[Senate Hearing 115-311]
[From the U.S. Government Publishing Office]


                                                        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

                               __________

                                     
                                     

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                          COMMITTEE ON FINANCE

                     ORRIN G. HATCH, Utah, Chairman

CHUCK GRASSLEY, Iowa                 RON WYDEN, Oregon
MIKE CRAPO, Idaho                    DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas                  MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming             BILL NELSON, Florida
JOHN CORNYN, Texas                   ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota             THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina         BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia              SHERROD BROWN, Ohio
ROB PORTMAN, Ohio                    MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania      ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada                  MARK R. WARNER, Virginia
TIM SCOTT, South Carolina            CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana

                     A. Jay Khosla, Staff Director

              Joshua Sheinkman, Democratic Staff Director

                                  (ii)
                            
                            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
National Child Health Organizations..............................    89
Nemours Children's Health System.................................    91
Oral Health America (OHA)........................................    93
UnidosUS.........................................................    94

 
       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 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 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.
    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.
    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.
    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.
    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 earlier, 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 
spouse-only 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.
    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 
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.
    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 
child-focused 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 high-quality pediatric care.
    Congress now faces an important decision regarding the 
future of CHIP during a period of great uncertainty affecting 
other health-care 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 health-care 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. 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 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 two-year 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.
    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.
    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 
health-care 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 low-
income 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 considered 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.
    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.
    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.
    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 
technology-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 CHIP-
eligible 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.
    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 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 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 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 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.
    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.
    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.
    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 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.
    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.
    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.
    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.
    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 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.
    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 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 long-term 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.
    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 
written 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.]

                            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 
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.
---------------------------------------------------------------------------
    \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.

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 out-of-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
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
       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

                                 ______
                                 
                  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 
electrician. 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 long-term 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 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 self-sufficiency. 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?

    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 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 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.

                                 ______
                                 
  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).
                            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 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.

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 (Sec. 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.
---------------------------------------------------------------------------
    \1\ The definition of targeted low-income child at section 2110(b) 
created a CHIP upper income-eligibility limit of no greater than 50 
points above the State pre-CHIP Medicaid income levels.

    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 
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 
(Sec. 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.
---------------------------------------------------------------------------
    \2\ Urban Institute analysis for MACPAC of Health Insurance Policy 
Simulation Model-
American Community Survey (HIPSM-ACS), August 2017.

    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.
---------------------------------------------------------------------------
    \3\ Premiums 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.

    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 
employer-
sponsored 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 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 (Sec. 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'' 
(Sec. 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 (Sec. 2104(m)(2)(B)(iv) of the Act).\5\
---------------------------------------------------------------------------
    \4\ MACPAC 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).
    \5\ 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.

    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).
---------------------------------------------------------------------------
    \6\ The projected FY 2018 Federal CHIP spending of $17.4 billion 
includes States and territories.


 Table 1. Projected Exhaustion of Federal CHIP Funds in Fiscal Year 2018
------------------------------------------------------------------------
                               Number of
   Quarter of fiscal year       States                 States
------------------------------------------------------------------------
First quarter                          4   Arizona, District of
(October-December 2017)                     Columbia, Minnesota, and
                                            North Carolina
------------------------------------------------------------------------
Second quarter                        27   Alaska, Arkansas, California,
(January-March 2018)                        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                         19   Alabama, Georgia, Illinois,
(April-June 2018)                           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                         1   Wyoming
(July-September 2018)
------------------------------------------------------------------------
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'' (Sec. 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

      Extending funding to support outreach and enrollment of 
Medicaid-and CHIP-eligible 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\
---------------------------------------------------------------------------
    \7\ Savings 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).

    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 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\
---------------------------------------------------------------------------
    \9\ Specifically, 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.

    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 
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\
---------------------------------------------------------------------------
    \10\ The 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.

                               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.

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-qualified-
health-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/chipra-irtc/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/health-reform/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-medicaid-and-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-when-will-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-the-future-of-childrens-coverage-
focus-on-affordability-2/.

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-medicaid-and-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-chip-314/.

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.


