Will Congress Leave Children Out in the Cold?

The first snow fell in Washington this past weekend. As I felt the chill in the air, I thought about the millions of children who get their health coverage under the Children’s Health Insurance Program (CHIP). For many of these children, the mercury is about to plummet. Federal CHIP funding expired September 30, but here we are, more than two months later, and Congress still has not extended funding for the program, other than to apply a temporary patch through December 31. That’s left states in a serious bind: Without the resources to continue offering coverage, honoring contracts and paying providers, states are obligated to begin dismantling their programs. That means advising families that their child’s coverage may be terminated, a step Colorado already has taken. Some states also will have to impose a CHIP freeze, meaning the state will stop enrolling new applicants.

Children have been left out in the cold before. Although the precipitating circumstances were different (state budget pressures, rather than a lack of federal support), Arizona froze CHIP enrollment in 2009, and six other states — Alabama, Colorado, Florida, Maryland, Montana and Utah – had done so years earlier. In a report published in 2003 by the Kaiser Commission on Medicaid and the Uninsured, my colleague, Laura Cox, and I described the conditions in those six states and included additional findings from North Carolina, which had frozen CHIP two years earlier. While some may say that families now have options that were not available in the past, such as access to health coverage through the marketplace, we’re skating on thin ice if we don’t recognize that CHIP benefits are tailored for children in ways that marketplace plans are not, and that CHIP offers families with limited incomes important cost-sharing protections. In fact, the experiences of the past are relevant today.

Our investigation revealed that:

  • A CHIP freeze can impose serious hardship for children and families. The North Carolina freeze left many children uninsured, and families confronted significant struggles when they tried to find care for their children, especially when they needed medication. During the freeze, many were forced to delay visits to the doctor or dentist, and families said they had to put off paying rent or utility bills, and even go without sufficient food. Some families incurred substantial medical debt that they were still trying to pay off years later.
  • State choices about how to implement a freeze can inflict greater challenges on particularly vulnerable children or shortchange others. For example, families could retain coverage for their children as long as they renewed their eligibility and paid required premiums on time. Children in families that were not able to complete the renewal process or fell behind on premium payments lost coverage and were treated as new applicants if they tried to reinstate their eligibility. As a result, children from families with higher incomes might keep their coverage, while children in families with lower incomes found themselves on the outside looking in. Similarly, babies born after the effective date of the freeze, or children with special health care needs who applied for coverage after the freeze, were iced out of coverage, despite having more intensive medical needs than some children who remained covered.

    Some states placed eligible children on a CHIP waiting list. When slots opened up, children on the waiting list could enroll. However, in states that had adopted the 12-month continuous eligibility option – which guarantees coverage for a year, regardless of changes in family circumstances – some children were denied a full year of coverage because the 12-month period was considered to start when the eligibility determination was made. If a child was admitted to the program after seven months on the waiting list, she got only five months of continuous coverage rather than the full year.

  • If not carefully crafted, public messages about a freeze can generate an overall chilling effect that undermines families’ faith in CHIP. In some states, newspapers carried headlines such as, “Door Closes on Children Who Lack Medical Coverage” or the program “Refuses New Patients.” These powerful, unwelcoming messages led many families to conclude erroneously that applying or even inquiring about the program was not worthwhile. Some states sent notices to families when enrollment opened, encouraging them to come back, but others left it to families to keep checking the program websites on their own. The decline in CHIP applications, even after the freeze lifted, suggests that families lost their trust in the program and this had ramifications into the future.
  • Children eligible for Medicaid may lose access to care during a CHIP freeze. While states are not allowed to freeze or cap Medicaid, a CHIP freeze can end up blocking the path to Medicaid coverage for eligible children. When families apply for coverage for their children, they often won’t know which program their child will qualify for — and they’re not expected to. It’s the system’s job to evaluate eligibility and enroll applicants in the right program. But if the public hears that children’s health coverage has “run out of money,” families may think it’s futile to apply at all, forgoing the opportunity to get Medicaid coverage even though their child may qualify.

All eligible children need access to the high quality, comprehensive, uninterrupted health coverage CHIP and Medicaid provide. Their families rely on these health coverage programs for financial support and peace of mind when they need it most. We’ve learned the hard way that freezing CHIP enrollment has negative effects that hurt children and their families long after the ice thaws. It’s now more than two months past the deadline to extend CHIP funding and it’s high time our leaders stopped giving children and families the cold shoulder.

Donna Cohen Ross is a vice president of the Center for the Study of Social Policy.