Tiene 15 años y vive con su novio. Él quiere tener hijos, y dice que no usará protección. Ella dice que lo ama. Pero no quiere quedar embarazada: sabe cuánto más difícil sería terminar la escuela secundaria.

En muchas escuelas, esta joven solo habría recibido algunos consejos de una enfermera escolar. Pero aquí, en Anacostia High School, en Washington, DC, recibe algo más de la partera Loral Patchen.

Patchen le pregunta sin dar vueltas qué va a hacer al respecto. Porque uno de estos días, la prueba dará positivo.

La partera le explica una variedad de métodos anticonceptivos. Hay una inyección que se aplica cada pocos meses, el Dispositivo Intrauterino (DIU), o un implante pequeño que se coloca en el brazo, lo que puede prevenir el embarazo durante años. Y, por supuesto, están las píldoras anticonceptivas. La estudiante elige las píldoras, y sale de la oficina de Patchen con un suministro de un mes, y con una orden permanente para renovaciones a través de la clínica escolar.

La esperanza es que esta interacción signifique un embarazo adolescente menos en la ciudad. En el vecindario de Washington, D.C. en donde vive esta estudiante, su probabilidad de quedar embarazada es casi tres veces mayor que el promedio nacional.

Si bien las tasas de embarazo adolescente en general a en la última década, siguen siendo altas en algunas comunidades. Las tasas para las adolescentes afroamericanas y latinas es aproximadamente el doble que la de las blancas no hispanas, y las tienden a tener tasas más altas.

El programa de parteras de Anacostia High School es un enfoque novedoso que promete enfrentar el problema.

Patchen ha estado tratando de combatir las tasas de embarazo adolescente de la ciudad durante 20 años como fundadora de en MedStar Washington Hospital Center. Contó que estaba contenta de los logros, pero quería acceso directo a las jóvenes que la necesitaban. Su organización recibió de la aseguradora CareFirst BlueCross BlueShield para comenzar a trabajar en dos escuelas. Ahora, Patchen es una de las pocas parteras escolares en el país, dijo.

“Es mucho mejor ir a donde está la necesidad, en lugar de sentarse y esperar que la necesidad venga a uno”, dijo.

Y su función va más allá de proveer atención prenatal para las cinco a ocho estudiantes embarazadas que reciben atención en la clínica de la escuela cada año. Estar en la escuela le da la oportunidad de ayudar a prevenir embarazos en primer lugar. “No hubiera visto a estas jóvenes en ningún otro entorno, no fácilmente”, dijo.

Como partera de la escuela, Patchen puede ser un recurso informal y confiable para contestar las preguntas de las estudiantes sobre sexo, anticoncepción y relaciones.

“Me encanta cuando estoy caminando por el pasillo durante el almuerzo porque veo gente y me reconocen”, dijo Patchen. “Y vienen a hacerme una pregunta y traen a sus dos amigas. Y hablamos sobre el uso del condón o un efecto secundario de un método en particular”.

Si estuviera en un hospital, viendo a las jóvenes solo cuando ya están embarazadas, nunca tendría este tipo de interacción, dijo Patchen. Además, la información que les brinda se extiende a sus círculos de amigos.

En la escuela, el horario de Patchen es flexible para dejar espacio para interacciones informales y citas no establecidas, junto con sus citas regulares con las estudiantes.

Cuando llega un estudiante, Patchen puede ofrecer asesoramiento y opciones inmediatas. Si una estudiante decide que quiere un DIU, Patchen puede colocarlo en el acto. Puede recetar píldoras anticonceptivas y luego entregarle un paquete a la alumna.

La subvención de CareFirst paga los servicios y cualquier método anticonceptivo que las estudiantes soliciten, por lo que los estudiantes no tienen que depender de un seguro para cubrirlos.

“Me siento realmente bien con el hecho que ofrecemos la gama completa de opciones y tenemos tasas muy, muy bajas de abandono”, dijo Patchen. Agregando que las estudiantes toman decisiones informadas. En los tres años que ha estado trabajando en Anacostia High School ninguna estudiante que participó en el programa tuvo un embarazo posterior. Y después de elegir un método anticonceptivo a largo plazo como un DIU, el 85% de los estudiantes de Anacostia todavía lo usan un año después.

Patchen también puede evaluar enfermedades de transmisión sexual (ETS), incluida pruebas rápidas de VIH en el laboratorio de la clínica escolar.

También es importante la capacidad de pasar tiempo hablando con los estudiantes sobre sus vidas, desde decidir no tener relaciones sexuales, hasta navegar las relaciones afectivas, agregó Patchen.

Por ejemplo, les pregunta: “‘¿Quién es una buena novia o novio? ¿Qué tipo de persona es? ¿Cómo toman decisiones juntos? ¿Qué haces cuando tienes un conflicto?'”

La otra parte del trabajo de Patchen es la atención prenatal en el sitio para los estudiantes que quedan embarazadas.

El año pasado, una de esas estudiantes fue Kiera, solo usamos los nombres de pila de las estudiantes para proteger su privacidad. Cuando Kiera quedó embarazada, tenía 15 años y estaba asustada.

