 States operated a combination of both approaches (Table 3, MACPAC 2017). 

SEPARATE CHIP

Of the 8.4 million children enrolled in CHIP-funded coverage during FY 2015, 

43.9 percent (3.7 million) were enrolled in separate CHIP. Once Federal CHIP funding is exhausted, States are not obligated to continue covering these children. In the 

absence of separate CHIP coverage, some of these children would be eligible for 

employer-sponsored insurance or subsidized exchange coverage. MACPAC’s prior estimates indicated that 1.1 million children would become uninsured (MACPAC 

2015).3 States that elect to shut down CHIP in the absence of Federal funding will 

bear little direct cost for children they formerly covered whether they move to 

employer-sponsored or subsidized exchange coverage, or become uninsured. 

72 

4 In FY 2017, the median CHIP matching rate is 94.0 percent and the median Medicaid 

matching rate is 58.5 percent (MACPAC 2016). 

MEDICAID-EXPANSION CHIP

In FY 2015, 4.7 million children were enrolled in Medicaid-expansion CHIP. If 

CHIP funding is exhausted, the Federal matching rate for these children falls back 

from the CHIP enhanced match to the regular Medicaid matching rate.4 Although 

States are generally prohibited from reducing eligibility levels in Medicaidexpansion CHIP through at least FY 2019, the budget consequences resulting from 

the higher State share of spending for those children could lead States to take other 

steps affecting access, such as lowering provider payment rates or increasing requirements for prior authorization. 

Table 3. State CHIP Program Type and Enrollment 

State Program type 1

CHIP-funded enrollment (FY 2015) Month and year of 

projected 

CHIP funding 

exhaustion (as of 

June 2017) 

Medicaidexpansion 

CHIP 

Separate CHIP 

Total 2

Birth–18 Unborn Total 

Total 4,702,185 3,362,642 327,175 3,689,817 8,397,651 

Alabama Combination 45,697 87,346 – 87,346 133,043 April 2018 

Alaska Medicaid 

Expansion 

10,182 – – – 10,182 March 2018 

Arizona 3 Combination 37,412 1,399 – 1,399 38,811 December 2017 

Arkansas Combination 108,706 – 4 3,365 3,365 112,071 March 2018 

California 5,6 Combination 1,787,470 2,461 122,197 124,658 1,912,128 January 2018 

Colorado Combination 23,687 62,446 – 62,446 86,133 February 2018 

Connecticut Separate – 24,884 – 24,884 24,884 January 2018 

Delaware Combination 238 16,141 – 16,141 16,379 February 2018 

District of 

Columbia 

Medicaid 

Expansion 

10,676 – – – 10,676 December 2017 

Florida Combination 134,708 293,386 – 293,386 428,094 January 2018 

Georgia Combination 53,906 176,909 – 176,909 230,815 April 2018 

Hawaii Medicaid 

Expansion 

27,239 – – – 27,239 March 2018 

Idaho Combination 8,937 25,576 – 25,576 34,513 February 2018 

Illinois Combination 113,105 191,328 26,138 217,466 330,571 May 2018 

Indiana Combination 69,462 31,098 – 31,098 100,560 May 2018 

Iowa Combination 21,777 60,880 – 60,880 82,657 April 2018 

Kansas Combination 54 77,085 – 77,085 77,139 March 2018 

Kentucky Combination 50,926 36,050 – 36,050 86,976 February 2018 

Louisiana Combination 122,878 3,498 9,238 12,736 135,614 March 2018 

Maine Combination 13,440 8,870 – 8,870 22,310 June 2018 

73 

Table 3. State CHIP Program Type and Enrollment—Continued 

State Program type 1

CHIP-funded enrollment (FY 2015) Month and year of 

projected 

CHIP funding 

exhaustion (as of 

June 2017) 

Medicaidexpansion 

CHIP 

Separate CHIP 

Total 2

Birth–18 Unborn Total 

Maryland Medicaid 

Expansion 

142,327 – – – 142,327 April 2018 

Massachusetts 7 Combination 79,299 76,519 13,123 89,642 168,941 February 2018 

Michigan 8 Combination 29,226 85,302 5,171 90,473 119,699 June 2018 

Minnesota Combination 474 – 3,361 3,361 3,835 December 2017 

Mississippi Combination 30,819 56,286 – 56,286 87,105 March 2018 

Missouri Combination 38,600 39,744 – 9 39,744 78,344 March 2018 

Montana Combination 16,008 29,253 – 29,253 45,261 February 2018 

Nebraska Combination 55,515 4,613 10 2,090 6,703 62,218 May 2018 

Nevada Combination 17,763 44,145 – 44,145 61,908 January 2018 

New Hampshire Medicaid 

Expansion 

16,651 – – – 16,651 April 2018 

New Jersey Combination 100,826 114,365 – 114,365 215,191 April 2018 

New Mexico Medicaid 

Expansion 

17,155 40 10 – 40 17,195 May 2018 

New York Combination 235,945 394,787 – 394,787 630,732 March 2018 

North Carolina Combination 134,413 100,237 4 11 100,241 234,654 December 2017 

North Dakota Combination – 4,955 – 4,955 4,955 May 2018 

Ohio Medicaid 

Expansion 

181,100 – – – 181,100 March 2018 

Oklahoma Combination 174,167 208 12 16,483 16,691 190,858 April 2018 

Oregon 13 Combination – 115,726 6,143 121,869 121,869 February 2018 

Pennsylvania Combination 64,638 229,704 – 229,704 294,342 February 2018 

Rhode Island Combination 29,948 1,376 10 – 14 1,376 31,324 February 2018 

South Carolina Medicaid 

Expansion 

98,336 – – – 98,336 June 2018 

South Dakota Combination 12,441 3,775 – 3,775 16,216 March 2018 

Tennessee 15 Combination 17,971 78,731 9,513 88,244 106,215 May 2018 

Texas Combination 336,769 614,417 98,437 712,854 1,049,623 April 2018 

Utah Combination 27,762 27,523 – 27,523 55,285 January 2018 

Vermont Medicaid 

Expansion 

4,766 – – – 4,766 January 2018 

Virginia Combination 86,551 102,815 – 102,815 189,366 February 2018 

Washington Separate – 37,883 8,154 46,037 46,037 January 2018 

74 

Table 3. State CHIP Program Type and Enrollment—Continued 

State Program type 1

CHIP-funded enrollment (FY 2015) Month and year of 

projected 

CHIP funding 

exhaustion (as of 

June 2017) 

Medicaidexpansion 

CHIP 

Separate CHIP 

Total 2

Birth–18 Unborn Total 

West Virginia 16 Combination 15,242 33,036 – 33,036 48,278 April 2018 

Wisconsin Combination 96,973 67,845 3,758 71,603 168,576 April 2018 

Wyoming 17 Combination 18 18 – 18 5,649 July 2018 

Notes: FPL is Federal poverty level. FY is fiscal year. Enrollment numbers generally include individuals ever enrolled during the year, even if 

for a single month; however, in the event individuals were in multiple categories during the year (for example, in Medicaid for the first half of the year but a separate CHIP program for the second half) the individual would only be counted in the most recent category. Enrollment data shown in the table are as of July 2016, the most current enrollment data available; States may subsequently revise their current or his- torical data. 

– Dash indicates zero. State does not use eligibility pathway. 

1 Under CHIP, States have the option to use an expansion of Medicaid, separate CHIP, or a combination of both approaches. Eleven States consider their programs to be separate but technically have combination programs due to the transition of children below 133 percent FPL from separate CHIP to Medicaid (Alabama, Arizona, Georgia, Kansas, Mississippi, Oregon, Pennsylvania, Texas, Utah, West Virginia, and Wyoming). 2 Total exceeds the sum of Medicaid expansion and separate CHIP columns due to Wyoming reporting total CHIP enrollment only. 

3 Arizona closed its separate CHIP (KidsCare) to new enrollment in January 2010. The State reinstated the program on September 1, 2016. 4 Although Arkansas transitioned its Medicaid-expansion CHIP to separate CHIP effective January 1, 2015, the State continued to report enrollment for children age 0–18 years under Medicaid-expansion CHIP. 5 California has separate CHIP in three counties only that covers children up to 317 percent FPL. 

6 Due to reporting system updates, California CHIP enrollment totals are estimates as a result of the exclusion of certain unborn CHIP enrollees in reporting. 7 Certain enrollees who should have been assigned to CHIP were assigned to Medicaid beginning in the second quarter of 2014, making FY 

2015 totals artificially low. 8 In Michigan, CHIP-funded Medicaid enrollees are included in Medicaid enrollment counts, rather than in CHIP for FY 2015. Therefore, the 

CHIP enrollment totals are artificially low. Michigan transitioned from separate CHIP to Medicaid-expansion CHIP effective January 1, 2016. 9Missouri began covering unborn children effective January 1, 2016. However, the State has not reported enrollment for this coverage 

group. 10 Separate CHIP enrollment in Nebraska, New Mexico, and Rhode Island are for the States’ section 2101(f) coverage group under the Patient Protection and Affordable Care Act. Section 2101(f) required that States provide separate CHIP coverage to children to who lost Medicaid 

eligibility (including through Medicaid-expansion CHIP) due to the elimination of income disregards under the modified adjusted gross incomebased methodologies. Children covered under section 2101(f) remained eligible for such coverage until their next scheduled renewal, their 

19th birthday, they moved out of State, they requested removal from the program, or were deceased. Coverage under section 2101(f) has now 

been phased out. 11 North Carolina does not provide unborn children with separate CHIP coverage. Errors in enrollment data reported are likely due to data 

quality issues. 12 Separate CHIP enrollment in Oklahoma is for children enrolled in the State’s premium assistance program. 13 Certain Oregon enrollees who should have been assigned to CHIP were assigned to Medicaid-funded coverage for FYs 2014 and 2015. 14 Lack of enrollment for separate CHIP unborn children coverage in Rhode Island is likely due to data quality issues. 15While Tennessee covers children with CHIP-funded Medicaid, enrollment is currently capped, except for children who roll over from traditional Medicaid. 16West Virginia’s enrollment totals are artificially high because children who transitioned between CHIP and Medicaid are reported in both 

programs, rather than the program they were last enrolled. 17 The Centers for Medicare and Medicaid Services (CMS) FY 2015 children’s enrollment report considers these values to be estimates. 18 Due to inconsistencies between the Statistical Enrollment Data System (SEDS) data and CMS’s FY 2015 children’s enrollment report, we 

do not report enrollment for Medicaid expansion and separate CHIP. We only report total CHIP enrollment as provided in CMS’s FY 2015 children’s enrollment report. 

Sources: For numbers of children: MACPAC analysis of CMS SEDS data from as of July 1, 2016; MACStats: Medicaid and CHIP 

Data Book, December 2016; personal communication with CMS staff on December 2, 2016; and December 9, 2016. For projected exhaustion of CHIP funds: MACPAC 2017 analysis using March June 2017 Medicaid and CHIP Budget and Expenditure System data from CMS, 

including quarterly projections provided by States in February–May 2017. 