                                                                             APPENDIX A: ELIGIBILITY AND ENROLLMENT
                                                           Table A-1. CHIP Eligibility Levels (2016) and Enrollment (FY 2015) by State
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                      Children in Medicaid-Expansion CHIP \1\                                        Children in separate CHIP
                                 ------------------------------------------------------------------------------------------------------------------------------------------------
                Program type \1\                                                               Separate CHIP: Age 0-18 \2\                Separate CHIP: Unborn         Total       Total CHIP-
     State        (as of July 1,   Infants <1  Age 1-5 (%   Age 6-18              ---------------------------------------------------------------------------------   separate     funded child
                      2016)         (% FPL)       FPL)       (% FPL)   Enrollment   Infants <1  Age 1-5  (%  Age 6-18 (%                                                CHIP      enrollment \4\
                                                                                     (% FPL)        FPL)         FPL)      Enrollment  Eligibility \3\  Enrollment   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             159-203     159-203     124-203      10,182            -            -            -            -              -             -             -         10,182
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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\  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
 , \8\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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     Medicaid             206-319     146-319     112-319      10,676            -            -            -            -              -             -             -         10,676
 Columbia        expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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             191-308     139-308     105-308      27,239            -            -            -            -              -             -             -         27,239
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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             194-317     138-317     109-317     142,327            -            -            -            -              -             -             -        142,327
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Massachusetts   Combination          185-200     133-150     114-150      79,299      201-300      151-300      151-300       76,519            200        13,123        89,642        168,941
 \10\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New Hampshire   Medicaid             196-318     196-318     196-318      16,651            -            -            -            -              -             -             -         16,651
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New Jersey      Combination                -           -     107-142     100,826      195-350      143-350      143-350      114,365              -             -       114,365        215,191
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New Mexico      Medicaid             200-300     200-300     138-240      17,155            -            -            -      40 \14\              -             -            40         17,195
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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             141-206     141-206     107-206     181,100            -            -            -            -              -             -             -        181,100
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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             194-208     143-208     107-208      98,336            -            -            -            -              -             -             -         98,336
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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             237-312     237-312     237-312       4,766            -            -            -            -              -             -             -          4,766
                 expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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   Combination                -           -     108-133      15,242      159-300      142-300      134-300       33,036              -             -        33,036         48,278
 \20\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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.
\13\ Missouri 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' Sec.  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 Sec.  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 Sec.  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.
\19\ While Tennessee covers children with CHIP-funded Medicaid, enrollment is currently capped, except for children who roll over from traditional Medicaid.
\20\ West 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.
\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-by-state/. 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-a-percentage-of-the-federal-poverty-level-for-children-and-pregnant-women-by-state/.


    APPENDIX B: CHIP ENHANCED FEDERAL MEDICAL ASSISTANCE PERCENTAGES
   Table B-1. CHIP Enhanced Federal Medical Assistance Percentages by
                          State, FYs 2013-2017
------------------------------------------------------------------------
                                               E-FMAPs for CHIP
                                     -----------------------------------
                State                   FY 2015     FY 2016     FY 2017
                                          \1\         \2\         \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
------------------------------------------------------------------------
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).

 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.
---------------------------------------------------------------------------
    \1\ States 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.

    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 (Hensley-Quinn 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 
(Sec. 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).


 Table 1. Projected Exhaustion of Federal CHIP Funds in Fiscal Year 2018
------------------------------------------------------------------------
  Quarter of fiscal     Number of
        year             States                    States
------------------------------------------------------------------------
First quarter                   4   Arizona, District of Columbia,
(October-December                    Minnesota, and North Carolina
 2017)
------------------------------------------------------------------------
Second quarter                 27   Alaska, Arkansas, California,
(January-March 2018)                 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                  19   Alabama, Georgia, Illinois, Indiana,
(April-June 2018)                    Iowa, Maine, Michigan, Maryland,
                                     Nebraska, New Hampshire, New
                                     Jersey, New Mexico, North Dakota,
                                     Oklahoma, South Carolina,
                                     Tennessee, Texas, West Virginia,
                                     and Wisconsin
------------------------------------------------------------------------
Fourth quarter                  1   Wyoming
(July-September
 2018)
------------------------------------------------------------------------
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)
----------------------------------------------------------------------------------------------------------------
                                    Unspent  FY      FY 2018       Total FY
                        Estimated       2017        projected        2018       FY 2018
                       unspent  FY   allotments  redistribution   projected    projected     Month projected to
        State              2017      available    funding from       CHIP       Federal    exhaust CHIP  funding
                        allotments   in FY 2018    prior year    funding D =      CHIP               F
                            A       B = A  .67   allotments C      B + C      spending E
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \2\ States 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.

