ThinkstockPhotos-78322012Since children often cannot speak for themselves when it comes to political debates before Congress, recent blogs by Clio Chang (Two Years of Children’s Health Insurance Is Not Enough) and Kathryn Baer (CHIP Renewal: Will the Perfect Be the Enemy of the Good?) are important to focus on the role that advocacy should play with respect to the current debate over extending the Children’s Health Insurance Program (CHIP). Beyond CHIP, both blogs are also relevant because they highlight different strategies for advocating on behalf of children that we all must consider.

For example, Chang advocates in favor of continued efforts to push for the Senate to modify H.R. 2, the “Medicare Access and CHIP Reauthorization Act of 2015,” and extend CHIP for four years rather than just the two years provided in the House-passed bill. She points to how children are far so often shortchanged in federal policy, including in H.R. 2, and argues, “If it’s easier for some to cite cutting costs over spending federal dollars to insure our children’s health, then we need to step back and re-evaluate the purpose of our government.”

In contrast, Baer looks at the debate around H.R. 2 and says, “The bill is far from perfect. CHIP supporters and others of progressive leanings will have to decide whether – and at what point – to say it’s good enough.” She points out that children’s advocates have “to balance priorities and prospects” and consider the pros and cons in advocating for what is best for kids. And, she warns that, if advocates continue to push, the package could blow up and leave CHIP “imperiled” and poses the question whether child advocates are making “the perfect be the enemy of the good.”

So, who is right? Should we push forward for better or accept something over nothing?

First, although Chang and Baer have different strategic emphasis, they are both correct in saying that the two-year extension of CHIP in H.R. 2 is clearly better than the program expiring, but that it is not as good for kids as a four-year extension.

Ironically, House Republican Whip Kevin McCarthy explains the problem with short-term extensions in his floor statement in support of H.R. 2. Although the bill creates a short-term extension for CHIP, McCarthy was referring to the bill’s permanent fix in the Medicare physician payment formula, which is known as the sustainable growth rate (SGR). As McCarthy explains, since enactment of the SGR in 1997, it has been necessary for Congress to pass 17 short-term fixes over the years to the program to prevent flaws in the formula that would have led to deep cuts in Medicare payments to doctors. He adds:

“There’s a common cycle. You have a problem, you kick the can down the road. You hit a cliff, then you rush to a short-term fix that doesn’t fix the problem. Then the cycle starts all over again. This isn’t a good way to govern. With this cycle, problems usually get worse. . . . But today the House will vote on a bipartisan bill to end the cliff for good. Stop the cycle, and most importantly, provide stability to the Medicare program for the seniors and their doctors.”

McCarthy’s arguments for fixing Medicare and avoiding short-term “kick the can” measures is right, but the fact is, those arguments are applicable to CHIP as well. But unfortunately, H.R. 2 creates the need for three extensions of CHIP in just five years (now, 2017, and again in 2019). This puts health coverage for over 8 million children in recurring risk and jeopardy.

While Baer points to possible pitfalls if H.R. 2 were to somehow fail, now is not the time to throw in the towel. An amendment to improve the CHIP provisions would have zero impact on the bill’s final passage or reconsideration in the House, as it passed there by a vote of 392-37. Worse, if we fail to even try to do what is best for children now, the problem is that the political environment could be far worse in 2017 than it is today and we may long regret not having at least tried.

In addition to the problem of subjecting CHIP and the health of over eight million children to risk in 2017 and beyond, a second concern is that nobody can project what the political environment will be after the 2016 presidential and congressional elections.

As an example, Grace-Marie Turner of the Galen Institute expressed her support for H.R. 2 and CHIP’s two-year extension in a Forbes article but not for the reasons that child advocates would hope. In fact, Turner implies CHIP should be used as a tool or a vehicle in 2017 to pursue other political and policy agendas. She writes:

“…the deal would extend the Children’s Health Insurance Program (CHIP) for two years. It is due to expire September 30, and the extension buys time for a new president to tackle health reform and begin to streamline the government’s wastefully-siloed health spending programs, including Medicaid, CHIP, and ObamaCare.”

Nobody should want CHIP to be subjected to hostage taking and political games.

Third, although Baer advocates in favor of the increased 23 percentage point increase in the federal matching rate for CHIP that the bill protects, the downside to that policy is that it brings a number of states to the point of a 100 percent federal payment for CHIP’s operation, including for administrative costs.

Consequently, while the State of Mississippi already has an enhanced federal medical assistance percentage (E-FMAP) of 81.51 percent in CHIP, the scheduled 23 percentage point bump raises the federal matching rate to 100 percent for Mississippi and another 10 states.  A number of other states would have their federal rate raised to a point where there would be a very small state match or even make money, if you factor in provider taxes that bring revenue to states. That has the effect of driving up the cost of CHIP’s extension.