References 

Financial Management Group, Center for Medicaid and CHIP Services, Centers for 

Medicare and Medicaid Services (CMS), U.S. Department of Health and Human 

Services. 2017. Email to MACPAC staff, March 22. 

Hensley-Quinn, M. and A. King. 2016. Looking ahead: A timeline of State policy and 

operational considerations if Federal CHIP funding ends for States. Portland, ME: 

National Academy for State Health Policy. http://www.nashp.org/looking-ahead/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2017. Recommendations for the future of CHIP and children’s coverage. January 2017. Washington, DC: MACPAC. https://www.macpac.gov/publication/recommendations-forthe-future-of-chip-and-childrens-coverage/. 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2016. Exhibit 6. 

‘‘Federal medical assistance percentages (FMAPs) and enhanced FMAPs (E–FMAPs) 

by State, FYs 2013–2017.’’ In MACStats: Medicaid and CHIP Data Book. December 

2016. Washington, DC: MACPAC. https://www.macpac.gov/publication/federalmedical-assistance-percentages-fmaps-and-enhanced-fmaps-e-fmaps-by-state-selectedperiods/. 

75 

Medicaid and CHIP Payment and Access Commission (MACPAC). 2015. Report to 

Congress on Medicaid and CHIP. March 2015. Washington, DC: MACPAC. https:// 

www.macpac.gov/publication/report-to-the-congress-on-medicaid-and-chip-314/. 

PREPARED STATEMENT OF HON. RON WYDEN, 

A U.S. SENATOR FROM OREGON

During this busy month, it would be easy for casual watchers of political news 

to get lost in a jumble of Washington lingo and acronyms. The continuing resolution, 

the debt ceiling, CSR payments, the NDAA, and the Children’s Health Insurance 

Program, or CHIP, whose funding authorization runs out in a matter of weeks. 

It is vital that the Congress springs into action in the days ahead to reauthorize 

CHIP’s funding. This program is a lifeline for nearly 9 million children. It’s a source 

of profound relief for parents in Oregon and across the country, like the single mom 

who works multiple jobs, pays the bills, and handles life’s many challenges on her 

own. The last thing she needs is a government letter stamped ‘‘NOTICE OF TERMINATION’’ explaining that her sick kids are on their own because CHIP’s funding 

has run out. 

She’s already juggling a lot—she’s not reading page A17 of the morning newspaper each day and decoding that Washington lingo to determine if and when Congress will act. She’s sitting in her kitchen, that scary termination letter is all she 

has to go by, and she wants to know how she’ll figure a way out of this mess. 

That’s the prospect families across the country are facing in a matter of weeks 

if Congress doesn’t act. Kids who desperately need care might not get it. States will 

be required to start planning for the worst. That means enrollment freezes, belttightening and emergency steps to try to preserve care for the kids currently in the 

program. But a vulnerable child not yet enrolled in CHIP might have to wait until 

Congress gets its act together. At best that will leave families with a mountain of 

stress, anxiety, and heartache. At worst, it’s a life and death proposition for some 

of the most vulnerable kids out there. 

So today the Finance Committee will discuss the leading health-care issue Congress needs to address this fall. Congress created CHIP with one goal in mind: to 

make sure no American child falls through the cracks of a health-care system with 

far too many. In the coming weeks, the Finance Committee has an opportunity to 

lead the way by creating a strong, bipartisan agreement that upholds CHIP’s promise to families and gives them security for years to come. 

Personally, I’m optimistic about this committee’s chances because of the leadership of our chairman. Chairman Hatch had a foundational role in the creation of 

CHIP, working in a bipartisan way with his late, great friend, Senator Ted Kennedy. 

In the decades since they led the Congress to create CHIP, the percentage of kids 

in America living without health coverage has fallen from nearly 14 percent to less 

than 5 percent. Chairman Hatch and Senator Kennedy offered proof that leaders 

with fierce disagreements can find common ground when it comes to big health-care 

challenges. This month the Finance Committee will have an opportunity to show 

that’s still possible 20 years later. 

It’s important for Congress to take action soon. There’s no kicking this can down 

the road with a short-term bill. And this cannot wait until December. Because 

States run their programs differently, some will run out of funding earlier than others. And in that time, no family should face the panic of being unable to get the 

care their sick child needs. 

As I wrap up, one point on how important it is to have CHIP and Medicaid working side-by-side. For American kids and families—particularly those families working hard every day to climb into the middle class—CHIP adds a level of security 

to their health care above and beyond Medicaid. CHIP can only work if Medicaid 

works. 

So let’s do the hard work now, colleagues, and uphold this body’s promise to 

America’s kids and their families. Today this committee is going to hear from a witness panel that knows CHIP from A to Z—a mother whose child counts on this program, an official who ensures CHIP runs smoothly in her State, and an independent 

expert who knows this program inside and out. 

76 

I hope that this hearing will be an opportunity for Senators on both sides to learn 

about and discuss this critical health-care program and to set the stage for the work 

to come. I’m confident that in short order Congress can pass a strong and bipartisan 

extension of CHIP that will last for many years—and that the Finance Committee 

can lead the way to get the job done. 

(77) 

COMMUNICATIONS

AASA ET AL. 

September 5, 2017 

Re: Extension of Children’s Health Insurance Program 

The Honorable Greg Walden The Honorable Frank Pallone 

Chairman Ranking Member 

House Energy and Commerce Committee House Energy and Commerce Committee 

U.S. House of Representatives U.S. House of Representatives 

Washington, DC 20515 Washington, DC 20515 

The Honorable Orrin G. Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Senate Finance Committee Senate Finance Committee 

U.S. Senate U.S. Senate 

Washington, DC 20510 Washington, DC 20510 

Dear Chairmen Hatch and Walden and Ranking Members Wyden and Pallone: 

The undersigned 39 national organizations of the Save Medicaid in the Schools Coalition urge you to support a full, clean extension of funding for the Children’s Health 

Insurance Program (CHIP) for 5 years at current funding levels. CHIP has benefitted from strong bipartisan support since its creation in 1997. By providing medical assistance to children who are not eligible for Medicaid, CHIP provides essential 

funding to support states to cover uninsured children. Any delay or a failure to immediately extend funding for CHIP will jeopardize coverage for children who are eligible for school-based health-related services leading to immediate and lasting 

harmful effects for America’s most vulnerable citizens. A lapse in coverage for children places more barriers on their ability to come to school ready to learn. During 

a time of great uncertainty in the health-care system, children need the consistent, 

reliable health coverage CHIP provides today. 

A school’s primary responsibility is to provide students with a high-quality education. However, children cannot learn to their fullest potential with unmet health 

needs. As such, school district personnel regularly provide critical health services to 

ensure that all children are ready to learn and able to thrive alongside their peers. 

Schools deliver health services effectively and efficiently since school is where children spend most of their days. The access to health care services that is supported 

through CHIP improves health care and educational outcomes for students. Providing health and wellness services for students ultimately enables more children 

to become employable and pursue higher education. 

More than half of the nearly 9 million children served by CHIP are eligible to receive services in school through their state Medicaid programs. Fifteen states exclusively use CHIP funds to extend their Medicaid programs, meaning all children who 

qualify for CHIP receive identical services and benefits as their traditional Medicaid 

counterparts. In most states a substantial portion of children served by CHIP receive Medicaid services and benefits protections. If Congress does not act quickly to 

extend funding for these children’s health care then school districts will lose funding 

for the critical health services these children receive that ensure they are healthy 

enough to learn. School districts depend on CHIP to finance many of these services 

and have already committed to the staff and contractors they require to provide 

mandated services for their upcoming 2017–2018 school year. 

Without a CHIP extension, every child educated in school districts across the country will feel the pain. No school district’s financial obligations and mandate to adVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00081 Fmt 6601 Sfmt 6621 R:\DOCS\31255.000 TIM
78 

dress a child’s health needs goes away simply because CHIP funds disappear. Children with unmet health needs miss more days of school and can fall behind. The 

failure to continue funding CHIP would merely shift the financial burden of providing services to the schools and the state and local taxpayers who fund them. 

School districts use their Medicaid and CHIP reimbursement funds in a variety of 

ways to help support the learning and development of the children they serve. In 

a 2017 survey of school districts, district officials reported that two-thirds of Medicaid dollars are used to support the work of health professionals and other specialized instructional support personnel (e.g., speech-language pathologists, audiologists, 

occupational therapists, school psychologists, school social workers, and school 

nurses) who provide comprehensive health and mental health services to students. 

Districts also use these funds to expand the availability of a wide range of health 

and mental-health services available to students in poverty, who are more likely to 

lack consistent access to health-care professionals. Further, some districts depend 

on Medicaid reimbursements to purchase and update specialized equipment (e.g., 

walkers, wheelchairs, exercise equipment, special playground equipment, and equipment to assist with hearing and seeing) as well as assistive technology for students 

with disabilities to help them learn alongside their peers. 

The loss of CHIP funds would also hinder many children’s ability to access basic 

health screenings for vision, hearing, and mental-health challenges and access to 

early identification and treatment. Left unaddressed, these challenges or delays undermine children’s ability to learn and make any problems more difficult and expensive to treat later. Loss of CHIP funding would also jeopardize schools’ ability to 

conduct routine screenings on-site and help to enroll eligible students in Medicaid 

or other public coverage programs or connect them with needed community-based 

services. 

Congress must act expediently to extend CHIP, so states and districts have the 

budget certainty necessary to continue to run CHIP programs and seek necessary 

reimbursements. We urge you to carefully consider the important benefits that 

CHIP provides to our nation’s children. Schools are often the hub of the community, 

and failing to extend funding for CHIP could lead to meaningful reductions to comprehensive health and mental and behavioral health care for children. 

If you have questions about the letter or wish to meet to discuss this issue further, 

please do not hesitate to reach out to the coalition co-chair Sasha Pudelski 

(spudelski@aasa.org). 

Sincerely, 

AASA, The School Superintendents Association 

Accelify 

AESA, Association of Education Service Agencies 

American Dance Therapy Association 

American Federation of School Administrators (AFSA) 

American Federation of Teachers 

American Psychological Association 

Association of School Business Officials International (ASBO) 

Association of University Centers on Disabilities (AUCD) 

Coalition for Community Schools 

Community Catalyst 

Council for Exceptional Children 

Council of Administrators of Special Education 

Council of Parent Attorneys and Advocates 

Division for Early Childhood of the Council for Exceptional Children (DEC) 

Family Voices 

First Focus 

Healthy Schools Campaign 

IDEA Infant Toddlers Coordinators Association (ITCA) 

Judge David L. Bazelon Center for Mental Health Law 

Learning Disabilities Association of America 

National Alliance for Medicaid in Education 

National Association of Elementary School Principals 

National Association of Pediatric Nurse Practitioners 

National Association of Secondary School Principals 

National Association of School Nurses 

National Association of School Psychologists 

National Association of Social Workers 

National Association of State Directors of Special Education (NASDSE) 

79 

1 Centers for Medicare and Medicaid Services, 2016 Enrollment Report, available at https:// 

www.medicaid.gov/chip/downloads/fy-2016-childrens-enrollment-report.pdf. 2 AAFP, 2015 Practice Profile Survey (excerpt), available at http://www.aafp.org/about/theaafp/family-medicine-facts/table-12.html. 3 AAFP Member Census (Dec. 31, 2016), available at http://www.aafp.org/about/the-aafp/ 

family-medicine-facts/table-13.html. 4 AAFP, 2015 Practice Profile Survey (July 15, 2016). 