“Cuando conocí a Loral y ella comenzó a cuidarme durante mi embarazo, me hizo sentir más feliz por ser madre”, dijo Kiera. “Ella me ayudó mucho”.

Patchen dijo que estar en la escuela le facilitó a Kiera visitarla muchas veces durante su embarazo y hablar sobre, por ejemplo, cómo hacerse una prueba de glucosa en sangre o los beneficios de la lactancia, y también sobre su relación con el padre del bebé, D ‘ Monte.

Dado que D’Monte también es un estudiante en la escuela, Patchen pudo hablarles a los dos sobre la crianza de los hijos. E incluso desde que Kiera y D’Monte terminaron su relación, Patchen todavía los ayuda a descubrir cómo mantener un vínculo para que su hija tenga dos padres.

Patchen estaba allí, junto con D’Monte y la madre de Kiera, cuando la joven dio a luz en enero pasado.

“Todo lo que vi fue emoción en la cara [de Patchen]”, recordó D’Monte. “Estaba tan emocionada y tan orgullosa. No puedo decepcionarla”.

La beba ahora tiene 1 año y va a la guardería que está en la misma escuela secundaria. Kiera puede llevarla a la clínica de la escuela cada vez que necesita una cita con el pediatra, o simplemente acercarse a saludarla.

“Me encanta cuando vienen a la oficina porque su hija se está riendo y responde a las cosas y son receptivos con ella”. Y es algo hermoso”, dijo Patchen.

El hecho que se trate de una familia feliz y comunicativa no es casual, dijo Patchen. Hubo momentos de frustración, tiempos de desacuerdo, podría haber salido mal. Pero todos, el equipo de TAPP, el personal de la clínica de la escuela y los padres de los estudiantes, hicieron un gran esfuerzo para hacer lo mejor que pudieran con esta niña.

La partera Loral Patchen quiere ser clara: de ninguna manera está diciendo que el embarazo adolescente es algo grandioso. Pero cree firmemente que una vez que se está embarazada, la estudiante necesita un apoyo real y constante.

“Las jóvenes embarazadas son muy conscientes de toda la condena, la suposición de que fallarán: ‘No podrás. Ahora no puedes'”, dijo Patchen. “Es nuestro mandato asegurarnos que todavía se vean a sí mismas teniendo un futuro y oportunidades. Y eso significa no creer que van a fallar en los próximos 60 años de sus vidas”.

Patchen contó que mucha gente le dice que su tarea suena “terrible”: trabajar con jóvenes que enfrentan el desafío de lidiar con la maternidad y la escuela secundaria al mismo tiempo. Ella aclaró que esa no era su experiencia.

“Mi día en el centro de salud escolar es lo más destacado de mi semana”, dijo Patchen. “Veo a las jóvenes ser valientes. Y veo gente dispuesta a descubrir cómo hacer cosas realmente difíciles. ¿Qué es mejor que eso?”.

Patchen quiere más -más días en la clínica de la escuela, más escuelas en el programa, más personal- para satisfacer la necesidad que ve todos los días. Piensa que ésta es una de las pocas intervenciones que podría tener un impacto directo en reducir la alta tasa de embarazos adolescentes entre las jóvenes del distrito.

Esta historia es parte de una alianza periodística de NPR con Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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She’s 15. She lives with her boyfriend. He wants kids — he won’t use protection. She loves him, she says. But she doesn’t want to get pregnant. She knows how much harder it would be for her to finish high school.

At many schools, she would have gotten little more than some advice from a school nurse. But here at Anacostia High School in Washington, D.C., she gets a dose of midwife Loral Patchen.

Patchen asks her bluntly what she’s going to do about it. Because one of these days, the test is going to show a positive.

Patchen talks her through a range of birth control methods. There’s a shot you take every few months, an IUD, or a small implant that goes into your arm, which can prevent pregnancy for years. And, of course there are birth control pills. The student opts for pills, and leaves Patchen’s office with a one-month supply with a standing order for refills through the school clinic.

The hope is that this interaction will mean one fewer teen pregnancy in the city. In the Washington, D.C., neighborhood where this student lives, her chance of getting pregnant is nearly three times the national average.

While U.S. teen pregnancy rates overall  in the past decade, they remain high in some communities. The rates for black and Latina teens is around twice that of whites, and kids  tend to have higher rates.

Anacostia High School’s midwife program is a novel approach that’s showing promise in tackling the problem.

Patchen had been trying to combat the city’s teen pregnancy rates for 20 years as the founder of  at MedStar Washington Hospital Center. She was happy with what they accomplished, but she wanted more access to the young people who needed her. Her organization received  health insurer to start working in two schools. Now she’s one of a handful of school midwives in the country, she said.

“It’s much better to go where the need is rather than to sit back and wait for the need to come to you,” she said.

And her role goes beyond providing prenatal care for the five to eight pregnant students who get care in the school clinic each year. Being at the school gives her a chance to help prevent pregnancies in the first place. “I wouldn’t have seen these youth in any other setting — not easily, anyway,” she said.

As the school midwife, Patchen can be an informal — and reliable — resource for students’ questions about sex and contraception and relationships.