    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
                        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 Medicaid-
expansion 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.
---------------------------------------------------------------------------
    \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).


                                 Table 3. State CHIP Program Type and Enrollment
----------------------------------------------------------------------------------------------------------------
                                               CHIP-funded enrollment (FY 2015)                  Month and year
                              -----------------------------------------------------------------   of  projected
    State       Program type    Medicaid-               Separate CHIP                             CHIP funding
                     \1\        expansion  ---------------------------------------  Total \2\    exhaustion (as
                                   CHIP       Birth-18      Unborn       Total                    of June 2017)
----------------------------------------------------------------------------------------------------------------
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            10,182            -            -            -       10,182   March 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
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  Combination      1,787,470        2,461      122,197      124,658    1,912,128   January 2018
 \,\6\
----------------------------------------------------------------------------------------------------------------
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    Medicaid            10,676            -            -            -       10,676   December 2017
 PColumbia     Expansion
----------------------------------------------------------------------------------------------------------------
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            27,239            -            -            -       27,239   March 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Maryland       Medicaid           142,327            -            -            -      142,327   April 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
Massachusetts  Combination         79,299       76,519       13,123       89,642      168,941   February 2018
  \7\
----------------------------------------------------------------------------------------------------------------
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            16,651            -            -            -       16,651   April 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
New Jersey     Combination        100,826      114,365            -      114,365      215,191   April 2018
----------------------------------------------------------------------------------------------------------------
New Mexico     Medicaid            17,155      40 \10\            -           40       17,195   May 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
New York       Combination        235,945      394,787            -      394,787      630,732   March 2018
----------------------------------------------------------------------------------------------------------------
North          Combination        134,413      100,237       4 \11\      100,241      234,654   December 2017
 Carolina
----------------------------------------------------------------------------------------------------------------
North Dakota   Combination              -        4,955            -        4,955        4,955   May 2018
----------------------------------------------------------------------------------------------------------------
Ohio           Medicaid           181,100            -            -            -      181,100   March 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
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          Medicaid            98,336            -            -            -       98,336   June 2018
 Carolina      Expansion
----------------------------------------------------------------------------------------------------------------
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             4,766            -            -            -        4,766   January 2018
               Expansion
----------------------------------------------------------------------------------------------------------------
Virginia       Combination         86,551      102,815            -      102,815      189,366   February 2018
----------------------------------------------------------------------------------------------------------------
Washington     Separate                 -       37,883        8,154       46,037       46,037   January 2018
----------------------------------------------------------------------------------------------------------------
West Virginia  Combination         15,242       33,036            -       33,036       48,278   April 2018
 \16\
----------------------------------------------------------------------------------------------------------------
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 historical 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.
\9\ Missouri 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 income-based
  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.
\15\ While Tennessee covers children with CHIP-funded Medicaid, enrollment is currently capped, except for
  children who roll over from traditional Medicaid.
\16\ West 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-for-the-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/federal-medical-assistance-percentages-
fmaps-and-enhanced-fmaps-e-fmaps-by-state-selected-periods/.

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, belt-tightening 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.

    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.

                                 ______
                                 

                             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 address 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 ([email protected]).

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)
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

                              [email protected]

                         AAFP Washington Office

                1133 Connecticut Avenue, NW, Suite 1100

                       Washington, DC 20036-1011

                    202-232-9033  Fax: 202-232-9044

                            [email protected]

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.
---------------------------------------------------------------------------
    \1\ Centers for Medicare and Medicaid Services, 2016 Enrollment 
Report, available at https://www.medicaid.gov/chip/downloads/fy-2016-
childrens-enrollment-report.pdf.

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.
---------------------------------------------------------------------------
    \2\ AAFP, 2015 Practice Profile Survey (excerpt), available at 
http://www.aafp.org/about/the-aafp/family-medicine-facts/table-12.html.

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 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.
---------------------------------------------------------------------------
    \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.

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\
---------------------------------------------------------------------------
    \6\ AAFP, Health Care for All (2014), available at http://
www.aafp.org/about/policies/all/health-care-for-all.html.
    \7\ See, 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.