According to the Congressional Budget Office, this increase in the federal matching rate costs the federal government billions of dollars each year in order to offset the dramatic decline in state funding for CHIP. That will make an extension more difficult in 2017 because of the need to find budgetary savings to offset this added spending.

Fourth, a clawback or budget gimmick was inserted into CHIP just hours before final passage of H.R. 2 that shortchanges even the bill’s two-year extension of CHIP. This clawback raids funding dedicated to children’s health coverage in 2018 and returns those dollars to the Federal Treasury in order to ensure the CHIP provisions in the bill are held below 2.7 percent of the overall spending level in H.R. 2. Again, in 2017, restoring the 2018 funding raided by the clawback will either cost more money or Congress will have to extend the budget gimmick into later years.

Fifth, reports by Wakely Consulting Group, the Government Accountability Office, the Urban Institute, and Medicaid and CHIP Payment and Access Commission all have shown that millions of children will either lose coverage or be left worse off if CHIP were not extended.

Nobody credibly believes or even suggests that Congress will enact a series of improvements to the Affordable Care Act (ACA) exchange plans to ensure coverage is comparable to CHIP in two years, and so, CHIP will need to be extended again in 2017 just to maintain the status quo. Congress should not gamble with the health of our nation’s children by unnecessarily subjecting CHIP to another extension in two years.

Therefore, although questions on strategy are far from clear and often grey, we should, as Chang says, continue advocating for what is best for children now. One reason is that the problem with children’s advocates is rarely that we are too aspirational. More often, it is that we are too accepting and have too little self-confidence that the issues we are pushing actually resonate with policymakers. We have witnessed children get shortchanged by Congress so often that it is widely accepted as a fait accompli in the community. That must end.

Chang, for example, recognizes that “even though kids comprise almost 25 percent of our population, they receive less than 10 percent of the federal budget.” For some, that argues for playing defense and undervaluing the resonance that a children’s program like CHIP has with the public and policymakers. But, in the case of CHIP, that presumption is false. CHIP is strongly supported by the American people (74-14 percent in an American Viewpoint poll), the nation’s governors (both Republicans and Democrats), and the Democratic Caucus in the Senate.

Unfortunately, there is already an enormous push to make sure no amendment can pass in the Senate, so that H.R. 2 can be sent to the president and be signed into law as soon as possible. According to Tom Nichols at the American Hospital Association (AHA), “With respect to CHIP, we would all like four years. But to reopen the whole package I think is a big mistake and I don’t see it happening.”

Nichols may be right that it is unlikely to happen. Passing an amendment to merely extend CHIP for four rather than just two years may not be feasible in the Senate because it would certainly be a hassle to send the modified bill back to the House, but that does not make it a “big mistake.” To those of us at First Focus Campaign for Children, we should try anyway because extending health coverage for millions of children is worth such a hassle and doing so now is less of a hassle than having the battle all over again in 2017.

In fact, CHIP would have been repealed and millions of children would have been left worse off if CHIP advocates had heeded that very same call to avoid the hassle in 2009. At that time, the House of Representatives, with the support of groups like the AHA, supported repealing CHIP as part of health reform.

A number of groups argued that children would either be better off by the House’s action or that the “greater good” in health reform was more important than CHIP, but child advocates argued that health reform and improving child health was not incompatible. Consequently, we supported an amendment by Senator Jay Rockefeller that saved both CHIP and health care coverage of millions of children from being put at risk.

Certainly, Baer is right that child advocates should not allow the perfect to be the enemy of the good. We must also be practical and know when successful defense is a win. For example, the upcoming budget fights in Congress in opposition to efforts to significant cut both Medicaid and the Supplemental Nutrition Assistance Program (SNAP) would both be victories.

However, we must never forget to keep our focus on the aspirational for our children. While others may be quick to sell kids short and embrace the “acceptable”, the status quo, or even a position that leave children worse off in the pursuit of the “greater good,” our nation’s vulnerable children need policy change and champions that error on the side of aspiration and the pursuit of what is in their best interest. In a nation where 1 in 5 children live in poverty, children need positive change and not merely the status quo.

According to Eugene Steuerle, Congress has set in place a series of budget priorities and a debt that will apply pressure to reduce spending “on the very types of programs on which children rely – domestic discretionary programs such as education that do not grow automatically.”

As a result, based on recent budget projections, Steuerle finds that:

“Children’s programs will be among those hit the hardest. Children’s spending will fall sharply as a share of the economy, from 2.2 percent of GDP in 2012 to 1.8 percent in 2023, pushing spending on children below pre-recession levels. In 2017, Washington will start spending more on interest payments than children.”

If we can agree on anything, it would seem that both political parties could at least acknowledge that we reached a place of clearly misplaced priorities if we will soon be spending more money on interest payments on the federal debt than investing in our children.

We must do better by our kids than mere acceptance of the status quo. There is simply too much at stake.

Is Acceptable Really the Best We Can Do for Our Children? v/ @brucelesley in @First_Focus blog | #ExtendCHIP 4 years
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