5 Id. 

National Black Justice Coalition 

National Disability Rights Network 

National Education Association 

National Health Law Program 

National Rural Education Association 

School Social Work Association of America 

The Arc of the United States 

The National Alliance on Mental Illness (NAMI) 

Union for Reform Judaism 

United Way Worldwide 

AMERICAN ACADEMY OF FAMILY PHYSICIANS (AAFP) 

AAFP Headquarters 

11400 Tomahawk Creek Pkwy. 

Leawood, KS 66211–2680 

800–274–2237 • 913–906–6000 

fp@aafp.org 

AAFP Washington Office 

1133 Connecticut Avenue, NW, Suite 1100 

Washington, DC 20036–1011 

202–232–9033 • Fax: 202–232–9044 

capitol@aafp.org 

On behalf of the American Academy of Family Physicians (AAFP), which represents 

over 129,000 family physicians and medical students across the country, thank you 

for the opportunity to submit testimony for the record to the Committee on Finance 

regarding the continuation of the Children’s Health Insurance Program (CHIP). 

Congress Should Swiftly Approve a Long-Term Extension of CHIP Funding 

The AAFP urges the Committee to swiftly approve a bipartisan long-term extension 

of CHIP, in order to promote stability and health security for 8.9 million low-income 

children 1 and their families. Time is of the essence in completing this work in order 

to ensure continuous access to primary and preventive services for this vulnerable 

population, protect progress in public health, and allow States to adequately plan. 

The AAFP has supported CHIP since its inception in 1997, and during each subsequent reauthorization and extension of funding (2007, 2009, and 2015), as a way 

to extend health coverage to uninsured children whose families do not meet eligibility requirements for Medicaid. Since the enactment of the Medicare Access and 

CHIP Reauthorization Act of 2015 (MACRA), in April 2015, the AAFP has reiterated support for CHIP funding beyond the current end-date of September 30, 2017— 

through letters to this Committee and to Congressional Leadership. As a medical 

specialty, family medicine is committed to the success of all of health insurance programs financed with public dollars, including CHIP. AAFP member data indicates 

that over two-thirds of AAFP members accept new Medicaid patients.2 Although the 

AAFP does not collect member survey data on CHIP participation, we know (due 

to the close connection between Medicaid and CHIP—including the fact that some 

states operate combined Medicaid/CHIP programs—and the fact that family physicians perform so many pediatric services) that family physicians are helping to carry 

out Congress’s intent behind CHIP: treating low-income children, many of whom 

would be uninsured without the program. 

Family physicians play an important role in addressing American children’s health 

needs. According to the AAFP’s latest member census, published December 31, 

2016, over 80 percent of AAFP members care for adolescents, and 73 percent care 

for infants and children.3 Other AAFP member survey data reflect that about 20 

percent of AAFP’s members deliver babies as part of their practice, with roughly 

6 percent delivering more than 30 babies in a recent calendar year.4 Of AAFP active 

members with full hospital privileges, 70 percent provide newborn care in the hospital, and 64 percent provide pediatric care in the hospital.5 This is consistent with 

80 

6 AAFP, Health Care for All (2014), available at http://www.aafp.org/about/policies/all/ 

health-care-for-all.html. 7See, e.g., The Robert Graham Center, ‘‘The Importance of Having Health Insurance and a 

Usual Source of Care,’’ Am. Fam. Physician (Sept. 15, 2004), available at http://www.aafp.org/ 

afp/2004/0915/p1035.html. 8 Health Resources and Services Administration, Teaching Health Center Graduate Medical 

Education Program, Academic Year 2014–2015, available at https://bhw.hrsa.gov/sites/default/ 

files/bhw/nchwa/teaching-health-center-graduate-highlights.pdf. 

family medicine’s traditional role of practicing in the entire scope of the physician 

license, in order to meet the needs of the community in which the family physician 

practices. A family physician who serves a small rural community without a pediatrician, for example, will often perform most or all pediatric care for that community. 

The AAFP also supports health care for all, consistent with the public-health mission of the specialty of family medicine. The AAFP promotes universal access to care 

in the form of ‘‘a primary care benefit design featuring the patient-centered medical 

home, and a payment system to support it,’’ for everyone in the United States.6

AAFP believes that all Americans should have access to primary-care services (e.g., 

in the case of infants and children, immunizations and other evidence-based preventive services, prenatal care, and well-child care), without patient cost sharing. The 

AAFP believes that universal health care also should include services outside the 

medical home (e.g., hospitalizations) with reasonable and appropriate cost sharing 

allowed, but with protections from financial hardship. Supporting universal access 

to care is also consistent with the ‘‘triple aim’’ of improving patient experience, improving population health, and lowering the total cost of health care in the United 

States. Research supports the AAFP’s view that having both health insurance and 

a usual source of care (e.g., through an ongoing relationship with a family physician) 

contributes to better health outcomes, reduced disparities along socioeconomic lines, 

and reduced costs.7

The AAFP urges Congress to pass a ‘‘clean’’ extension of CHIP with a minimum of 

unnecessary policy changes. Accordingly, Congress should extend the current enhanced federal medical assistance percentage (FMAP), as well as the current maintenance of effort (MOE) provisions, which are both in effect through September 30, 

2019, to align with an extension of CHIP funding. For example, if Congress extends 

CHIP funding for 5 years, then it should extend the enhanced FMAP and MOE provisions for 3 years. The AAFP also supports maintaining the enhanced FMAP on 

policy grounds: Maintaining the enhanced FMAP allows states to more easily devote 

scarce resources to their Medicaid programs, which collectively cover some 70 million low-income Americans. Destabilizing the enhanced FMAP in CHIP could also 

discourage the 19 ‘‘non-expansion’’ states from expanding their Medicaid programs 

and covering yet more uninsured children and adults. 

Unlike Medicare and Medicaid, which provide stable and reliable federal funding 

under current law, CHIP funding is contingent upon congressional action at regular 

intervals. Given the importance of the program to almost 9 million children from 

low-income families, the AAFP urges the Committee to swiftly extend and stabilize 

the program on a long-term basis. 

Congress Should Also Provide Long-Term Support for the Teaching Health 

Center Graduate Medical Education Program 

As an additional note, the AAFP would like to emphasize to the Committee the importance of providing long-term support for the Teaching Health Center Graduate 

Medical Education (THCGME) program, which will also expire on September 30, 

2017, absent Congressional intervention. THCGME is a successful primary-care 

training program, currently financing training for 742 medical and dental residents 

in community-based ambulatory settings. Residents in the THCGME program train 

exclusively in primary-care specialties. 

Of relevance to the legislative process surrounding CHIP, two-thirds of the 

THCGME residents are training in family medicine and pediatrics.8 The THCGME 

program, administered by the Health Resources and Services Administration 

(HRSA), accounts for less than 1 percent of the annual federal spending devoted to 

graduate medical education, yet it is the only GME program that is devoted entirely 

to training primary-care physicians and dentists. Residents in the program train in 

community health centers (including federally qualified health centers), and tend to 

be concentrated in rural and underserved areas that need access to more providers, 

particularly primary-care physicians. American Medical Association Physician MasVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00084 Fmt 6601 Sfmt 6621 R:\DOCS\31255.000 TIM
81 

9 E. Blake Fagan, M.D., et al., ‘‘Family Medicine Graduate Proximity to Their Site of Training,’’ Family Medicine, Vol. 47, No. 2, at 126 (Feb. 2015). 10 Candice Chen, M.D., MPH, et al., ‘‘Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions,’’ Academic Medicine, Vol. 88, No. 9, p. 

1269 (Sept. 2013). 

terfile data confirms that a majority of family medicine residents practice within 

100 miles of their residency training location.9 By comparison, fewer than 5 percent 

of physicians who complete training in hospital-based GME programs provide direct 

patient care in rural areas.10 Thus, the most effective way to get family and other 

primary-care physicians into rural and underserved areas is not to recruit them 

from remote academic medical centers but instead to train them in these underserved areas. 

AMERICAN COLLEGE OF PHYSICIANS (ACP) 

25 Massachusetts Avenue, NW, Suite 700 

Washington, DC 20001–7401 

202–261–4500, 800–338–2746 

190 N. Independence Mall West 

Philadelphia, PA 19106–1572 

215–351–2400, 800–523–1546 

www.acponline.org 

The American College of Physicians (ACP) commends the Chairman of the Senate 

Finance Committee Senator Orrin Hatch and Ranking Member Ron Wyden for convening this hearing on the importance of extending the Children’s Health Insurance 

Program (CHIP) which is set to expire at the end of the month. We applaud your 

working together to examine solutions that will ensure that this program will continue to provide funding for low income children who depend on it to ensure that 

they have health insurance coverage that meets their needs. 

ACP is the largest medical specialty organization and the second largest physician 

group in the United States, representing 152,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians 

are specialists who apply scientific knowledge and clinical expertise to the diagnosis, 

treatment, and compassionate care of adults across the spectrum from health to 

complex illness. 

ACP Urges Congress to Act Now to Continue CHIP 

ACP has been a stalwart supporter of CHIP and we are pleased to know that an 

agreement on legislation to extend CHIP funding for 5 years has been reached between Chairman Hatch and Ranking Member Wyden. We urge Congress to support 

and pass this legislation, S. 1827, the Keep Kids Insurance Dependable and Secure 

Act of 2017, so that the nearly 9 million children who depend on it will not lose 

coverage. A 5 year extension of the program will provide states that administer the 

CHIP program with the certainty needed to plan a long-term budget that meets the 

needs of their children. It will alleviate the anxiety of many parents who are now 

wondering whether or not their children, who currently receive coverage under 

CHIP, will continue to have such coverage if Congress does not act by the end of 

September. State officials have warned the Congress that they may have to freeze 

CHIP enrollment or terminate coverage if funding is not extended by the end of the 

month. 