“I love it when I’m walking in or in the hall during lunch because I see people and they recognize me,” Patchen said. “And they come in to ask me a question and they’ve got their two girlfriends with them. And we’ll talk about condom use or a side effect of a particular method or they’ll say ‘I heard …'”

If she were in a hospital, seeing young people only after they’re pregnant, she would never get this kind of interaction, Patchen said. Plus, the information she gives them spreads through their circle of friends.

At the school, Patchen keeps her schedule flexible to leave room for informal interactions and walk-in appointments, alongside her regular appointments with students.

When a student comes in, Patchen can offer counseling and immediate options. If a student decides she wants an IUD, Patchen can insert it on the spot. She can prescribe birth control pills and then hand the student a packet.

The CareFirst grant pays for the services and any contraception the students request, so students don’t have to rely on insurance to cover them.

“I feel really good about the fact that we offer the full range of options and we have very, very low removal rates,” Patchen said. She said that she talks students through the different methods and their adverse effects, and leaves the decision about which — if any — method they want to use. “And if the decision is ‘yes,’ it’s a very informed and well-grounded decision,” she said.

In the three years that she’s been working out of Anacostia High School, Patchen said, no students participating in the program have had a subsequent pregnancy. And after choosing a long-term birth control method like an IUD, 85 percent of Anacostia students are still using it one year later.

Patchen can also test for sexually transmitted diseases, or STDs, including doing rapid HIV tests in the school clinic’s lab.

Just as critical, she said, is the ability to spend time talking with students about their lives — from deciding ²Ô´Ç³ÙÌýto have sex, to navigating relationships.

For instance, she asks: “‘Who makes a good girlfriend or a boyfriend? What is that kind of person? How do you make decisions together? What do you do when you have conflict?'”

The other part of Patchen’s job is on-site prenatal care for students who do get pregnant.

Last year, one of those students was Kiera — we’re using students’ first names only, to protect their privacy. When Kiera got pregnant, she was 15 — and scared.

“When I met Loral and she started taking care of me in my pregnancy, she made me feel happier about being a parent,” Kiera said. “She helped me out a lot.”

Patchen said being in the school made it easy for Kiera to come in many times throughout her pregnancy, and talk about things like getting a required blood glucose test, or the benefits of breastfeeding — and also about her relationship with the baby’s father, D’Monte.

Since D’Monte is also a student at the school, Patchen could talk to them about parenting together. And even since Kiera and D’Monte broke up, Patchen still helps them figure out how to maintain a relationship so their daughter will have two parents.

Patchen was there, along with D’Monte and Kiera’s mother, when Kiera gave birth to her daughter last January.

“All I saw was excitement on [Patchen’s] face,” D’Monte recalled. “She was just so excited and she was so proud. So I couldn’t let her down.”

The baby is now a toddling 1-year-old who goes to the day care on-site at the high school. Kiera can bring her by the school clinic whenever she needs a visit with the pediatrician, or just to say hi.

“I love it when they come to the office because her daughter is laughing and she’s responsive to things and they’re responsive to her. And it’s a beautiful thing,” Patchen said.

The fact that this is a happy, communicative family is not an accident, Patchen said. There were times of frustration, times of disagreement — it could have gone badly. But everyone — the TAPP team, the school clinic staff and the student parents — put in a lot of hard work to do the best they could by this child.

Midwife Loral Patchen wants to be clear: She is by no means saying that teen pregnancy is a great thing. But Patchen feels strongly that once pregnant, a student needs real, steady support.

“Youth that are pregnant, they are very aware of all the judgment, the assumption they will fail: ‘You won’t be able to. Now you can’t.'” Patchen said. “It’s our mandate to make sure they still see themselves as having a future and an opportunity. And that means not buying in to the fact that they will fail with the next 60 years of their lives.”

She said a lot of people tell her her job sounds “dire” — working with young people facing the challenge of dealing with parenthood and high school at the same time. She said that’s not her experience.

“My day at the school health center is the highlight of my week,” Patchen said. “I see young people be brave every single day that I show up there. And I see people willing to figure out how to do really hard things. What’s better than that?”

She wants more — more days in the school clinic, more schools in the program, more staff — to meet the need she sees every day she’s there. She thinks this is one of the few interventions that could have a direct impact on bringing down the high rate of teen pregnancy for these young women in the district.

This story is part of NPR’s reporting partnership with .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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When taken daily by people who are at high risk for contracting HIV via sex or shared needles with someone who is infected, this , or PrEP, can cut the risk of HIV infection by 92 percent, studies show.

PrEP has been around for years now, but only a small portion of those at high risk for HIV infection use it, partly because many still don’t know it exists. The medicine is also quite expensive, for a month’s supply. It is usually covered by insurance, including Medicaid.

To cut the rate of new infections in half by 2020, D.C. health officials estimate the city will need to more than quadruple the number of residents who are on PrEP. The department of health and community groups are pulling out all the stops to raise awareness.

“Thinking about sex? Then think about PrEP,” one public health commercial says, over video clips of a woman sensually licking an ice cream cone, or a man stroking a golf club. You .

There are also social media pushes, and an ad campaign called “PrEP for Her” targeting African-American women, who, along with gay and bisexual African-American men, are at high risk of infection in the district.

At a recent conference in the city on LGBTQ issues, Sarah Fleming stopped by the PrEP information table put together by Ìý´Ç´ÚÌý, a community health center that focuses on providing care to LGBTQ patients.