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 Masterfile 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.
---------------------------------------------------------------------------
    \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.
    \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).

                                 ______
                                 
                  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 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\
---------------------------------------------------------------------------
    \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-and-childrens-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-childrens-enrollment-
report.pdf.

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\
---------------------------------------------------------------------------
    \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.
    \4\ Samantha 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-on-health-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-
and-issues-for-the-future/.

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 poverty, 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\
---------------------------------------------------------------------------
    \6\ Samantha 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 at: http://www.kff.org/
disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-
examining-changes-under-the-aca-and-the-remaining-uninsured/.
    \7\ Deborah 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.

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\
---------------------------------------------------------------------------
    \8\ CHIP Benefits, Medicaid.gov, available at: https://
www.medicaid.gov/chip/benefits/index.html.

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.
---------------------------------------------------------------------------
    \9\ Lenna 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/.

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.
---------------------------------------------------------------------------
    \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.

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.
---------------------------------------------------------------------------
    \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-
and-issues-for-the-future/.

For questions, contact Amina Ferati, Senior Director of Government 
---------------------------------------------------------------------------
Relations and Policy at [email protected] (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 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.
---------------------------------------------------------------------------
    \1\ http://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/.

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\
---------------------------------------------------------------------------
    \3\ https://www.congress.gov/bill/111th-congress/house-bill/2; 
https://www.congress.gov/bill/114th-congress/house-bill/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. 
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\
---------------------------------------------------------------------------
    \4\ https://www.cdc.gov/obesity/strategies/healthcare/index.html.
    \5\ https://www.cdc.gov/obesity/strategies/healthcare/cord2.html.

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 communities 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, cost-
effective solutions to combat childhood obesity.
---------------------------------------------------------------------------
    \1\ https://www.congress.gov/bill/111th-congress/house-bill/2.
    \2\ https://www.congress.gov/bill/114th-congress/house-bill/2.

Through CORD, the Centers for Disease Control and Prevention (CDC), has 
funded multiple community grantees and evaluation centers to target 
children from low-
income 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\
---------------------------------------------------------------------------
    \3\ https://www.cdc.gov/obesity/strategies/healthcare/index.html.
    \4\ https:// www.cdc.gov/obesity/strategies/healthcare/cord2.html.

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.
---------------------------------------------------------------------------
    \5\ http://obesityactionfund.org/page.asp?id=28.
    \6\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322789/.

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\
---------------------------------------------------------------------------
    \7\ https://www.ncbi.nlm.nih.gov/pubmed/25381647.
    \8\ http://www.galllup.com/businessjournal/145778/cost-obesity-
cities.aspx.

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
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: [email protected]

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 
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. 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 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 [email protected]/(505) 803-
5304

                                 ______
                                 
                  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 African-American 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 health-care 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

                                 ______
                                 
                  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
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
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: [email protected]         Email: [email protected]

                                 ______
                                 
                    Nemours Children's Health System

                    1201 15th Street, NW, Suite 520

                          Washington, DC 20005

                            www.nemours.org

                       Contact: Daniella Gratale

                  Email: [email protected]

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 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.

                                 ______
                                 
                       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 
Well-being

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\
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    \1\ Health Policy Institute, American Dental Association. Thomas 
Wall, Marko Vujicic. ``Emergency Department Use for Dental Conditions 
Continues to Increase.'' April 2015.

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.
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    \2\ https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/
chip/index.html.
    \3\ https://www.macpac.gov/topics/chip/.

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Respectfully submitted,

Beth Truett
CEO and President

                                 ______
                                 
                                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\
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    \1\ Medicaid 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 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 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\
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    \3\ Vera Gruessner, ``Arizona's Children's Health Insurance Program 
Back in Action,'' Health Payer Intelligence, July 26, 2016.

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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
      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\
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    \5\ The 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-below-200-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-Race-and-Ethnicity.pdf (accessed August 2017).
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      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\
---------------------------------------------------------------------------
    \6\ Georgetown 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).

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.
---------------------------------------------------------------------------
    \7\ Genevieve 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).

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 
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\
---------------------------------------------------------------------------
    \8\ Medicaid 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).
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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\
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    \10\ Ibid.

    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 looking 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.

                                  [all]