Results of the CHIP Program 

CHIP was created to provide health-care coverage for children who did not qualify 

for Medicaid but often found it difficult to obtain affordable health-care coverage in 

the private market. CHIP builds on the success of Medicaid and recent estimates 

determine that in 2016, CHIP covered 8.9 million children while 37.1 million children were enrolled in Medicaid coverage. CHIP has been an overwhelming success 

in reducing the uninsured rate among our nation’s children and reducing the financial stress of families that must bear the cost of this coverage. As a result of the 

passage of CHIP, and Medicaid, new census data reflects that the uninsured rate 

among children has reached an all-time low of 4.5 percent. According to a recent 

study by the Urban Institute, ‘‘from 1997 when the CHIP program was enacted, to 

2012, the uninsured rate among all children declined by 6 percentage points and 

by even more (12 percentage points) among children with incomes below 200 percent 

of the federal poverty level.’’ The Urban institute also notes that CHIP and Medicaid 

have also improved access to care and reduced the financial burden for families with 

children enrolled in these programs. Not only do these programs result in improved 

82 

1 Recommendations for the Future of CHIP and Children’s Coverage, MACPAC, March 2017, 

available at: https://www.macpac.gov/publication/recommendations-for-the-future-of-chip-andchildrens-coverage-2/. 2 Children’s Health Insurance Program (CHIP): FY 2016 Children’s Enrollment, Medicaid.gov, 

February 15, 2017, available at: https://www.medicaid.gov/chip/downloads/fy-2016-childrensenrollment-report.pdf. 3 Joan Alker and Alisa Chester, Children’s Health Coverage Rate Now at Historic High of 95 

Percent, Georgetown University Health Policy Institute: Center for Children and Families, October 2016, available at: https://ccf.georgetown.edu/wp-content/uploads/2016/11/Kids-ACS-update-11-02-1.pdf. 4Samantha Artiga, et al., Key Facts on Health and Health Care by Race and Ethnicity, Kaiser 

Family Foundation, June 7, 2016, available at: http://www.kff.org/report-section/key-facts-onhealth-and-health-care-by-race-and-ethnicity-section-4-health-coverage/. 5 Elizabeth Cornachione, et al., Children’s Health Coverage: The Role of Medicaid and CHIP 

and Issues for the Future, Kaiser Family Foundation, June 27, 2016, available at: http:// 

kff.org/health-reform/issue-brief/childrens-health-coverage-the-role-of-medicaid-and-chip-andissues-for-the-future/. 6Samantha Artiga, et al, Health Coverage by Race and Ethnicity: Examining Changes Under 

the ACA and the Remaining Uninsured, Kaiser Family Foundation, November 4, 2016, available 

access to health care for our children, but studies also show that Medicaid and 

CHIP coverage result in positive outcomes in health, educational advancement, and 

financial success. 

Conclusion 

As evidence has shown, CHIP has been a very successful program and it is critically 

important that Congress act now to extend the program for an additional 5 years. 

We thank Chairman Hatch and Ranking Member Wyden for working together, in 

a bipartisan fashion, on legislation to ensure the continuation of CHIP funding for 

the long term. ACP is pleased to lend its support to S. 1827, the Keep Kids Insurance Dependable and Secure Act, and help advance it through the legislative process. We urge Congress to act quickly to approve this legislation as only a few days 

remain before the program expires at the end of this month. 

ASIAN AND PACIFIC ISLANDER AMERICAN HEALTH FORUM (APIAHF) 

1629 K Street, NW, Suite 400 

Washington, DC 20006 

The Asian and Pacific Islander American Health Forum (APIAHF) submits this 

written testimony for the record for the September 7, 2017 hearing before the Senate Committee on Finance entitled ‘‘The Children’s Health Insurance Program: The 

Path Forward.’’ 

As the nation’s oldest and largest health policy and public health organization working with Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) 

communities, APIAHF provides a voice in the nation’s capital for AA and NHPI 

communities. APIAHF works toward health equity and health justice for all by influencing policy, mobilizing communities, and strengthening programs and organizations to improve the health of the over 20 million AAs and nearly 1 million NHPIs 

in the United States. 

This hearing seeks to address continued funding for the Children’s Health Insurance Program (CHIP). APIAHF strongly urges the Committee to follow the Medicaid 

and CHIP Payment and Access Commission (MACPAC) guidance and extend funding for CHIP for 5 years, through fiscal year 2022.1 Over 8.9 million children rely 

on CHIP, and states need the security of knowing CHIP funding will be set for the 

next 5 years.2

CHIP funding has dramatically reduced the coverage gap for children of 

color. 

Over the course of 20 years, CHIP, together with Medicaid, has led to historic coverage rates for children of color. As of 2015, 95.9% of AA and NHPI children, for 

example, have coverage thanks to the combined efforts of CHIP, Medicaid, and the 

ACA.3 Importantly for this Committee, 28% of AA children and half of NHPI children rely on CHIP and Medicaid for their coverage.4 Similarly, 56% of Latino children, 58% of African American children, and 50% of American Indian Alaska Native 

children are covered by CHIP and Medicaid.5

Despite these coverage gains, communities of color remain more likely to be uninsured than whites.6 This coverage disparity is due to many factors, including povVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00086 Fmt 6601 Sfmt 6621 R:\DOCS\31255.000 TIM
83 

at: http://www.kff.org/disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-examining-changes-under-the-aca-and-the-remaining-uninsured/. 7Deborah Povich, et al., Low-Income Working Families: The Racial/Ethnic Divide, The Working Poor Families Project, 2015, available at: http://www.workingpoorfamilies.org/wp-content/ 

uploads/2015/03/WPFP-2015-Report_Racial-Ethnic-Divide.pdf. 8 CHIP Benefits, Medicaid.gov, available at: https://www.medicaid.gov/chip/benefits/ 

index.html. 9Lenna L. Liu, MD, MPH, et al., ‘‘Type 1 and Type 2 Diabetes in Asian and Pacific Islander 

U.S. Youth,’’ Diabetes Care, Vol. 32 (Suppl. 2), March 2009, available at: https:// 

www.ncbi.nlm.nih.gov/pmc/articles/PMC2647693/. 10 Children’s Environmental Health Disparities: Black and African American Children with 

Asthma, Environmental Protection Agency, 2014, available at: https://www.epa.gov/sites/production/files/2014-05/documents/hd_aa_asthma.pdf. 11 Elizabeth Cornachione, et al., Children’s Health Coverage: The Role of Medicaid and CHIP 

and Issues for the Future, Kaiser Family Foundation, June 27, 2016, available at: http:// 

kff.org/health-reform/issue-brief/childrens-health-coverage-the-role-of-medicaid-and-chip-andissues-for-the-future/. 

erty, health and English literacy and proficiency and immigration based restrictions. 

CHIP is vital for continuing to close this coverage gap because it specifically seeks 

to cover low-income working families. The program covers children and pregnant 

women that make too much to qualify for Medicaid, but not enough to afford private 

insurance. It also includes protections that are designed to directly serve low-income 

enrollees, including restrictions on cost-sharing. This coverage is critical for working 

families of color, who comprise 60% of all working families in this country.7

Children of color experience higher rates of chronic health conditions, and 

CHIP provides access to quality preventive care to prevent and treat those 

conditions. 

Children of color face higher rates of health disparities due to a multitude of factors 

including poverty, living in less environmentally healthy areas, lack of access to 

fresh healthy food, and lack of health coverage. CHIP coverage is uniquely situated 

to address these disparities because it requires a broad scope of coverage and links 

children to continuous preventive care.8

Preventive care is important for AA and NHPI children who suffer from high rates 

of diabetes compared to other groups. AA children are 60% more likely to develop 

diabetes than white children, and NHPI children are three times more likely to develop diabetes than white children.9 CHIP coverage helps to reduce the burden of 

expensive and life-changing chronic conditions for AA and NHPI children by offering 

access to routine preventive care to screen early for conditions like diabetes, obesity, 

and cancer. 

Similarly, African American children are four times more likely to die from asthma 

than white children, even though this condition is easily treated with regular care.10

By diagnosing conditions early and keeping children in treatment, CHIP helps to 

identify health challenges before they arise, and contributes to better health outcomes across the child’s lifespan. 

In conclusion, 8.9 million children are at risk of losing coverage if CHIP is not extended. If Congress does not act, children of color will be particularly impacted 

given that almost half are enrolled in CHIP or Medicaid.11 States need to know that 

CHIP will remain as a major source of coverage with secure funding in order to effectively continue to plan enrollment and operate their programs. Therefore, 

APIAHF strongly urges the adoption of the MACPAC 5 year continued funding plan 

for CHIP. 

For questions, contact Amina Ferati, Senior Director of Government Relations and 

Policy at aferati@apiahf.org (202–466–3550). 

CAMPAIGN TO END OBESITY ACTION FUND (CEO–AF) 

1341 G Street, NW, 6th Floor 

Washington, DC 20005 

www.obesityactionfund.org 

Who Is the Campaign to End Obesity Action Fund? 

The Campaign to End Obesity Action Fund (CEO–AF) is a group of leaders from 

industry, academia, public health, and associations dedicated to reversing one of 

America’s costliest diseases: obesity. Right now, more than one-third of adults and 

nearly one in six children have obesity. Taxpayers, governments and businesses 

84 

1http://www.kff.org/other/state-indicator/annual-chip-enrollment/?currentTimeframe=O&sor 

tModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 2 Robert Wood Johnson Foundation and Trust for America’s Health. State of Obesity: 

Socioeconomics of Obesity, https://stateofobesity.org/socioeconomics-obesity/. 3https://www.congress.gov/bill/111th-congress/house-bill/2; https://www.congress.gov/bill/ 

114th-congress/house-bill/2. 4https://www.cdc.gov/obesity/strategies/healthcare/index.html. 

5https://www.cdc.gov/obesity/strategies/healthcare/cord2.html. 

spend billions on obesity-related conditions each year, including over $300 billion in 

medical costs. 

Ending this epidemic requires change—in individuals, institutions and communities. 

CEO–AF advocates for federal policies to reverse the obesity epidemic and promote 

healthy weight in children and adults. 

Timely Reauthorization of CHIP is Essential. 

CHIP provides health-care services to approximately 8.9 million 1 Americans—many 

of whom have or are at risk for obesity. Nationwide, obesity rates continue to trend 

upward and some projections show that 50 percent of Americans will have obesity 

by 2030. Low-income children and families suffer from obesity rates that are 2.7 

times higher than those living above federal poverty guidelines.2 As such, it is imperative that Congress reauthorize CHIP as soon as possible so that services to 

these children are not interrupted. 

CHIP reauthorization presents a unique opportunity to set these at-risk children up 

for a lifetime of healthy eating and exercise through early interventions within the 

health-care system. The continued availability of CHIP is crucial to improving children’s access to obesity prevention and treatment therapies, which can help them 

become healthy adults. 

CEO–AF and 30 Other Groups Urge the Senate Finance Committee to Include CORD in CHIP Reauthorization. 

