By Gene Lewit, The David and Lucile Packard Foundation

Children with health insurance coverage start off life on the right foot: they are healthier, miss fewer days of school and their parents and guardians miss less work. Happily, recent efforts to grow and strengthen Medicaid and the Children’s Health Insurance Program have extended coverage to more children than ever before. Part of the excitement generated by the Patient Protection and Affordable  Care Act (ACA) is that it promises to reduce the number of uninsured children even further and extends coverage to parents so that children can be covered in the context of their families which will strengthen families and holds the promise of simplified administration and improved health outcomes. But as a recent front page article in the New York Times observed, we live in a very different America “from the 1950s when the TV characters Ozzie and Harriet were a national archetype”.

A new Packard Foundation-funded Research Brief from the Urban InstituteAddressing Barriers to Health Insurance Coverage Among Children: New Estimates for the Nation, California, New York, and Texas, raises concerns about the challenges some children may face in obtaining health insurance coverage as a result of the complexity of modern family situations and the way in which child and family coverage options are structured. For example, complex coverage scenarios (potential mismatches between family characteristics and program characteristics) arise when children are eligible for Medicaid or CHIP but their parents are not, or when children live in households with at least one absent parent (single parent households, grandparent or other kinship care arrangements, etc.).

Top line findings include:

  • More than half of American children may face at least one complex coverage scenario under the ACA.
  • An estimated 18.7 million children will be eligible for Medicaid or CHIP but their parents will not be eligible for such coverage.
  • An even larger group of children, 27.7 million, live in households with at least one absent parent.
  • Children facing at least one complex coverage scenario are currently much more likely to be uninsured than other children and account for 62 percent of all currently uninsured children.
  • The uninsured rate for children not in a complex coverage scenario is 7.1 percent vs. a rate of 11.7 percent for children with at least one absent parent.
  • 76 percent of Medicaid/CHIP eligible uninsured children are in complex coverage scenarios.

More detailed data are presented in the brief. Since states will lead the implementation of the ACA, the brief also presents estimates for California, New York, and Texas, states with large juvenile populations but different rates of uninsured children and health policy environments.

Because so many children will find themselves in these complex scenarios, it is important to implement regulations, policies, programs, and strategies which explicitly address some of the potential barriers to coverage in order to maximize the benefits of the ACA for children. Families will need to be educated about the changes well in advance and oriented to their new coverage options. States have important roles to play and should use data and input from parents, outreach and enrollment providers and others involved to determine the best way to address these issues in their states.

Even though there is some uncertainty over the future of the ACA, the data in this new brief highlight that now is the time to pay attention to these issues. A large proportion of currently eligible but uninsured children are facing these complex coverage scenarios.  As a result, policymakers can feel confident that the payoff to a focus on these children will be immediate and lasting regardless of the resolution of current uncertainties over ACA implementation.

Most American children face at least one complex coverage scenario, which means we have to design coverage programs with this norm in mind. ACA implementation provides the perfect opportunity for public policy and practice to reflect the new norm when it comes to covering children and their families.

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