When Alice Mayall rushed her daughter Hannah to the hospital for a head injury after a water polo tournament a few years ago, she didn’t think twice about whether she could afford it. Her daughter was covered by the Children’s Health Insurance Program.

Mayall is a self-employed psychologist in Livermore, in the Bay Area, and the mostly federally funded program has helped her get through tough economic times over the years by insuring her twins. It has kept her kids healthy when she needed to give up work hours to be at home with her son Owen, who is autistic.

“What ends up being an ongoing issue with any of these publicly funded programs is the uncertainty, especially with what is going on right now,” she said.

She was referring to the question of whether Congress will reauthorize funding for CHIP, a program that covers more than 1.3 million California children, including hers, but now hangs in the balance. Federal funding expired in September, and state officials are considering what to do if Congress doesn’t act soon—perhaps this week. Coverage for about 32,000 residents is at risk most immediately.

CHIP has benefited from bipartisan support since its inception in 1997, and lawmakers from both sides of the aisle in Washington say they want to renew it. But there’s been disagreement over where the money should come from, and Congress has lately been focused on the tax overhaul.

CHIP covers children and pregnant women in families that earn too much to qualify for Medi-Cal, the federal and state health care program for California’s lowest-income residents, but not enough to afford private insurance. These families earn between 108 percent and 266 percent of the federal poverty level, up to about $65,000 for a family of four, depending on the children’s ages.

Without congressional action, California expects its federal funds to run out by early January, if not sooner, leaving state officials to figure out how to make up the difference, which could involve taking money from other programs.

“It’s a Sophie’s choice we shouldn’t have to make,” said Anthony Wright, executive director of Health Access California, which advocates for consumers. “Part of the evil genius of this is that the cuts show up at the state level and forces state lawmakers to make tough choices.”

California received $3.1 billion from the federal government for the program for the last federal fiscal year, which ended Sept. 30. Those funds make up 88 percent of the costs, said H.D. Palmer, spokesman for the Department of Finance. The state picks up the rest, about $734 million.

Families in some other states have begun receiving notices that their insurance is going to end. But not in California.

When California expanded Medi-Cal under the Affordable Care Act in 2014, it rolled in nearly all CHIP recipients for administrative purposes. The state agreed with the federal government to keep them enrolled through September 2019.

The remaining 32,000 are in families with slightly higher incomes—up to $79,000 for four—and would no longer be eligible for any publicly funded coverage if CHIP, which in California used to be called Healthy Families, were eliminated. This group includes recipients in three county programs, in San Francisco, Santa Clara and San Mateo Counties, said Anthony Cava, spokesman for California’s Department of Health Care Services.

If the state decides to continue covering them, its options include absorbing all of the costs or helping the families pay for insurance on the Obamacare exchange, according to Wright.

What it would cost to cover the majority of the 1.3 million recipients if Congress demurs is unclear. Palmer noted that the state could be on the hook for the entire $3.1 billion that Washington had been providing if California is required to maintain most of its current coverage, or the federal government could agree to pay half, as it does for regular Medi-Cal patients.

“The worst-case scenario is that the kids still stay in Medi-Cal and we do the 50/50 match,” said Democratic state Sen. Ed Hernandez of Azusa, chairman of the Senate Committee on Health. “I believe we need to make sure these children are insured. I can’t imagine that we would not make up the difference.”

The Legislature anticipated a cut in the federal funding and budgeted an extra $396 million for CHIP through June 30, which could allow the program to limp along until the next budget is worked out in mid-2018, Hernandez said. Gov. Jerry Brown will give the Legislature his proposal for that budget by January 10. It is likely to contain possibilities for CHIP funding, especially if Congress’ intentions remain murky, Palmer said.

Hernandez said that if the state has to fund the program, “then something else has to suffer.”

The state could reduce the cost by altering eligibility requirements for adults, lowering payments to doctors, hospitals and other health care providers or changing the menu of benefits, said Kelly Hardy, senior managing director of health policy at Children Now, a research and advocacy organization. She said none of those are great options.

However, she said, “the state has made a commitment toward a culture of coverage. I would be really surprised if the state went back on that promise.”

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