Fleming told Cebas she’s surprised she had never heard of PrEP. She even got tested for HIV recently.

“They told me nothing about this!” she said. “I was negative — but, I feel like, it’s a preventative, so you should tell people about it.”

 vice president and director of public policy at the , said some health care providers don’t mention PrEP because of their mistaken belief that it would increase risky sexual behavior; research hasn’t shown that to be the case.

Millett added that there are other reasons why people — especially people of color — haven’t requested PrEP as much as he and other public health officials would like. Some African-Americans distrust the medical community because of historical mistreatment, he said. And there’s still a stigma attached to HIV, especially in some minority communities.

“In order to be prescribed PrEP, you need to be ‘out’ to your provider,” Millett said. “And we see that for African-American men, as well as for Latino gay men, they’re less likely to tell their providers that they are gay or bisexual.”

Several cities across the U.S. — including Seattle, Boston and San Francisco, as well as Washington — are making concerted efforts to overcome these challenges and promote PrEP as a tool for reducing HIV transmission, Millett said.

There are signs of progress in Washington. Whitman-Walker Health has seen a recent uptick in new PrEP patients, including 28-year-old Ricardo Cooper, who lives in the district.

Cooper is gay and HIV-negative. He’s been taking PrEP for a few months, and said he hasn’t experienced many side effects,Ìýwhich can commonly include headaches, nausea and cramping. According to the U.S. Centers for Disease Control and Prevention, these side effects tend to .

Cooper said taking the drug gives him peace of mind.

“It just makes me feel so much better about engaging in sexual activity,” he said, knowing that he won’t get or transmit HIV to a partner.

He also has found he now talks more openly about HIV, which still carries a lot of stigma among his friends. He said he even walks up to people at bars and sells them on PrEP.

“The professionals can’t really force PrEP on people, but I can,” he chuckled. “And I’ve done that to my friends. It’s like, ‘You don’t have an option.'”

Cooper said, turning serious, that he’s usually a private person but that to him this is important — he wants to do everything he can to spread the word.

“If I need to be the face of PrEP for this African-American community or the communities that are underrepresented — to let them know that, ‘It’s OK, it’s cool, I mean, you should at least try it,’ then I’m perfectly fine with stepping out of myself and doing that,” he said.

Health providers say this kind of community evangelism — along with the bus ads and sexy commercials — will be key to reaching the ultimate goal of ending the HIV epidemic in Washington, D.C.

This story is part of NPR’s reporting partnership with .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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En un ventoso día de enero, Milton estaba con los asistentes de investigación de pregrado Louie Gold y Amara Fox tratando que los estudiantes se inscribieran en su nuevo estudio sobre . Entregaban vales para la tienda de la escuela, chocolate caliente gratis y letreros hechos a mano.

Milton esperaba que docenas de estudiantes se inscribieran. Para que cuando alguno de ellos se enfermara, fuera enviado a la clínica de la Escuela de Salud Pública, justo al cruzar de la calle.

Ese mismo día, llegó una estudiante enferma, pero no calificó.

“Tenía algunos de los síntomas correctos: tos, un poco de secreción nasal, pero no tenía mucha fiebre”, explicó la , quien la examinó para el estudio. En otras palabras, están buscando al tipo de engripados de los que todos quieren alejarse.

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Si un estudiante está lo suficientemente enfermo, lo envían a una sala con una máquina que parece salida de una película protagonizada por un científico loco, conocida como la “Máquina Gesundheit”.

Durante media hora, el estudiante se sienta ante la máquina. Mientras respira, la máquina recoge cualquier virus presente en .

Luego, los investigadores utilizarán los contactos de los estudiantes para tratar de descubrir cómo se propagan las infecciones de persona a persona.

“Compañeros de cuarto, de estudio, novias y novios”, dijo Milton. “Vamos a tomarles hisopados de saliva todos los días durante una semana para ver si se infectan”.

Si se infectaron, los investigadores tratarán de descifrar si se contagiaron del sujeto original o de otra persona.

“Vamos a secuenciar el código genético del agente viral en profundidad, para ver si fue exactamente el mismo”, explicó Milton. El experto sabe que confirmar que tu compañero de cuarto o tu novio te contagió la gripe puede tensionar las relaciones. Pero bueno, todo sea por la ciencia.

Entornos más seguros

El hecho es que no sabemos mucho sobre el proceso de propagación de los gérmenes, explicó Milton. Por eso, agregó, estamos tratando de entenderlos desde todos los ángulos posibles.

“Estamos midiendo el ambiente en las habitaciones, los contactos, los biomarcadores de sangre, las partículas que se vierten en el aire”, dijo.

“Todos los datos no son solo para nuestra información, sino para poder diseñar espacios en los que las infecciones no se puedan propagar con demasiada facilidad y protegernos de manera más efectiva”, apuntó.

Así es como Milton y su equipo pueden estar cerca de personas enfermas todo el tiempo sin infectarse. Todos se vacunaron contra la gripe, por supuesto, pero Milton fue más allá.

