‘Skinny Repeal’ Bill Would Put Medicaid for Children and Families at Risk (Part 2)

Last night I wrote a blog about how Medicaid is clearly not protected in a “skinny repeal” even though there are no direct changes in what’s reportedly being contemplated because it is merely a tool to get to substantial Medicaid cuts later.

But here is another risk. The Congressional Budget Office’s score of how Medicaid would be impacted by a version of “skinny repeal” was released yesterday and it estimates a cut of $220 billion over ten years and a Medicaid coverage loss of 7 million people over ten years with 3 million happening in the second year. Why would that be since there aren’t any Medicaid provisions in “skinny repeal”?

There isn’t CBO text to explain this that I have seen. But based on CBO’s other work, I think their estimate goes there because the bill repeals the individual mandate, and that this (and possibly other things) would contribute to lower Medicaid participation rates over time.

This is something that I have been meaning to blog about for a few weeks now –– the “unwelcome mat” effect. The “unwelcome mat” effect will result in fewer children and families having Medicaid coverage because participation rates in Medicaid will start moving in the opposite direction and start going down. I have already been of the mind that even if Congress does nothing to repeal the ACA there will be an “unwelcome mat” effect because of all of the talk of repeal and other factors.[1]

Readers of SayAhhh! know very well that the majority of uninsured children are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) but are not currently enrolled. This comes as a surprise to many people though. The latest estimate from the Urban Institute which tracks Medicaid/CHIP participation rates found that 57% (2.1 million kids) of uninsured children in 2015 fell into this category – a substantial decline of 40% from 2013. Children’s Medicaid/CHIP participation rate rose to an all time high of 93% as the uninsured rate for children fell to a historic low of just under 5%. [2] And yes the two are closely related!

Parents’ Medicaid participation rate is lower but also went up from 72 to 80% – with sharper increases in Medicaid expansion states. But even in non-expansion states, some parents are eligible for Medicaid and their participation rates went up.

Readers of SayAhhh! know as well that covering parents through Medicaid expansion results in more children having coverage.  But even states that didn’t expand Medicaid have seen a welcome mat effect because of the assumption that everyone should have a path to coverage (even if not directly subject to the individual mandate) that was an underpinning of the Affordable Care Act, not to mention outreach for new marketplace options that covered parents who then discovered their children could get Medicaid or CHIP.

Last night when Senator Heller offered his “Sense of the Senate” Medicaid amendment he talked about this very phenomenon working for children! He said:

In fact, Nevada has seen one of the most significant decreases in uninsured children in the country. 

In 2013, our state had the highest rate of uninsured children in the country. We were ranked 50th in the nation. Now I can proudly say that Nevada is the most improved state when it comes to addressing our rate of uninsured children. Our state had made significant progress since the state’s decision to expand Medicaid, and that has made an impression on me.

I believe he was using data from our most recent report on uninsured children where we did indeed find that Nevada was the most improved state with respect to decline in uninsured rates for children – going from a whopping 15% in 2014 to 7.6% in 2015. This is not because children by and large became eligible for something new as a result of the ACA. It is because enrollment in Medicaid for already eligible children went up. During this time period the Urban Institute report estimates that Nevada’s participation rate for children went from 74% to 88% — again the largest jump in the country which is closely correlated with the decline in uninsured children and families.

This effort to reduce the number of uninsured children and families by improving their participation rates has been multi faceted and bipartisan across the country – with outreach campaigns, enrollment simplification steps, and other policy changes – in short a successful effort to put out the welcome mat for families. Studies show that families are very satisfied with their Medicaid coverage, but oftentimes they don’t realize they are eligible or children have dropped off at renewal. Many of you reading this blog have likely been working on this for years. But current Congressional action threatens this progress.

Editor’s Note: Read Joan Alker first blog on the “Skinny Repeal” to learn more. 

[1]Also the Trump Administration has 1) pulled back CMS outreach efforts for the marketplace and 2) created a hostile climate for immigrant families which may inhibit parents who are not citizens from enrolling their children who are.

Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy.