Editor’s Note: This blog originally appeared on the Health Affairs blog.
By Joan Alker, Georgetown CCF and Genevieve M. Kenney, Urban Institute
Following the implementation of the major coverage provisions of the Affordable Care Act (ACA) in 2014, the question arises: “How is the health law affecting uninsured children and their families?” Today, the Urban Institute released two new briefs using the Health Reform Monitoring Survey (HRMS) to begin to answer that question. The bottom line is that between September 2013 and June of 2014, coverage increased for parents, particularly in states that have expanded Medicaid under the ACA, but no coverage changes were yet apparent for children. This early look suggests that the ACA is contributing to coverage gains for parents, which in turn should be beneficial to both them and their children.
The report on children’s coverage from The Urban Institute and the Georgetown University Center for Children and Families found that the uninsured rate for children remained at historically low levels—close to 7 percent–but did not decline further for children under age 18 between September 2013 and June 2014. But, this national snapshot does not capture all of the fluctuations in children’s coverage that may be occurring across the country in particular states–we will have to wait for data from federal data sources to have a definitive assessment of how coverage is changing at the state level. Moreover, there are reasons to believe that coverage for children will grow in future years under the ACA – particularly if current levels of Medicaid and CHIP eligibility are maintained. Because the majority of uninsured children appear to be eligible for Medicaid or CHIP coverage but are not currently enrolled, the Medicaid and CHIP programs have the potential to drive further reductions in the uninsured rate among children.
Why didn’t the number of uninsured children go down in a noticeable way over this time period? Due to the success of Medicaid and CHIP over the last several decades, children’s uninsured rates were already at historic lows, making it more difficult to move the needle further for children as compared with adults. In addition, there were a number of obstacles to enrollment in this start-up year as states and the federal government transitioned to new IT systems and adapted to changes in eligibility such as the conversion to a new income standard (known as MAGI). Also, the potential “welcome mat” effect, wherein coverage expansions to parents lead to increased take up of coverage among their children, was not as strong for uninsured children as anticipated since four of the six states (Florida, Georgia, North Carolina, and Texas) with the largest number of uninsured children have not yet elected to expand Medicaid for parents or other adults. Looking ahead, as IT systems and the interface between marketplace and Medicaid/CHIP enrollment improve, we expect that enrollment in Medicaid and CHIP will increase among eligible children in the coming year.
This report also found that uninsured children are more likely to have health care access problems and unmet health care needs. They are also less likely to receive preventive care than insured children. In fact, uninsured children were nearly 27 percentage points less likely than insured children to have received a routine checkup in the past year.
The second report by The Urban Institute examined changes in uninsured rates for parents between September 2013 and June 2014. For those parents who live in Medicaid expansion states, the uninsured rate fell by about 33% while the uninsured rate was basically unchanged for parents living in states that have not yet expanded Medicaid. While there are a variety of factors that likely contribute to this differential, including differences in the structure of the new health insurance marketplaces and the outreach actions of states, it is striking how much stronger the health insurance coverage gains were for parents in states that expanded Medicaid. Nationally, most of the gain in insurance coverage was among parents in the low- and middle-income groups targeted by the ACA’s Medicaid and Marketplace coverage provisions.
Who are the uninsured parents who have not yet been helped by the new health law? Nearly half of the parents who remained uninsured in March or June 2014 lived in the South and over 60 percent lived in a state that had not expanded Medicaid. More than half were Hispanic. About 17 percent said they were in fair or poor health and 18 percent reported that they had had poor mental health days for one third of the prior month or more.
Research has shown that children thrive when their parents are healthy and economically secure so improvements in health coverage for parents benefit the whole family. For example, depression in parents has been shown to pose risks to children’s cognitive, socio-emotional, and behavioral development, especially early in childhood, and is linked to health and mental health problems for children as they grow. Prior coverage expansions targeting parents have also been found to increase children’s enrollment in Medicaid and CHIP.
The Affordable Care Act holds great promise to improve the lives of uninsured parents and children. These issue briefs serve as progress reports on how well our nation is doing in delivering on that promise. They contain important insights for policymakers on how decisions regarding the enrollment and re-enrollment processes, particularly for Medicaid and CHIP, and whether or not to expand Medicaid could be affecting families. They also underscore the importance of ongoing monitoring of health insurance coverage for children and their parents as the implementation of the ACA continues to evolve.