It means figuring out how to enact a cap, freeze, or shutdown—something many states have never done. “We’re beginning to figure out how to modify IT systems,” Nablo told me. “There are at least two that will involve probably significant costs, to both cancel people with current coverage as well as to stop approving kids when they apply.” She said the state was also figuring out how to modify a dozen contracts. States must also figure out how to inform parents and providers, with many states drafting and sitting on letters informing families of the program changes. “There’s been this tension,” said Robin Rudowitz of Kaiser. “States don’t want to send notices out.” But they also do not want to surprise their parents, and give them no time to try to find other coverage should their state’s CHIP program end.
The policy effects are already being felt in terms of wasted money and diverted personnel hours, state administrators have said. Some states have stopped pushing sign-ups too, something that might depress enrollment in the short and medium term, with lower-income and more disconnected parents not realizing that their kids are eligible. “We haven’t been doing even our regular outreach activities,” Stacey Shamblin, West Virginia’s acting CHIP director, told the Charleston Gazette-Mail.
If states were to start to send their letters to parents—Nablo said Virginia is just days away from that point—the policy implications would be significant, health analysts have warned. Parents might find themselves confused by the program and less trusting in its soundness. Kids might never sign up, or might drop out. “It’s not something you can easily turn on and off,” Rudowitz said. “You could put in a cap. But the education and notices to beneficiaries—even if there is no cap, that reeducation can take a long time, and maybe doesn’t reach everybody.”
A brief hiccup in state coverage would have yet more dire effects. During it, some kids might be denied care or their parents might get hit with significant medical bills. After it, parents might not recognize that they could re-enroll their kids. Arizona scaled back its CHIP program in 2014, and even after expanding it again its uninsured rate for children remains one of the highest in the country, double that of California. The effects are felt not just in terms of lost coverage, but lost care. “Some of the children went without needed health services and medications,” a study by researchers at Georgetown University found. “A child with Lupus and heart and respiratory ailments was hospitalized because her family could not afford the doctor visits and medications she required. Other children did without medications for their asthma or ADHD.”
A true program lapse would be worse. Nablo said she worried most about newborns and pregnant women in Virginia. “We put a lot of effort to get pregnant women enrolled early, to help get them prenatal care and to have healthy babies,” she said. “It’s great for the kid, great for the mother, and great for the taxpayer, so we’re not paying for a kid in the NICU if we don’t have to.” She also said children currently undergoing treatment would be hard-hit. “We treat kids with cancer,” she said. “We treat babies born with HIV. We treat babies addicted to substances. We have some really sick kids. We’re paying for their treatment. To suddenly say, ‘Sorry, you’re on your own’? I can’t imagine getting that word as a parent.”
What is perhaps scariest: Even strong bipartisan support for CHIP has not protected it from the effects of polarization and the breakdown of the normal budgeting process in Congress. And it is kids who stand to bear the worst of the consequences.