CHIP, for the last two reauthorization cycles, has contained an important and 

ground-breaking pilot program: the Childhood Obesity Research Demonstration, or 

CORD.3

CORD 1.0 successfully identified childhood obesity intervention models, which were 

then tested further in CORD 2.0, with the intention of eventually expanding these 

evidence-based programs on a national level. Specifically through CORD, the Centers for Disease Control and Prevention (CDC), was able to fund multiple community grantees and evaluation centers to target children from low-income families at 

risk for or suffering from obesity.4 Through this funding, CDC was able to focus on 

prevention and management of childhood obesity by increasing obesity screenings 

and counseling services in the community and referring overweight and obese children to appropriate and evidence based lifestyle modification programs.5

A letter from CEO–AF and 30 other groups urging the reauthorization of CORD is 

attached as part of this statement. 

CAMPAIGN TO END OBESITY ACTION FUND (CEO–AF) 

September 7, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chair Ranking Member 

Senate Finance Committee Senate Finance Committee 

U.S. Senate U.S. Senate 

Washington, DC 20510 Washington, DC 20510 

The Honorable Greg Walden The Honorable Frank Pallone 

Chair Ranking Member 

Committee on Energy and Commerce Committee on Energy and Commerce 

U.S. House of Representatives U.S. House of Representatives 

Washington, DC 20515 Washington, DC 20515 

Dear Chairman Hatch, Chairman Walden, Senator Wyden, and Representative Pallone: 

The Campaign to End Obesity Action Fund (the CEO Action Fund) is a coalition 

of leaders from industry, academia, public health, and patient and disease commuVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00088 Fmt 6601 Sfmt 6621 R:\DOCS\31255.000 TIM
85 

1https://www.congress.gov/bill/111th-congress/house-bill/2. 

2https://www.congress.gov/bill/114th-congress/house-bill/2. 

3https://www.cdc.gov/obesity/strategies/healthcare/index.html. 

4https:// www.cdc.gov/obesity/strategies/healthcare/cord2.html. 

5http://obesityactionfund.org/page.asp?id=28. 

6https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322789/. 

7https://www.ncbi.nlm.nih.gov/pubmed/25381647. 

8http://www.galllup.com/businessjournal/145778/cost-obesity-cities.aspx. 

nities that advocates before Congress and federal agencies on needed policy solutions to reverse the U.S. obesity epidemic. As you may know, childhood obesity in 

the United States has reached epic proportions—one in five U.S. children already 

has obesity, a fact that also triggers long term health risks and related expenses 

to taxpayers—and we believe there are important opportunities to advance policies 

that can move the needle on this. 

Specifically, as you work to put together the Children’s Health Insurance Program 

(CHIP) reauthorization package, we request that you include an extension of the 

Child hood Obesity Research Demonstration (CORD). This program—now in its second iteration—has been pivotal in beginning to identify scalable approaches to addressing childhood obesity in America. 

CORD 1.0 was first authorized in 2009 through the Children’s Health Insurance 

Program Reauthorization Act (CHIPRA) 1 and ran from 2011–2015. The project, as 

CORD 2.0, was reauthorized in the Medicare Access and CHIP Reauthorization Act 

of 2015 for an additional 2 years, and is set to expire in Fiscal Year 2017.2 CORD 

1.0 successfully identified childhood obesity intervention models, which were then 

tested further in CORD 2.0, with the intention of eventually expanding these 

evidence-based programs on a national level. CORD 2.0 is an ongoing project—it is 

essential that CORD continues to receive funding so that the project can continue 

to expand incrementally with the goal of continuing to identify scalable, costeffective solutions to combat childhood obesity. 

Through CORD, the Centers for Disease Control and Prevention (CDC), has funded 

multiple community grantees and evaluation centers to target children from lowincome families at risk for or suffering from obesity.3 Without this program, CDC 

would be without needed, dedicated resources to focus on the prevention and effective management of childhood obesity. Of particular importance, CORD funding empowered CDC to increase obesity screenings and counseling services in the community and refer obese children to appropriate and evidence based lifestyle modification programs.4

Today, some 30 states have childhood obesity rates of 30 percent or more.5 Childhood obesity is a major contributor to other costly health conditions, such as cancer, 

cardiovascular disease, dyslipidemia, Type 2 Diabetes, fatty liver disease, asthma, 

and psychological conditions. Because it can negatively impact school performance 

and social development,6 the toll on families, communities, the health care system, 

and the budget of this very troubling trend is enormous and growing. Congress must 

continue to fund the tools, such as CORD, that are making a difference in communities that are hit hardest by this epidemic. 

Indeed, U.S. taxpayers, businesses, communities, and individuals spend over $300 

billion per year in medical costs due to obesity.7 Accordingly, we must continue to 

invest—as we have with CORD—in programs that can reduce obesity and, in the 

long-run, saves lives and taxpayer money. According to a recent Gallup study, if the 

10 cities in the U.S. with the highest rates of obesity were able to cut their obesity 

rates down to the 2009 national average of 26.5%, each city would save nearly $500 

million every year.8

Today, CORD remains an essential tool in combatting childhood obesity, and we 

urge the Committee to reauthorize the program in September. 

Thank you again for your leadership, and for your consideration of our request. For 

any questions you may have, please contact Michelle Seger at michelle@ 

obesityactionfund.org or 202–466–8100. 

Sincerely, 

The Campaign to End Obesity Action Fund 

Afterschool Alliance 

American College of Sports Medicine 

American Council on Exercise 

American Heart Association 

86 

American Medical Women’s Association 

American Psychological Association 

American Society for Metabolic and Bariatric Surgery 

Arkansas Center for Health Improvement 

Center for Science in the Public Interest 

Consortium to Lower Obesity in Chicago Children 

Healthcare Leadership Council 

Healthy Schools Campaign 

National Association for Health and Fitness 

National Association of County and City Health Officials 

National Association of School Nurses 

National Coalition for Promoting Physical Activity 

National Hispanic Medical Association 

Nemours Children’s Health System 

Obesity Action Coalition 

Obesity Medicine Association 

School Based Health Alliance 

The American Cancer Society Cancer Action Network 

The Endocrine Society 

The Hope Heart Institute 

The Obesity Society 

Trust for America’s Health 

United States Bone and Joint Initiative 

University of Wisconsin American Family Children’s Hospital 

Weight Watchers 

YMCA of the USA 

CHILDREN’S HOSPITAL ASSOCIATION

600 13th St., NW, Suite 500 

Washington, DC 20005 202–753–5500 

16011 College Blvd., Suite 250 

Lenexa, KS 66219 

913–262–1436 www.childrenshospitals.org 

Contact us: public.policy@childrenshospitals.org 

The Children’s Hospital Association represents 220 hospitals nationwide dedicated 

to the health and well being of our nation’s children. On behalf of our nation’s children’s hospitals and the patients and families they serve, we thank the Senate Finance Committee (the Committee) for its steadfast commitment to the Children’s 

Health Insurance Program (CHIP). The Committee’s support and dedication over 

CHIP’s long bipartisan history has resulted in improved access to health care for 

millions of vulnerable children improving their lives and the overall health of our 

nation. We greatly appreciate the joint statement by Chairman Hatch and Ranking 

Member Wyden, released on the 20th anniversary of the program, reaffirming their 

strong support for a swift and bipartisan CHIP renewal. We share these goals and 

it is our hope that, following the Committee’s consideration of the program during 

its hearing, Congress will take prompt steps to renew funding for CHIP. We urge 

Congress to pass a long-term extension of current policy and funding of CHIP before 

the end of the fiscal year in order to give children and families the certainty and 

stability they need. 

CHIP is an important health coverage program for over 6 million low-income children. Congress created CHIP in 1997, with strong bipartisan support, to fill a gap 

in the coverage landscape. CHIP builds off of a strong Medicaid program by providing coverage for children who fall above Medicaid eligibility levels, but lack access to other health coverage options. Congress designed CHIP with children in 

mind and included child appropriate benefits, access to pediatric providers, and costsharing limits to protect vulnerable children and families. CHIP, together with Medicaid, has brought the rate of uninsured U.S. children to an all-time low, with 95 

percent of all children insured. If this program is not extended beyond 2017, many 

CHIP-enrolled children will likely become underinsured or uninsured altogether, 

threatening our nation’s historic gains in insuring children over the past two decades. Healthy children grow up to become healthy adults, and CHIP helps ensure 

that the children covered by the program are able to reach their full potential. 

Congress must act now to enact a long-term CHIP extension to give states and families the certainty they need. State budget cycles and regulations make it difficult 

87 

for states to maintain their CHIP programs in the absence of federal funding certainty, and many states have already planned for the funding to continue. If CHIP 

funding were to lapse, states may be forced to make tough choices at the expense 

of vulnerable children, including steps to disenroll children, impose lock-outs and 

waiting periods, or wind down their CHIP programs altogether. A clean 5-year extension of CHIP is supported by the National Governors Association, the Medicaid 

and CHIP Payment and Access Commission, and child health advocates because it 

provides predictability in the program and encourages states to make programmatic 

improvements. 

Efforts to extend CHIP should maintain current policy, which includes the underlying CHIP program along with items like the Pediatric Quality Measures Program 

(PQMP), express lane eligibility, and outreach and enrollment grants—all of which 

are important components of CHIP. The PQMP is the only significant federal investment in pediatric health-care quality. An extension of this program with CHIP is 

particularly important in order to continue to improve care and lower costs for families and purchasers of care, such as state and federal governments. To ensure maximum stability for children, families and states, we ask Congress to enact a 5-year 

extension of current policy. 

We thank the Chairman, Ranking Member, and Committee members for their leadership and resolute support for CHIP. We are thankful for champions for children 

like these leaders, and we look forward to working with the Committee this month 

to maintain a strong CHIP program and strengthen health care for children into 

the future. 

THE FED IS BEST FOUNDATION

Based on June 2017 Medicaid data, there are more than 35 million Medicaid child 

and Children’s Health Insurance Program (CHIP) enrollees nationwide whose 

health needs depend on coverage by these important health insurance programs. 

The Fed Is Best Foundation is a non-profit, public health education organization led 

by health-care professionals who believe that (1) babies should never go hungry, and 

(2) mothers should be informed of the signs and consequences of preventable hunger 

and should be supported in choosing clinically safe feeding options for their babies. 

The most recent peer-reviewed clinical data shows alarming trends in infant feeding, namely a rise in rehospitalizations for feeding complications in exclusively 

breastfed newborns who do not receive enough milk in the first days of life, including increasing rates of jaundice, hypoglycemia, and dehydration, which threaten a 

newborn’s brain and can lead to life-long and costly medical needs. 

Programs like Medicaid and CHIP are the most significant payors of infant medical 

care and are well-positioned to establish infant nutritional criteria that will protect 

infants against accidental starvation and the medical complications that follow 

while reducing costs for both one-time and, in many cases, life-long care needs that 

infants who suffer from jaundice, hypoglycemia, and dehydration face. These are 

costly and avoidable outcomes and could save the health-care system millions of dollars each year. Clinical data show that insufficient breast milk production affects 

at least 1 in 5 women in the first days of an infant’s life. Without enough milk, infants can starve, and accidental starvation can cause brain injury leading to preventable cognitive and developmental delays and an increased risk of seizure disorders. 