“En la planta baja, por donde ingresan los pacientes, tenemos rayos UV para desinfectar el aire en esas habitaciones”, dijo. Funcionó bien durante su último estudio sobre la gripe. “Ni una sola persona en mi equipo de investigación contrajo la gripe ese año. Aunque vimos a 156 personas, algunas de las cuales perdían hasta 10 millones de copias de virus cada media hora, ninguno se enfermó”.

Milton espera que medidas medioambientales como éstas puedan usarse para combatir virus que son incluso peores que la gripe.

“¿Qué hay de las pandemias y de las nuevas infecciones? ¿Cómo podemos defendernos? “, se preguntó. “Es posible protegerse, incluso si están en el aire. Solo necesitamos entender cómo funciona la diseminación”.

La información que obtienen de este estudio podría, por ejemplo, conducir a mejores sistemas de ventilación que dificultarían la propagación de la gripe y de virus aún más peligrosos.

Esta historia es parte de una alianza que incluye a , y Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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On a blustery January day, Milton was with undergraduate research assistants Louie Gold and Amara Fox trying to get students to sign up for his  on how the flu — and other viruses — spread.ÌýThey had vouchers for the school convenience store, free hot chocolate and handmade signs.

Milton was hoping dozens of students would enroll. And when any of them gets sick, they would be sent to the clinic at the School of Public Health, just across the street from the dorms.

That very day, a sick student did come by, but she didn’t make the cut.

“She had some of the right symptoms: cough, little bit of runny nose, but didn’t have much of a fever,” said , who screened her for the study. In other words, they’re looking for the people whom everyone else wants to stay away from.

Gesundheit!

If a student is sick enough, they get sent around the corner, to a room with a crazy-looking, Rube-Goldberg-like contraption known as the “Gesundheit Machine.”

For half an hour, the student sits in the machine. As they breathe, the machine collects whatever virus they’ve got from the droplets .

The researchers will then use the students’ contacts to try to figure out how infections spread from person to person.

“Roommates, study buddies, girlfriends and boyfriends,” Milton said. “We’re going to swab them every day for a week to see if they get infected.”

If they do get infected, researchers will try to pin down if they got the bug from the original subject, or someone else.

“We’re going to deep-sequence the genetic code of the agent to see if it was really exactly the same thing,” Milton explained. He’s aware confirming that your roommate gave you a horrible flu could ruin some perfectly nice roommate relationships, but it’s for science.

Information For Safer Environments

The fact is, he said, we don’t know that much about the mechanics of how bugs spread. He’s trying to understand it from every possible angle.

“We’re measuring the environment in the rooms, contact, biomarkers from blood, what they’re shedding into the air,” he said.

All the data is not just for our information, but so we can design spaces to keep infections from spreading too easily, and protect ourselves more effectively.

That’s how he and his research staff can be around sick people all the time without getting infected themselves. They all got flu shots, of course, but Milton went further.

“Downstairs where the patients come in, we have upper-room UV to sanitize the air in those rooms,” he said. During his last flu study, it worked. “Not a single person on my research team got the flu that year. Even though we saw 156 people, some of whom were shedding up to 10 million copies per half-hour of the virus, none of my people got sick.”

He hopes environmental measures like these could be used to fight bugs that are even worse than the flu.

“What about pandemics and what about new infections that come along? How can we defend against those?” Milton asked. “It is possible, even if it’s airborne, to protect against it. We just need to understand how it works better.”

The information they get from this study could, for example, lead to better ventilation systems that would make it harder for the flu and even more dangerous viruses to spread.

This story is part of a partnership that includes , and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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One said the federal government had failed to extend CHIP after funding expired in September and the stopgap funding had run out. The program would be shutting down and families would lose their insurance.

The other letter said they could stop worrying because federal funding had finally come through and the program’s future was assured.

Since Monday’s  included a six-year reauthorization of CHIP, enrolled families in Virginia will get that second letter. The program will go on and no children will lose their health insurance.

Taking Stock Of Costs

After months of uncertainty, Nablo said she’s relieved. “Hugely relieved. It’s over and the program is safe, and we can all go back to our normal jobs,” she said.

Preparations to shut down the program in Virginia began over the summer, even before funding expired. Staff spent untold hours gearing up to end the program, retooling enrollment systems, changing contracts and more.

“Those aren’t huge dollar amounts,” Nablo said. “I think the cost more is in the worry from parents.”

CHIP covers children in low-income families — most can’t afford private insurance and their children . Nationally, about  get health coverage through CHIP.

An Unprecedented Situation

In its , CHIP had always been uncontroversial, even . Its funding needs to be periodically renewed, and it always had been taken care of well in advance of the money running out.

CHIP is a match program — states and the federal government split the cost. When states made their budgets for this year, they assumed federal funding for CHIP would be there, so they were blindsided by the funding gap.

Every state’s calculus for how long they could run on leftover money was different. In Texas, Hurricane Harvey . Because of the disaster, it waived fees for CHIP and enrollment spiked, so it had less money coming in and more going out.

A handful of states —  — sent out letters warning families their coverage was in jeopardy because of the uncertainty in Congress.

“One state — Connecticut — did freeze enrollment between the week of Christmas and New Year’s,” said Joan Alker of the Georgetown University Center for Children and Families, which  the past few months.

Virginia’s Nablo said there might be other, more subtle, costs from all the uncertainty.

“I can’t quantify it, but I am sure there are states that held off on things like mounting an outreach program to encourage people to enroll because they didn’t know if the program was going to be there for them,” she said. “There may have been states that were thinking of implementing some efficiencies or innovations, but didn’t because — again — is the program going to be there?”

Six Years Of Certainty

Alker said she is  Congress passed. It’s the same one they , she noted, so she’s not sure why it took a shutdown to finally get it through.

The deal keeps the federal investment in the program at its current level for two fiscal years. After that, the amount that states have to pay for the program will increase.

“At least states now have time to plan for that,” Alker said. “Overall, it really was a fair and reasonable compromise.”

What puzzles her is why it was extended only for six years when the Congressional Budget Office estimated extending CHIP for 10 years would  she said.

“The six-year [extension] is a small saver — it saves just under a billion dollars,” Alker said. “Now there’s nothing preventing Congress from coming back as they move ahead with the bigger budget deal — they could come back and extend CHIP for four more years and grab those savings.”

Impact On Children’s Uninsured Rate

Alker does worry that the months of uncertainty around CHIP may have already caused children to drop out of the program, increasing the uninsured rate among children, she said. That should become clear in the fall, when the Georgetown Center For Children and Families does its annual assessment of the .

If that trend develops nationally, it hasn’t been the case in Virginia, where CHIP enrollment went up this past fall.

“We actually saw a boost in enrollment,” Nablo said. “I can’t really quite explain it.”

Maybe, she said, it was all the attention the unprecedented funding crisis brought to CHIP. A silver lining, perhaps, to many months of anxiety.

This story is part of a partnership that includes , and Kaiser Health News. Selena Simmons-Duffin is a producer at NPR’s “All Things Considered,” currently on an exchange with Washington, D.C., member station WAMU.

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But how did it go for individual consumers shopping for plans this year? Much depended on where you live and what your financial situation is.

In Tennessee, where state regulators approved average rate increases ranging from 20 percent to 40 percent, consumers might have reasonably expected to brace for a big hit to their wallets. But Brenda Linn saw the opposite happen.

Linn had been paying $750 a month in 2017 just to cover her own medical needs; so the retired kindergarten teacher and her husband logged on to HealthCare.gov to check the price of 2018 plans. To her surprise, the website brought up a great deal.

She thought it was a mistake. The price Linn was quoted was less than $5 a month. Why? A slight loss of income had made her eligible for a subsidy for 2018. “Because we didn’t qualify last year, I wasn’t really that hopeful,” Linn said.

But a large majority of marketplace shoppers do get subsidies. And for 2018, on aggregate, these subsidies are larger.

Tony Garr, a volunteer application assistant with the , said more than ever this year, people needed to shop around on the exchange.

“Generally speaking, they will find out that help is there,” he said.

Any many people who got a subsidy in the past found even more for their money this year.

For example, Daniel Prestwood, who is self-employed and cleans fish tanks around Nashville, said he found a better plan for 2018, with monthly premiums that dropped from $300 to $200. He said he tries not to get too frustrated by the political wrangling over health care.

“All I know is that for 2018 I’ll have a good health care plan in place,” he said, “and that’s the best I can hope for at this point.”

And even with the Trump administration’s efforts to , in Tennessee, the number of applications processed by federally funded insurance guides — known as navigators and certified application counselors — surpassed last year’s. With 10 days left in open enrollment, more than 1,200 individuals had applied with official help, eclipsing the total from all of 2016, when the enrollment period was several weeks longer.

While application assistants only work with a tiny fraction of the 235,000 Tennesseans who have marketplace plans, Sandy Dimick of Family and Children’s Services Nashville, said she expects total enrollment will exceed last year’s total, as well.

But many people across the country had a very different experience than Linn and Priestwood.

Gene Kern of Frederick, Md., has been an enthusiastic enrollee in  since it began in 2014. The 63-year-old retired early from Fujifilm, where he sold professional videotape. “When the product became obsolete, so did I,” he said, “and that’s why I retired.”

This fall, Kern said, he received a letter from his insurer explaining that the cost of his policy’s premium would jump from $800 a month to $1,300 in 2018.

“Because of my income, I am slightly above the 400 percent poverty level,” he said, “and as a result I get no subsidy from the government.”

So Kern shopped around on Maryland’s exchange — which announced on Wednesday that it will be open an extra week, through Dec. 22 — and he found an HMO plan for around $900 a month. That’s more than 20 percent of his income, which comes partly from Social Security and partly from his retirement account. But, he said, “It’s the best I can get.” Kern wants to stay insured for the next two years, until he will qualify for Medicare.

, a health insurance broker and analyst in Colorado, said there are a number of people like Kern who earn too much for a subsidy and will pay more for health insurance next year than they did in 2017. “Rates are high,” she said. “There’s no way to sugarcoat that.”

But she warns her clients against the temptation to shop off the exchanges for a less expensive plan that doesn’t comply with the  set out by the ACA.

“It seems like a good deal because it’s cheap,” Norris said. “But then you find yourself being that person who has a heart attack and needs triple bypass. And hundreds of thousands of dollars later you wish you had that ACA-compliant plan.”

