"The question really arose, given the existence of subsidized exchange coverage, is CHIP still needed?" Anne Schwartz, MACPAC's executive director, said during the June meeting. The commission's short-term answer was yes, to avoid coverage losses for kids, she said, "but over the long term, it would be worth rethinking the system."
Democrats also believe that the ACA could eventually help replace CHIP, though they are skeptical that they can figure out a plan before the next expiration date.
"The goal ultimately is 2020, '22, but it will not be 2018, I wouldn't guess, when it comes to that stuff," Brown said. "But the answer is yes, eventually."
In the eyes of groups like First Focus, the solution can't be as simple as transitioning CHIP enrollees to Obamacare coverage. Their problem with that can be summed up as one of generosity: The plans offered under the ACA can have fewer benefits, more cost-sharing, and less robust networks than CHIP.
On networks, First Focus staff cited the example of Washington state, where the insurance marketplace was sued in 2013 by the Seattle Children's Hospital because many health plans being offered didn't include the hospital in their coverage.
So First Focus staff is meeting periodically to start figuring out how to avoid a falloff if CHIP is replaced by the ACA. They are holding regular calls with other groups like the Children's Defense Fund and the Urban Institute; there is also a quarterly meeting of interested groups examining health-reform implementation more broadly.
They don't have a set list of legislative fixes yet, but everything is on the table: from new requirements about what Obamacare plans cover and decreased cost-sharing for plans covering kids, to offering CHIP as a plan on the law's marketplaces. The goal is to create some kind of model legislation—complete with Title I, Title II, etc.—to frame the upcoming debate. There is a fear that, without it, lawmakers might move children to ACA coverage and then go about figuring out how to address some of these other issues.
"It's sort of, 'CHIP is enabling this system that is kind of jerry-rigged, so let's let it go and see what happens and then we'll fix the things that need to be fixed,'" said Lisa Shapiro, vice president of health policy at First Focus. "Which for us, that's terrifying."
Part of the problem will be one of cost. Extending CHIP for two years in the doc-fix deal added $5.6 billion to the deficit, according to the Congressional Budget Office. Implementing the kind of changes that First Focus and other groups would likely want to see would likely cost tens of billions of dollars.
The politics could be tricky, too: Reauthorization talk will pick up almost as soon as the new Congress and president are sworn in. Even if Hillary Clinton, who counts CHIP among her biggest achievements as first lady, wins the White House, Lesley asked rhetorically how House Republicans might use that to their advantage.
"If you're John Boehner and you're trying to think, 'What can I take hostage that Hillary Clinton might care about, so I can get my Keystone passed, or my whatever that I've been trying to get passed?'—could that possibly be CHIP?" Lesley said.
Reprinted with permission from National Journal. The original story can be found here.