As reported by the Centers for Medicare and Medicaid Services’ (CMS) Maternal 

and Infant Health Initiative, Medicaid currently funds about 45% of all births in 

the U.S. In 2014, an expert panel was convened by CMS to examine program policies ‘‘that could result in better care, improve birth outcomes, and reduce the costs 

of care for mothers and infants in Medicaid and CHIP.’’ There is more work to be 

done, including closing the critical gap in public-health education and protocols for 

infant nutrition monitoring and support. Such policy changes can prevent accidental 

starvation-related care and hospitalization costs which give rise, in many cases, to 

life-long cognitive and developmental medical care needs for both CHIP and Medicaid beneficiaries. 

Contact 

Christie del Castillo-Hegyi, M.D., Board Certified Emergency Physician, Co-Founder, Fed Is Best Foundation at christie@fedisbest.org/(505) 803–5304 

88 

HEALTHCARE LEADERSHIP COUNCIL (HLC) 

September 7, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Committee on Finance Committee on Finance 

U.S. Senate U.S. Senate 

Washington, DC 20510 Washington, DC 20510 

Dear Chairman Hatch and Ranking Member Wyden: 

As the Committee prepares to hold a hearing on the Children’s Health Insurance 

Program (CHIP), the Healthcare Leadership Council (HLC) welcomes the opportunity to share our thoughts on this important program with you. 

HLC is a coalition of chief executives from all disciplines within American health 

care. It is the exclusive forum for the nation’s health-care leaders to jointly develop 

policies, plans, and programs to achieve their vision of a 21st century health system 

that makes affordable, high quality care accessible for all Americans. Members of 

HLC—hospitals, academic health centers, health plans, pharmaceutical companies, 

medical device manufacturers, laboratories, biotech firms, health product distributors, pharmacies, post-acute care providers, and information technology companies— 

advocate for measures to increase the quality and efficiency of health care through 

a patient-centered approach. 

CHIP is a critical part of our country’s health-care infrastructure. HLC urges Congress to support some of our most vulnerable citizens—children from families with 

low and moderate incomes—by continuing to fund this program. CHIP has provided 

coverage and encouraged participation by simplifying the enrollment and renewal 

process. Along with other factors, this has led to a steep decline in the number of 

uninsured children, from around 10 million in 1997 (when the program was enacted) 

to around 3 million in 2015. Coverage has especially increased among racial and 

ethnic minorities. CHIP and Medicaid cover more than half of Hispanic and AfricanAmerican children, compared to about one-quarter of White and Asian children. 

HLC strongly believes that keeping children healthy by giving them access to care 

is essential to the well-being of our society. Diagnosing and treating problems at an 

early age increases the likelihood that children will grow into healthy adults. This 

care will also save costs, as these children will be more able to work and contribute 

to our nation’s economy in the future. 

Without congressional action to extend CHIP beyond September 30th, states will 

soon exhaust their CHIP funds. In this time of limited state resources and tight 

budgets, a lack of federal assistance means that states will have to remove children 

from CHIP. Many of these children will not be eligible for Medicaid nor will their 

parents be able to afford a private insurance plan. They will then become uninsured 

and will have to go without necessary doctor visits, prescriptions, and other healthcare services. They will not be able to access preventive care and will instead likely 

be treated in emergency rooms and other high-cost settings. 

HLC urges Congress to extend CHIP funding for 5 years. In addition, we ask the 

Committee to consider giving states flexibility in administering this program. For 

example, states could reduce their costs by making CHIP a wraparound option for 

children who are eligible for the program but who have access to private insurance 

through their parents. This option would fill in the gaps in what the private plan 

covers and would also cover the cost-sharing expenses of the private plan. States 

could also be given incentives for managing CHIP efficiently and streamlining the 

enrollment process. 

Thank you for your work on this important issue. HLC looks forward to continuing 

to collaborate with you. If you have any questions, please do not hesitate to contact 

Debbie Witchey at (202) 449–3435. 

Sincerely, 

Mary R. Grealy 

President 

89 

NATIONAL CHILD HEALTH ORGANIZATIONS

Statement for the Record Urging Quick Bipartisan 

Action on a Strong, Five-Year Extension of Funding for the 

Children’s Health Insurance Program 

As advocates for children and pregnant women, we call on Congress to take immediate action to enact a 5-year extension of CHIP funding. Since its inception in 1997, 

CHIP, together with Medicaid, has helped to reduce the numbers of uninsured children by a remarkable 68 percent. With CHIP funding set to expire on September 

30, 2017, now is the time for Congress to stabilize the CHIP funding stream and 

protect the gains in children’s health coverage that have resulted in more than 95 

percent of all children in America being enrolled in some form of insurance coverage. 

CHIP has a proven track record of providing high-quality, cost-effective coverage for 

low-income children and pregnant women in working families. CHIP was a smart, 

bipartisan solution to a real problem facing American children and families when 

it was adopted in 1997 and its importance and impact in securing a healthy future 

for children in low-income families has only increased. Senators, representatives, 

and governors all recognize the importance of CHIP in providing affordable, pediatric-specific coverage to almost 9 million children who cannot afford private coverage or lack access to employer-based coverage. CHIP also delivers quality, affordable care to pregnant women in 19 states, allowing them to obtain the care they 

need to have healthy pregnancies and give birth to healthy infants. 

With federal CHIP funding set to end on September 30, 2017, states are facing critical decisions about the future of their CHIP programs. Many states are just weeks 

away from setting in motion processes to establish waiting lists and send out 

disenrollment notices to families. Once undertaken, these actions will have an immediate effect, creating chaos in program administration and confusion for families. 

Extending CHIP is particularly important in light of the ongoing debate on and uncertainty regarding the future of the Affordable Care Act (ACA), Medicaid, and the 

stability of the individual insurance markets. With state budgets already set for the 

coming year, states are counting on CHIP to continue in its current form. Changes 

to CHIP’s structure—including changes to the Maintenance of Effort or the enhanced CHIP matching rate—would cause significant disruption in children’s coverage and leave states with critical shortfalls in their budgets. Given CHIP’s track 

record of success, changes to CHIP that would cause harm to children must not be 

made. 

Today, we stand united in urging Congress to honor CHIP’s 20 years of success by 

securing this critical source of coverage for children and pregnant women into the 

future. As Congress continues to work on larger health system reforms, a primary 

goal should be to improve health coverage for children, but at a minimum, no child 

should be left worse off. We urge our nation’s leaders to work together to enact a 

5-year extension of CHIP funding as an important opportunity for meaningful, bipartisan action. 

Contact: Ari Goldberg, VP Communications, First Focus, 240–678–9102; agoldberg@ 

firstfocus.org. 

#KeepKidsCovered 

#CHIPworks 

Endorsing Organizations 

1,000 Days 

Academic Pediatric Association 

ADAP Advocacy Association (aaa+) 

AFSCME 

AIDS Alliance for Women, Infants, Children, Youth, and Families 

Alliance for Strong Families and Communities 

America’s Essential Hospitals 

American Academy of Family Physicians 

American Academy of Nursing 

American Academy of Ophthalmology 

American Academy of Pediatrics 

American Association for Pediatric Ophthalmology and Strabismus 

American Association of Child and Adolescent Psychiatry 

American Congress of Obstetricians and Gynecologists 

90 

American Dental Education Association 

American Heart Association 

American Lung Association 

American Muslim Health Professionals 

American Network of Oral Health Coalitions 

American Pediatric Society 

American Public Health Association 

American Society for Radiation Oncology 

American Society of Pediatric Hematology/Oncology 

Asian and Pacific Islander American Health Forum 

Association for Community Affiliated Plans 

Association of Asian Pacific Community Health Organizations (AAPCHO) 

Association of Maternal and Child Health Programs 

Association of Medical School Pediatric Department Chairs 

Association of Pediatric Hematology/Oncology Nurses 

Association of School Business Officials International (ASBO) 

Association of University Centers on Disabilities (AUCD) 

Autism Speaks 

Cancer Support Community 

Center for Law and Social Policy (CLASP) 

Center for Popular Democracy 

Child Care Aware of America 

Child Welfare League of America 

Children and Family Futures 

Children’s Brain Tumor Foundation 

Children’s Cause for Cancer Advocacy 

Children’s Defense Fund 

Children’s Dental Health Project 

Children’s Health Fund 

Children’s Hospital Association 

Children’s Leadership Council 

Children’s Mental Health Network 

Clearinghouse on Women’s Issues 

Coalition on Human Needs 

Community Access National Network (CANN) 

Community Catalyst 

Cystic Fibrosis Foundation 

Division for Early Childhood of the Council for Exceptional Children (DEC) 

Doctors for America 

Easterseals 

Every Child Matters 

Families USA 

Family Focused Treatment Association 

Family Voices 

First Focus 

First Star Institute 

Forum for Youth Investment 

Generations United 

Health Care for America Now 

Healthy Schools Campaign 

Healthy Teen Network 

Heart Rhythm Society 

HIV Medicine Association 

IDEA Infant Toddler Coordinators Association (ITCA) 

Judge David L. Bazelon Center for Mental Health Law 

Justice in Aging 

League of Women Voters of the United States 

Leukemia and Lymphoma Society 

Make Some Noise: Cure Kids Cancer Foundation, Inc. 

March of Dimes 

Mental Health America 

NAACP 

National Alliance on Mental Illness (NAMI) 

National Alliance of State and Territorial AIDS Directors (NASTAD) 

National Alliance of Children’s Trust and Prevention Funds 

National Association for Children’s Behavioral Health 

National Association of Community Health Centers 

National Association of Councils on Developmental Disabilities 

91 

National Association of County Human Services Administrators 

National Association of Pediatric Nurse Practitioners 

National Association of Perinatal Social Workers 

National Association of Social Workers 

National Black Women’s HIV/AIDS Network 

National Center for Transgender Equality 

National Consumers League 

National Council of Jewish Women 

National Crittenton Foundation 

National Health Law Program 

National Immigration Law Center 

National Partnership for Women and Families 

National Patient Advocate Foundation 

National Respite Coalition 

National Women’s Health Network 

Nemours Children’s Health System 

NETWORK Lobby for Catholic Social Justice 

National Minority AIDS Council (NMAC) 

Nurse-Family Partnership 

Oral Health America 

Out2Enroll 

Partnership for America’s Children 

Pediatric Infectious Diseases Society 

Pediatric Policy Council 

Physicians for Reproductive Health 

Raising Women’s Voices for the Health Care We Need 

Religious Institute 

RESULTS 

School-Based Health Alliance 

Society for Pediatric Research 

Solving Kids’ Cancer 

The Children’s Partnership 

The Jewish Federations of North America 

The United Methodist Church—General Board of Church and Society 

Trust for America’s Health 

United Way Worldwide 

Universal Health Care Action Network 

Voices for Progress 

Young Invincibles 

ZERO TO THREE 

For more information, please contact: 

Lisa Shapiro Kathleen King 

Vice President, Health Policy Deputy Director, Child Health 

First Focus Children’s Defense Fund 

1400 Eye Street, NW, Suite 650 25 E Street, NW 

Washington, DC 20005 Washington, DC 20001 

Office: (202) 657–0675 Office: (202) 662–3576 

Email: lisas@firstfocus.org Email: kking@childrensdefense.org 

NEMOURS CHILDREN’S HEALTH SYSTEM

1201 15th Street, NW, Suite 520 

Washington, DC 20005 www.nemours.org Contact: Daniella Gratale 

Email: daniella.gratale@nemours.org 

Nemours Children’s Health System owns and operates freestanding children’s hospitals in Wilmington, DE and Orlando, FL, as well as primary and specialty practices and urgent care clinics throughout the Delaware Valley and Florida. As one 

of the nation’s largest pediatric-focused health systems specializing in serving the 

needs of children, including medically complex children, our 7,000 associates provide 

direct care and services to more than 350,000 children, with over 1.3 million unique 

patient encounters annually. 

