States around the country, including Pennsylvania, face notifying millions of working class and special needs families that their children may soon lose their health care coverage.
The problem: a politically locked Congress.
Little has changed since Congress missed a Sept. 30 deadline to extend funding for the Children's Health Insurance Program (CHIP), a 25-year-old program that pays for health care for nearly 9 million children and 370,000 pregnant women across the nation.
Arizona, California, Minnesota, Ohio, Oregon and Washington, D.C., could run out of money by the end of this month, according to Georgetown University's Center on Children and Families.
New Jersey, with about 113,000 children insured, has money to operate CHIP until sometime this spring, according to a spokeswoman for the state's Department of Human Services.
But Pennsylvania expects to run out of CHIP funds by the end of January. In case the stalemate continues, the Commonwealth's Department of Human Services (DHS) is preparing notification letters for the families of the nearly 179,000 children its program covers.
"We're trying to use the best information we have, and we're trying not to scare families, but we're also trying to do our due diligence and be prepared," said Acting DHS Secretary Teresa D. Miller.
Some political observers blame continued attacks on the Affordable Care Act (ACA) for the missed deadline. Recently, a Republican-led plan to finance CHIP by cutting the ACA cleared the House, over Democrats' opposition.
In Pennsylvania, there is an additional complication.
In October, the state Senate passed a reauthorization bill that would deny CHIP funds for transgender children to have gender reassignment surgery. The state House, for a second time, recently passed a reauthorization bill without the transgender limitation. The matter is now back in the Senate's court.
In 2016, just 34 Pennsylvania children received transgender-related care, including counseling, according to the state. How many, if any, received gender reassignment surgery was not available.
U.S. Sen. Bob Menendez (D., N.J.), blasted congressional Republicans for not quickly reauthorizing CHIP.
"Every day that passes injects more uncertainty into the lives of millions of working families who depend on CHIP to provide kids with the care they need," Menendez said. A bipartisan bill he co-sponsored that would extend CHIP for five years hasn't come to the Senate floor for a vote.
Meanwhile, concern is mounting. This week, Colorado mailed out warning letters to its CHIP families, advising them to look into other coverage options in case the program isn't renewed by the end of January.
Also this week, the National Governors Association sent a letter to the majority and minority leaders of both houses of Congress, urging "immediate action" on funding for CHIP and the community health center and home visiting programs that also expired on Sept. 30.
If CHIP is not renewed, families will have to look for other alternatives. Often families in the program are not poor enough to qualify for Medicaid but can't afford other options, like ACA coverage, which requires them to pay. Working families may not have employer-provided insurance for their children.
Despite the uncertainty, Pennsylvania's CHIP enrollment has actually increased in recent months, suggesting how important it is to families, said Miller.
"This is a program that has enjoyed bipartisan support for years," Miller said. "I cannot figure out why on earth we're playing politics with kids' health care."