Children’s Health Bill Clears House as States Struggle to Keep Programs Afloat

The House passed a bill on Friday that would provide five years of funds for the popular Children’s Health Insurance Program, over vehement objections from Democrats who opposed the way it would be financed.

The vote, 242 to 174, came a month after funds for the program expired.

The Senate plans major surgery on the legislation to avoid the partisan strife that split the House. But some states may have no choice but to freeze enrollment or start to shut down the program before Congress clears legislation to renew funding. No new funds have been available since Oct. 1.

In the House, 15 Democrats joined 227 Republicans in voting for the measure on Friday. Only three Republicans voted against it.

The bill would provide money for the Children’s Health Insurance Program and clinics known as community health centers, which care for low- and moderate-income people around the country. Both programs have enthusiastic support across the political spectrum.

But lawmakers clashed over how to pay for them. To offset the cost, the House bill would increase premiums for Medicare beneficiaries with income of more than $500,000 a year, remove some lottery winners from the Medicaid rolls, and cut $6.35 billion over 10 years from a fund established by the Affordable Care Act to pay for public health initiatives such as preventing diabetes, heart disease, cancer and opioid abuse.

In addition, the bill would end insurance coverage for several hundred thousand people who fail to pay their share of premiums for insurance purchased in marketplaces under the 2010 health care law.

Most people who buy insurance through the Affordable Care Act marketplace receive subsidies to help pay their monthly premiums. Under the law, if they do not pay their share of premiums, insurers must give them a three-month grace period before terminating their coverage. The House bill would reduce the grace period to one month unless a state specified a different period.

The Congressional Budget Office estimates that the government would save nearly $5 billion over a decade because fewer people would have government-subsidized coverage.

Republicans said some people were abusing the longer grace period to skip out of their financial obligations. But Representative Diana DeGette, Democrat of Colorado, said, “Nobody should have to lose coverage in order for others to keep it.”

“Colorado is likely to run out of CHIP funding in January, with termination notices going out to worried families in the next few weeks,” Ms. DeGette said. “Yet here we are with a partisan bill that asks us to pay for low-income children’s insurance on the backs of seniors and the most vulnerable.”

Republicans defended their path to pay for the children’s health program, especially the higher Medicare premiums. It was reasonable to require wealthy people to help defray the cost of care for children from families of modest means, they said.

“When you are making a half-million dollars a year, you can pay a little bit more,” said Representative Tom Cole, Republican of Oklahoma. “Warren Buffett and Donald Trump don’t need the same Medicare program that Ma and Pa Kettle living on Social Security do.”

Democrats, who often seek higher taxes on high-income people, denounced the proposal.

“I’m not worried about whether wealthy families can afford to pay increased Medicare premiums,” said Representative Debbie Dingell, Democrat of Michigan. “But I’m worried that these changes will result in wealthy people abandoning the program in large numbers, which would worsen the risk pool and ultimately increase the cost for middle- and lower-income seniors. It would fracture the universal nature of Medicare and put the entire program at risk.”

AARP, the lobby for older Americans, strongly supports the children’s insurance program, but tried to block the increase in Medicare premiums.

“Higher-income Medicare beneficiaries already pay more in monthly premiums,” Nancy LeaMond, an executive vice president of AARP, said in a letter to House members. In addition, she said, “higher-income seniors have been paying more into the Medicare program throughout their working lives.”

But Representative Greg Walden, Republican of Oregon and the chief author of the bill, said, “We are just asking the wealthiest seniors in America, those making $40,000 a month — not a year, a month — to pay about $135 a month more for their Medicare, so we can fund children’s health insurance for five years.”

Five states — Arizona, California, Minnesota, Oregon and Washington — have received emergency infusions of federal cash to prevent an interruption in coverage of children. But the amount of unused funds available for that purpose is far less than the expected need, and an independent commission that advises Congress warned this week that 29 states “will exhaust all available federal funds” by March unless Congress passed legislation to provide more money.

In the Senate, work on CHIP legislation has been bipartisan from the start. The Senate Finance Committee has voted to provide five years of funds for the program, but it has not specified a way to cover the cost.

The committee chairman, Senator Orrin G. Hatch of Utah, and Senator Ron Wyden of Oregon, the senior Democrat on the panel, have been discussing ways to pay for the bill. They have not reported much progress toward an agreement, but their talks hold more promise than negotiations between Republicans and Democrats in the House.

The Senate is unlikely to take up a free-standing CHIP bill. Funds could be included in a larger piece of legislation, perhaps a sprawling spending bill in December to keep the government open, senators say.

The House bill would send $1 billion in additional Medicaid funds to Puerto Rico as it tries to cope with damage from Hurricane Maria, and the island’s delegate in Congress, Jenniffer González-Colón, a Republican, endorsed the legislation.

Representative Frank Pallone Jr., Democrat of New Jersey, said Republicans had missed the deadline for renewing the children’s insurance program because they “chose to spend the first nine months of this year trying to repeal the Affordable Care Act.”

But Mr. Walden said Democrats were partly responsible because they had requested delays in hopes of finding other ways to pay for the legislation.

“We cannot wait any longer,” Mr. Walden said Friday. “Patients cannot wait any longer. Patients need care. These critical programs need funding. And we must move forward.”