We join with our nation’s children’s hospitals and the patients and families they 

serve, in thanking the Senate Finance Committee (the Committee) for its steadfast 

commitment to the Children’s Health Insurance Program (CHIP). The Committee’s 

92 

bipartisan support over CHIP’s long history has resulted in improved access to 

health care for millions of vulnerable children—improving their lives and the overall 

health of our nation. We greatly appreciate the joint statement by Chairman Hatch 

and Ranking Member Wyden, released on the 20th anniversary of the program, reaffirming their strong support for a swift and bipartisan CHIP renewal. Particularly, Nemours would be remiss not to recognize and thank Chairman Hatch for 

working hand in hand with former Senators Kennedy, Rockefeller and Chafee to 

pass the original CHIP program. It is our hope that, following the Committee’s consideration of the program during its hearing, Congress will take prompt steps to 

renew funding for CHIP before the current authorization expires on September 30, 

2017. 

CHIP is an important health coverage program for over 6 million low-income children. Congress created CHIP in 1997, with strong bipartisan support, to fill a gap 

in the coverage landscape. CHIP builds off a strong Medicaid program by providing 

coverage for children who fall above Medicaid eligibility levels but lack access to 

other health coverage options. Congress designed CHIP with children in mind and 

included child appropriate benefits, access to pediatric providers, and cost-sharing 

limits to protect vulnerable children and families. CHIP, together with Medicaid, 

has brought the rate of uninsured U.S. children to an all-time low, with 95 percent 

of all children insured. 

At Nemours, in 2016 nearly 15,000 CHIP-enrolled children sought care within our 

system across the Delaware Valley and Florida (a total of 35,000 visits and discharges). Healthy children are more likely to grow up to become healthy adults with 

a greater chance of success in life, and CHIP helps ensure that the children covered 

by it have greater opportunity to reach their full potential. If this program is not 

reauthorized, many CHIP-enrolled children will likely become underinsured or uninsured, threatening our nation’s historic gains in insuring children over the past two 

decades. 

Nemours joins the National Governors Association, the Children’s Hospital Association, the Medicaid and CHIP Payment and Access Commission (MACPAC), and 

many other child health advocates in supporting a clean, 5-year reauthorization of 

CHIP in order to provide certainty, stability and predictability in the program for 

states and families and enable states to make programmatic improvements. 

Time is of the essence for Congress to act. State budget cycles and regulations make 

it difficult for states to maintain their CHIP programs in the absence of federal 

funding certainty, and many states have already planned for the funding to continue. If CHIP funding were to lapse, states may be forced to make tough choices 

at the expense of vulnerable children, including steps to disenroll children, impose 

lock-outs and waiting periods, or wind down their CHIP programs altogether. 

Efforts to reauthorize CHIP should maintain current policy, which includes the underlying CHIP program along with items like the Pediatric Quality Measures Program (PQMP), express lane eligibility, Childhood Obesity Research Demonstration 

Projects (CORD) and outreach and enrollment grants—all of which are important 

components of CHIP. The PQMP is the only significant federal investment in pediatric health-care quality. An extension of this program with CHIP is particularly 

important in order to continue to improve care and lower costs for families and purchasers of care, such as state and federal governments. Similarly, CORD supports 

promising health care and community strategies to combat childhood obesity in children age 2–12, who are enrolled in or eligible for Medicaid or CHIP. An extension 

of CORD (as well as PQMP) is recommended by MACPAC and dovetails with Nemours’ longstanding priority to focus on preventive services to reduce childhood obesity across the nation. 

We thank the Chairman, Ranking Member, and Committee members for their leadership and resolute support for CHIP. We are thankful for these champions for children, and we look forward to working with the Committee this month to maintain 

a strong CHIP program and strengthen health care for children into the future. 

93 

1 Health Policy Institute, American Dental Association. Thomas Wall, Marko Vujicic. ‘‘Emergency Department Use for Dental Conditions Continues to Increase.’’ April 2015. 2https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/chip/index.html. 

3https://www.macpac.gov/topics/chip/. 

ORAL HEALTH AMERICA (OHA) 

180 N. Michigan Ave., Ste. 1150 

Chicago, IL 60601 

phone (312) 836–9900 

fax (312) 836–9986 

www.oralhealthamerica.org 

September 5, 2017 

The Honorable Orrin Hatch The Honorable Ron Wyden 

Chairman Ranking Member 

Senate Committee on Finance Senate Committee on Finance 

219 Dirksen Senate Office Building 219 Dirksen Senate Office Building 

Washington, DC 20510 Washington, DC 20510 

Re: CHIP Reauthorization is Essential to Children’s Oral Health and Wellbeing 

Dear Chairman Hatch and Ranking Member Wyden: 

On behalf of Oral Health America (OHA), a leading nationwide organization dedicated to changing the lives by connecting communities with resources to increase 

access to care, education, and advocacy for all, especially those most vulnerable, I 

write to submit a statement for the record following the Senate Committee on Finance’s September 7, 2017 hearing on ‘‘The Children’s Health Insurance Program: 

The Path Forward.’’ OHA requests the importance of extending funding for the Children’s Health Insurance Program (CHIP) be taken into strong consideration by the 

Committee as the September 30th deadline approaches. Specifically, OHA urges 

Congress to support a 5-year extension through to fiscal year 2022 as has been 

widely-recommended. OHA is deeply concerned the President’s FY 2018 budget cuts 

CHIP by an estimated $6 billion, or a 20% cut, despite the program being extended 

through to 2019. 

Since 1997, CHIP has helped children whose families have incomes too high to qualify for Medicaid, but too low to afford private health insurance. CHIP has reduced 

the number of uninsured children by more than 50% while improving health outcomes and access to care for children and pregnant women across the nation. Of 

direct interest to the oral health community is the fact CHIP is the only 

insurance that guarantees 8 million children a dental health benefit that 

includes coverage for screenings and exams, cleanings, fluoride, and 

sealants. Untreated tooth decay can cause pain that may lead to difficulty eating, 

sleeping, and concentrating in school, leading to poor school attendance, and academic performance. Without CHIP, these children would lose much needed medical 

and dental coverage. According to the Medicaid and CHIP Payment and Access 

Commission (MACPAC), without CHIP some families would be susceptible to additional premiums and cost sharing to access dental services in marketplace plans 

and/or employer-sponsored insurance. This is particularly concerning for low-income 

families and children. Furthermore, CHIP contributes to overall cost-savings to the 

system by decreasing the number of emergency room visits that are 10-times more 

expensive than routine, preventative care.1

Historically, CHIP has had bipartisan support. It gives states flexibility in designing 

their programs, allowing them to implement the program by expanding Medicaid, 

creating a separate program, or a combination of both approaches.2 With that flexibility, states can design a program that works best for their state and its children. 

Simply stated, CHIP provides states needed ‘‘certainty’’ in planning their budgets. 

MACPAC estimates all states would exhaust federal CHIP funding at some point 

in FY18, with four states and the District of Columbia running out of federal funds 

as early as December 2017.3 Therefore, time is of the essence. OHA urges Congress 

to act soon with a 5-year CHIP funding extension. 

Respectfully submitted, 

Beth Truett 

CEO and President 

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1Medicaid and CHIP Payment and Access Commission, Child Enrollment in CHIP and Medicaid by State, FY 2016 (Washington, DC: MACPAC, 2017), Exhibit 31, https://www. 

macpac.gov/wp-content/uploads/2015/01/EXHIBIT-31.-Child-Enrollment-in-CHIP-and-Medicaid-by-State-FY-2016.pdf (accessed August 15, 2017). 2 Jason Gates et al., Uninsurance Among Children, 1997–2015: Long-Term Trends and Recent 

Patterns (Washington, DC: Urban Institute, 2016), http://www.urban.org/research/publication/ 

uninsurance-among-children-1997-2015-long-term-trends-and-recent-patterns (accessed August 

2017), and Sonya Schwartz et al., ‘‘Latino Children’s Coverage Reaches Historic High, But Too 

Many Remain Uninsured’’ (DC: Georgetown University Health Policy Institute Center for Children and Families and National Council of La Raza, December 2016), http://publications.nclr.org/handle/123456789/1672 (accessed August 2017). 

UNIDOSUS 

1126 16th Street, NW, Suite 600 

Washington, DC 20036–4845 

Submitted by Eric Rodriguez, Vice President 

Office of Research, Advocacy, and Legislation 

Introduction 

UnidosUS, formerly the National Council of La Raza, is the largest national Hispanic civil rights and advocacy organization in the United States. We have a long 

history of advancing opportunities for middle- and working-class Latino children 

and families, including immigrant and mixed-status households, to achieve the highest level of health possible. 

In this capacity, UnidosUS and its Affiliate network of over 260 local, community 

based organizations in 41 states, the District of Columbia, and Puerto Rico, work 

diligently to ensure that the needs of our community are met. Through our work 

with these affiliates we help ensure that all individuals—regardless of who they are 

or where they are from—have access to affordable, quality health coverage and care. 

Advancing health equity is crucial for all Americans, including Latino children who 

are more likely to be uninsured than their peers. Our children are the future of this 

nation, and it is important that every child has the opportunity and ability to grow 

up healthy. 

