By Catherine Hess, NASHP

As the National Academy for State Health Policy’s (NASHP) recent webinars The Future of CHIP and Children’s Coverage and Keeping a Focus on Children in Health Care Reform conveyed, the Affordable Care Act (ACA) includes boosts for children’s coverage but raises myriad questions and issues.  The country has achieved tremendous progress in reducing the uninsured rate for low-income children, from 23 percent in 1997 to 10 percent in 2010.  The ACA extended CHIP funding to 2015, required maintenance of effort for children’s CHIP and Medicaid coverage to 2019, and created the opportunity for parents to obtain affordable insurance through Medicaid or health insurance exchanges. These and other provisions offer potential for continued progress in assuring that all children have access to quality health coverage—one important ingredient in the formula for their healthy development.

At the same time, the fact that the health care reform law focused primarily on insuring adults poses many specific challenges in terms of how it will work for children.  Our brief Keeping Children’s Coverage Strong in the Context of the Affordable Care Act: Perspectives from State Children’s Health Insurance Leaders identifies key areas for policymakers’ consideration. In addition to the need to maintain gains in children’s coverage, the brief highlights reform issues specific to children and families.  Some relate to the affordability of exchange health plans for families with children, because of the way the affordability test works, or because they may pay multiple premiums. Another key consideration from the perspective of states is the need to support flexibility in developing innovative strategies to integrate children’s coverage with new policies and systems. Finally, the brief emphasizes the importance of continuing to provide strong state and federal support for Medicaid and CHIP coverage for children. Keeping current programs strong will be especially important while new, untested systems are launched and the bugs worked out over time.

The work of Jenny Kenney and Stacey McMorrow of the Urban Institute, highlighted in our webinar on Keeping a Focus on Children in Health Care Reform, has shed light on the complexities of coverage for many children and families.  Roughly 40 million children live apart from one or more of their parents, or are eligible for different types of coverage than their parents.  These children make up nearly two-thirds of uninsured children and more than three-quarters of Medicaid or CHIP eligible children.  This data underscores the need to work on integrating Medicaid, CHIP and exchange eligibility. Other strategies, such as robust child-only plans offered through exchanges, also could help address these situations.

States also need to plan effectively for children moving from CHIP to Medicaid and vice-versa. These shifts will result from changes in eligibility in the ACA, or possibly as a result of changes some states may make prior to the 2014 launch. New York is moving CHIP children who clearly will be Medicaid eligible come 2014 in advance of that busy launch date. In the process, the state will be able to plan and test procedures for moving children from one program to another, as well as assess the implications. Responding to tough budget situations, California and Alabama are planning to end their separate CHIP programs, offering children the potential of richer benefits but raising concerns about the strain on provider capacity and willingness to serve more Medicaid clients.

On top of these thorny implementation and budget challenges affecting children’s coverage, now comes the recent Supreme Court decision. As NASHP Executive Director Alan Weil wrote in a recent Health Affairs blog, Decision Time for States On The Affordable Care Act, the Court’s upholding of the law leaves states with important decisions to make. These choices too will have a significant impact on children’s coverage. Even the time and analytic resources some states now will devote to assessing their new choice with the Medicaid expansion will add yet one more competing demand on strained state officials. With ranks thinned by recessionary belt-tightening, all states are challenged to keep a focus on progress in Medicaid and CHIP coverage for children while simultaneously addressing the ACA and other policy concerns.

Of particular importance to low-income children is how state decisions on the Medicaid expansion affect coverage for their parents. The Center for Children and Families, with Urban Institute researchers, has determined that an estimated 4.9 million parents could become eligible for Medicaid coverage under the ACA.  Most of these parents have children eligible for Medicaid or CHIP. We know that not only does coverage for parents benefit their own access and use of health care, but it also benefits their children. Covering parents is associated with increased coverage for children, and improved parental health has positive effects for child health.

So, as the days of decision making and planning culminate in the dawning of new coverage opportunities and systems, do you know how these decisions and plans will work for children?  Maintaining and building on the tremendous gains we have made in insuring our children demands that we take the implications for children into account.