While people in states that use HealthCare.gov have until Dec. 15 to sign up,Ìýresidents of nine states (California, Colorado, Connecticut, Maryland, Massachusetts, Minnesota, New York, Rhode Island and Washington) and the District of Columbia have .

This story is part of NPR’s reporting partnership with local member stations and .Ìý, a producer at NPR’s All Things Considered, is working temporarily with NPR member station WAMU, as part of an exchange program at the network. Blake Farmer is the health reporter at .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Casi 9 millones de niños están asegurados a través de , que cubre principalmente a familias de ingresos medios y bajos. El programa cuenta con el respaldo bipartidista tanto en la Cámara de Representantes como en el Senado, pero el Congreso dejó que expirara el financiamiento federal en septiembre.

La National Governors Association al Congreso a volver a autorizar el programa este año porque los estados están empezando a .

En Virginia, Linda Nablo, oficial del Departamento de Servicios de Asistencia Médica, está redactando una carta para los padres de los 66,000 niños inscritos en CHIP en ese estado.

“Nunca tuvimos que hacer esto antes”, dijo. “Cómo se escribe una carta que diga: ‘Su hijo podría perder la cobertura, pero aún no es seguro. Mientras tanto, estas son algunas cosas en las que debe pensar’”.

Los niños pueden inscribirse en el Medicaid, sumarse a un plan familiar en los mercados establecidos por la Ley de Cuidado de Salud Asequible (ACA) o incluirse en un plan de salud del empleador. Pero las opciones varían según el estado y pueden ser muy costosas.

Si el Congreso reautoriza los fondos de CHIP, los estados estarán bien. Pero aún no pueden contar con eso, y tienen que prepararse para cerrar si los fondos no llegan. Virginia tendría que hacerlo el 31 de enero.

“Básicamente estamos haciendo todo lo que necesitamos para cerrar el programa a fines de enero”, dijo Nablo. “Tenemos un grupo de trabajo con todos los diferentes componentes de esta agencia, y hay muchos”.

Por ejemplo, deberán reprogramar sus sistemas de inscripción, informar a los pediatras y hospitales, y capacitar al personal para enfrentar los reclamos y preguntas de familias confundidas.

Joan Alker, quien dirige el Center for Children and Families de la Universidad Georgetown, dijo que la mayoría de los estados deben notificar a las familias con 30 días de anticipación.

“Pero [los funcionarios del estado] están oyendo rumores de que el Congreso podría hacer esto en las próximas dos semanas, y no quieren asustar a las familias”, dijo. “Los estados están realmente en un aprieto. Es muy difícil saber qué hacer”.

Colorado fue el primero en enviar un aviso, y otros estados están muy cerca. Hay un puñado que está empezando a quedarse sin dinero en diciembre, dijo Alker, como Oregon, Minnesota y el Distrito de Columbia.

Es complicado calcular cuál es la fecha exacta en que las arcas de un estado para financiar el programa CHIP quedarán vacías, porque la cantidad de dinero que cada uno tiene depende de cuán rápido lo haya gastado, y de cuánta ayuda adicional haya recibido del gobierno federal.

Algunos estados se están volviendo creativos. Oregon que gastará dinero del estado para mantener al CHIP funcionando, dijo Alker, “y están asumiendo que el Congreso lo aprobará y se le reembolsará retroactivamente”. Eso es lo que esperan”.

Texas se quedará sin fondos de CHIP mucho antes de lo esperado. Y hay una gran razón: el huracán Harvey, dijo Laura Guerra-Cardus, del Children’s Defense Fund en Austin.

“Los desastres naturales a menudo son una forma en que las personas que nunca tuvieron que depender de programas como el Medicaid y CHIP los necesitan por primera vez”, dijo.

Guerra-Cardus dijo que después de Harvey muchas nuevas familias se inscribieron en CHIP y también que hubo una mayor demanda de servicios. “Cuando hay un evento tan traumático, las necesidades de atención médica aumentan. Ha habido una gran cantidad de casos de estrés postraumático en los niños”, dijo.

Y para ayudar a esas familias, los funcionarios de Texas también renunciaron a las tarifas que generalmente tienen que pagar para unirse a CHIP. Por lo tanto, últimamente ha habido menos dinero entrando y más dinero saliendo. Al igual que Virginia, sin reautorización, Texas tendría que cerrar el CHIP a fines de enero.

Es algo a lo que teme mucho Amy Ellis, de Alpine, Texas. “Es algo que me hace perder el sueño”.

Ellis tiene una hija de 8 años que ha estado en CHIP desde que nació. La niña tiene asma y alergias, dijo Ellis, y el seguro de salud es muy importante porque su familia no gana mucho dinero. La medicina para la alergia de su hija es costosa.

Ellis vive en las zonas rurales del oeste de Texas, casi cuatro horas al sudeste de El Paso y “a tres horas de la ciudad más cercana”, dijo.

El aislamiento significa que Ellis no tiene muchas opciones además de CHIP, explicó. Una opción sería inscribir a su hija en el plan de salud que ella y su esposo tienen a través de ACA. Pero Ellis dijo que sería costoso.