As evidence of our commitment to improving access to health coverage and care, 

UnidosUS has published several reports on policies and programs, like the Children’s Health Insurance Program (CHIP), demonstrated to have had a positive impact on the health and well-being of Latino children, including: 

• Latino Children’s Coverage Reaches Historic High, But Too Many Remain Uninsured, published by UnidosUS and the Georgetown Center for Children and 

Families (December 2016) 

• Toward a More Equitable Future: The Trends and Challenges Facing America’s 

Latino Children, published by UnidosUS and the Population Reference Bureau 

(September 2016) 

• Historic Gains in Health Coverage for Hispanic Children in the Affordable Care 

Act’s First Year, published by UnidosUS and the Georgetown Center for Children and Families (January 2016) 

The Children’s Health Insurance Program (CHIP), has proven to be essential to 

keeping millions of children and families, including Latinos, healthy and financially 

secure. Since 1997, CHIP has provided no-cost and low-cost health insurance for 

children of working families who earn too much to qualify for Medicaid, but not 

enough to afford private insurance. This program has enjoyed bipartisan support 

throughout its 20-year history. Chief among these champions has been Chairman 

Hatch, along with Democratic counterparts, including the late Senator Edward Kennedy and Senator Jay Rockefeller. 

CHIP’s impact on our children has only grown during this time. In 2016, there were 

nearly 9 million children enrolled in the CHIP program. Most of these children (89 

percent) are in working families earning between $24,600 and $49,200 for a family 

of four, or between 100 percent and 200 percent of the Federal Poverty Level (FPL).1

The increase in coverage for children in working families has precipitated a dramatic decline in the number of all uninsured children. Since 1997, the overall child 

uninsured rate has declined by two-thirds, from 14.9 percent in 1997 to 4.8 percent 

in 2015, the lowest rate ever recorded.2

UnidosUS recognizes the power of this program and, along with our Affiliates, has 

worked over the past 20 years to expand access to CHIP coverage for Latino children. Most recently, we have engaged with partners at the state level to ensure that 

95 

3 Vera Gruessner, ‘‘Arizona’s Children’s Health Insurance Program Back in Action,’’ Health 

Payer Intelligence, July 26, 2016. 4 Jason Gates et al., Uninsurance Among Children, 1997–2015: Long-Term Trends and Recent 

Patterns (Washington, DC: Urban Institute, 2016), http://www.urban.org/research/publication/ 

uninsurance-among-children-1997-2015-long-term-trends-and-recent-patterns (accessed August 

2017), and Sonya Schwartz et al., ‘‘Latino Children’s Coverage Reaches Historic High, But Too 

Many Remain Uninsured’’ (DC: Georgetown University Health Policy Institute Center for Children and Families and National Council of La Raza, December 2016), http://publications.nclr.org/handle/123456789/1672 (accessed August 2017). 5The Annie E. Casey Foundation, Children Below 200 Percent of Poverty by Race (Baltimore, 

MD: Annie E. Casey, 2016), http://datacenter.kidscount.org/data/tables/6726-children-below200-percent-poverty-by-race?Ioc=1&loct=1#detailed/1/any/false/573/12,1/13819,13820 

(accessed August 2017), and Georgetown Center for Children and Families, Snapshot of Children’s Coverage by Race and Ethnicity (Washington, DC: CCF, 2017), https://ccf.george 

town.edu/wp-content/uploads/2017/04/Snapshot-of-Children%E2%80%99s-Coverage-by-Raceand-Ethnicity.pdf (accessed August 2017). 6Georgetown Center for Children and Families, Snapshot of Children’s Coverage by Race and 

Ethnicity (Washington, DC: CCF, 2017), https://ccf.georgetown.edu/wp-content/uploads/2017/ 

04/Snapshot-of-Children%E2%80%99s-Coverage-by-Race-and-Ethnicity.pdf (accessed August 

2017). 7Genevieve M. Kenney et al., CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Final Findings (Washington, DC: Urban Institute, 2014), https://www. 

medicaid.gov/chip/downloads/chip_report_congress-2014.pdf (accessed August 2017). 

children have access to coverage through the CHIP program in their states. For example, in 2016, we worked with child advocacy groups in Arizona to reinstate their 

CHIP program, expanding access to quality, affordable health coverage for an estimated 30,000–40,000 children.3

Despite this success, funding for this vital program ends on September 30, 2017. If 

CHIP funding is delayed or allowed to expire, the health and well-being of nearly 

9 million children currently enrolled in CHIP will suddenly be at risk, along with 

the tremendous progress made in narrowing health inequities experienced by all 

children of color, including Latinos. With the uncertainty surrounding other important health programs like the Affordable Care Act and Medicaid, it becomes even 

more important for Congress to meet this deadline. 

This written testimony will focus on the importance of the CHIP program to the 

Latino community, narrowing inequities in health coverage for Latino children, and 

the steps Congress must take to safeguard the well-being of millions of children. 

CHIP Narrows Coverage Gaps for Latino Children 

While CHIP plays an important role in health coverage for nearly 9 million children, 

it has been especially influential in providing access to health coverage and care for 

Latino children, who have historically been more likely to be uninsured than their 

peers. Every child deserves to grow up healthy and thrive, and many Latino children and families depend on CHIP coverage for this opportunity: 

• Along with the Affordable Care Act, CHIP is responsible for reducing the rate 

of uninsured Latino children from 28.6 percent in 1997, to 7.5 percent in 2015.4

• Most Latino children (61 percent) live in families earning below 200 percent 

FPL, which makes them income-qualified for Medicaid/CHIP coverage in nearly 

every state. 56 percent of Latino children are enrolled in Medicaid or CHIP coverage.5

• Latino children account for the largest share of Medicaid and CHIP enrollees 

(37 percent) of any ethnic group, despite accounting for only 25 percent of the 

child population.6

CHIP not only has allowed more children to have health coverage, it has dramatically reduced health-care inequities affecting children of color from working families. 

From 1997 to 2015, the coverage disparity between White children and Latino children narrowed from 13 percentage points to 3.7 percentage points, with CHIP accounting for much of this decline.7 Further, a recent federally mandated evaluation 

of CHIP enrollment across 10 states found that over half of CHIP enrollees (54 percent) were Latino. 

Finally, the coverage provided by CHIP is unique in our health-care system because 

its benefits are specifically tailored for children in working families and may be 

more effective in detecting or preventing certain conditions. Children with Medicaid 

or CHIP coverage are more likely than children with private insurance to have had 

a routine checkup, and are just as likely to have a primary, consistent source of 

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8Medicaid and CHIP Payment and Access Commission, The Future of CHIP and Children’s 

Coverage, Chapter 1 (Washington, DC: MACPAC, 2017). 9 Anita Cardwell et al., Benefits and Cost Sharing in Separate CHIP Programs (Washington, 

DC: Georgetown CCF and National Academy for State Health Policy, 2014), http://ccf.george 

town.edu/wp-content/uploads/2014/05/Benefits-and-Cost-Sharing-in-Separate-CHIP-Programs. 

pdf (accessed August 2017). 10 Ibid. 

care.8 Most children enrolled in CHIP have access to the Early and Periodic Screening, Diagnostic, and Treatment Benefit (EPSDT), which enables these children to 

receive medically necessary services—like treatment for vision, dental, and hearing 

problems—ensuring that children of all ages in this income bracket have access to 

the specific services appropriate at their current stage of development.9

Moving Forward with CHIP Funding Reauthorization 

Since its inception, CHIP has enjoyed bipartisan support, including the last time the 

program was reauthorized in the Medicare Access and CHIP Reauthorization Act 

of 2015 (MACRA). This bipartisan support has helped make CHIP an especially effective program, capable of reducing child uninsured rates regardless of the political 

or economic climate. 

While most states do not officially exhaust their CHIP funding until later this year 

or next year, the state budget cycle requires many to begin winding down their programs and sending out cancellation letters several months in advance. If Congress 

does not authorize funding past September 30th, children across the nation will face 

coverage disruptions, causing them to fall behind on their well-child visits or delay 

medically necessary treatment. Any delay in reauthorizing this funding could reverse course on the tremendous progress that has been made in reducing the number of uninsured children. 

We believe that CHIP funding should be reauthorized in a way that enables the program to continue to meet the unique health-care needs of children in working families, including Latinos. As Congress considers ways to continue to fund the CHIP 

program, we urge you to put children first, and build on the foundation laid under 

previous reauthorizations of this program including MACRA and the Children’s 

Health Insurance Program Reauthorization Act of 2009 (CHIPRA). UnidosUS 

strongly believes that Congress should consider the following priorities as they work 

to reauthorize funding for CHIP: 

1. Extend federal CHIP funding on time. It is essential for the health and 

well-being of our children that Congress reauthorize CHIP funding by the September 30th deadline. This will allow states the budgetary certainty they need 

to continue providing coverage for children eligible for CHIP. Given the tremendous uncertainty surrounding other parts of our health-care system, congress must ensure that CHIP funding is not allowed to lapse for any period 

of time or children will lose their health coverage. 

2. Extend current funding levels established in the Medicare Access and 

CHIP Reauthorization Act of 2015 (MACRA) and the Affordable Care 

Act (ACA). The enhanced Federal Medical Assistance Percentage (E–FMAP) 

authorized under MACRA, along with the current CHIP Maintenance of Effort 

provision established under the ACA, has given states the ability to provide 

coverage, without gaps, for children in families earning under a specific income 

threshold. The increase of funding authorized by MACRA provides states the 

ability to continue expanding access to coverage to more children, and opened 

the doors for Arizona to reinstate its program. If CHIP is not funded at current 

levels, some states will once again impose waiting lists and enrollment caps on 

their programs and currently eligible children may suddenly find themselves 

without access to CHIP coverage. 

3. Authorize a five-year extension of federal CHIP funding through FY 

2022. Renewing federal funding for an additional 5 years, as opposed to a more 

short-term extension, will provide states with long-term budgetary certainty 

necessary to develop and test approaches for a more coordinated delivery system of comprehensive, affordable coverage for children. A 5-year extension, at 

current funding levels, would also better synchronize the program’s funding 

with the current CHIP authorization timeline.10

4. Ensure the eligibility of at least as many children as allowed under 

current law. When it comes to children’s coverage, we should always be lookVerDate Sep 11 2014 17:37 Aug 29, 2018 Jkt 000000 PO 00000 Frm 00100 Fmt 6601 Sfmt 6621 R:\DOCS\31255.000 TIM
97 

ing forward, not back. It is critical to the success of this program, and to the 

health and well-being of America’s children, that current eligibility standards 

are maintained or expanded. All children, no matter who they are or where 

they are from, deserve the opportunity to live healthy lives and thrive. Congress must ensure that CHIP continues to play this role within our health-care 

system. 

Conclusion 

Despite undeniable success, long-standing bipartisan support, and program reauthorization through 2019, funding for this vital program is at risk. UnidosUS believes that the stakes—the health and well-being of nearly 9 million children, a significant share of whom are Latino—are too high for any delay or lapse in funding. 

CHIP is a foundational part of our nation’s health-care system, and helps ensure 

a stronger and brighter future for our children. The millions of children enrolled in 

CHIP cannot afford to go without coverage; children with health coverage are more 

likely than those who go without to graduate high school, attend college, and attain 

economic success in adulthood. By investing in our children today we help ensure 

not only their individual success but that of our nation. CHIP is a truly effective 

program that helps give our children the healthiest start they need in life. It is 

paramount that funding for this program remains strong for years to come. 

Æ