“Cuesta $300 a $400 por mes agregarla a nuestro plan, que sería una gran parte de nuestros ingresos”, dijo. “Ese es el dinero que tenemos para comprar comida y gasolina”.

Muchas familias en Texas podrían encontrarse en la misma situación si el Congreso no actúa pronto, dijo Guerra-Cardus. “Esto va a afectar la vida de los niños con necesidades crónicas o de atención médica especiales”.

Aproximadamente 450,000 niños están cubiertos por CHIP en Texas. Funcionarios dicen que le están pidiendo al gobierno federal que les dé dinero para mantener al CHIP con vida hasta febrero.

Pero debido a que los funcionarios deben avisar a las familias con 30 días de anticipación si el programa finalizará, las familias en Texas podrían recibir cartas cerca de Navidad que indiquen que sus hijos están perdiendo su seguro de salud.

Esta historia es parte de una asociación informativa con NPR, estaciones miembro locales y Kaiser Health News. Selena Simmons-Duffin es productora de All Things Considered, de NPR, y está actualmente en un intercambio con la estación miembro de Washington, D.C., WAMU.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Nearly 9 million children are insured through , which covers mostly working-class families. The program has bipartisan support in both the House and Senate, but Congress let federal funding for CHIP expire in September.

The National Governors Association  Wednesday, urging Congress to reauthorize the program this year because states are .

In Virginia,Ìý, an official with the Department of Medical Assistance Services, is drafting a letter for parents of the 66,000 Virginia children enrolled in CHIP.

“We’ve never had to do this before,” she said. “How do you write the very best letter saying, ‘Your child might lose coverage, but it’s not certain yet. But in the meantime, these are some things you need to think about’?”

Children may be able to enroll in Medicaid, get added to a family plan on the Affordable Care Act’s health exchange or be put on an employer health plan. But the options vary by state and could turn out to be very expensive.

If Congress reauthorizes CHIP funding, states are in the clear. But they can’t bank on it yet, and states have to prepare to shut down if the funding doesn’t come through. Virginia would have to do so on Jan. 31.

“We’re essentially doing everything we would need to shut down the program at the end of January,” Nablo said. “We’ve got a work group going with all the different components of this agency, and there are many.”

For example, they will need to reprogram their enrollment systems, inform pediatricians and hospitals, and train staff to deal with an onslaught of confused families.

, who runs the Georgetown University Center for Children and Families, said most states need to give families 30 days’ notice.

“But [state officials] are hearing rumors that Congress might get this done in the next couple of weeks, and they don’t want to scare families,” she said. “States are really in a bind here. It’s very tough to know what to do.”

Colorado was the first to send out a notice, and . There are a handful that are starting to run out of money in December, Alker said, such as Oregon, Minnesota and the District of Columbia.

The exact deadline for when CHIP funding runs out in each state is tricky to calculate, because the amount of money each has depends on how fast a state spends it — and how much stopgap help the federal government gives them.

Some states are getting creative. Oregon  it will spend state money to keep CHIP running, said Alker, “and they’re assuming that Congress will pass it and they’re get reimbursed retroactively. That’s what they’re hoping.”

Texas is set to run out of CHIP funds a lot sooner than was expected just a few months ago. And there’s a big reason for that: Hurricane Harvey, said with the Children’s Defense Fund in Austin.

“Natural disasters are often a way that individuals that never had to rely on programs like Medicaid and CHIP need them for the first time,” she said.

Guerra-Cardus said that after Harvey a lot of new families enrolled in CHIP and that there was also a higher demand for services. “When there is such a traumatic event, health care needs also rise. There’s been a lot of post-traumatic stress in children,” she said.

And to help those families out, Texas officials also waived fees they usually have to pay to join CHIP. So, lately there’s been less money coming in and more money going out. Like Virginia, without reauthorization, Texas would have to shutter CHIP by the end of January.

For Amy Ellis in Alpine, Texas, that’s something she’s dreading. “Losing a lot of sleep,” she said. “Still losing a lot of sleep.”

Ellis has an 8-year-old daughter who has been on CHIP since she was born. The girl has asthma and allergies, Ellis said, and health insurance is really important because her family doesn’t make a lot of money. Her daughter’s allergy medicine is expensive.

Ellis lives in rural West Texas, nearly four hours southeast of El Paso and “three hours from the closest city,” she said.

The isolation means that Ellis doesn’t have many options other than CHIP, she said. One would be enrolling her daughter in the insurance plan she and her husband have through the Affordable Care Act marketplace, but Ellis said that would be expensive.

“It would cost $300 to $400 a month for us to add her to our plan, which would be a huge chunk of our income,” she said. “That’s our grocery money and our gas money.”

A lot of families in Texas could find themselves in the same situation if Congress doesn’t act soon, said Guerra-Cardus. “Kids with chronic or special health care needs, this is going to turn their lives absolutely upside down.”

Roughly 450,000 children are covered by CHIP in Texas. Officials say they are asking the federal government to give them money that will keep CHIP alive through February.

But because officials must give families 30 days’ notice if the program will end, families in Texas could get letters right around Christmas that say their children are losing their health insurance.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News. Selena Simmons-Duffin is a producer at NPR’s All Things Considered, currently on an exchange with Washington, D.C. member station WAMU.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).