How Can Policymakers Stop More Children From Losing Health Coverage and Regain Enrollment Momentum?

See our full blog series on evidence-based policies available to policymakers to prevent more eligible children from losing health coverage.

Sometimes you just hate to be right. The release of topline Census data last week confirmed our fears that the most recent health insurance data would reveal that we lost ground in providing health coverage to the nation’s children. As Joan Alker wrote last week, the number of children without health insurance rose by 425,000 in 2018. Many of these children lost Medicaid or CHIP but remain eligible.

We know how to fix this problem. In our enrollment decline report released in May, we summarized a number of policy and procedural steps that state agencies can take to regain enrollment momentum. These are the same strategies that helped reduce the rate of uninsured children to an historic low of 4.7 percent – a milestone that wasn’t reached by chance. It was achieved by expanding Medicaid and CHIP and through a concerted effort on the part of CMS and state agencies to increase the participation of eligible children. The gains made in covering children over the years inspired many of the data-driven, streamlined enrollment and renewal processes included in the Affordable Care Act (ACA).

As we wrote in the annual 50-state survey on Medicaid and CHIP Eligibility, Enrollment, and Cost-Sharing Policies, Medicaid has evolved from a program with limited eligibility and burdensome enrollment rules to a modernized source of coverage. But policies and procedures pushed by the current Administration are increasing the complexity of eligibility determinations and eroding the enrollment and renewal simplifications realized under the ACA.

In a new blog series, we’ll dive into the policies and actions summarized in our May report that are proven to maximize enrollment and retention of eligible children. These strategies have been well documented over time in numerous reports like this and this. These strategies fall into four buckets:

Policy Options that Foster Enrollment and Retention

There are many state-level policy options to promote child enrollment and retention. At the top of our list are: providing children with 12-month continuous eligibility; relying on eligibility findings or data from SNAP and other public benefit programs to verify Medicaid eligibility; and using presumptive eligibility to allow qualified entities to temporarily enroll or re-enroll children while the regular process is underway.

Outreach and Consumer Assistance

Outreach should be targeted to families whose children are uninsured and likely eligible for Medicaid or CHIP. Additionally, many families need personalized assistance to overcome challenges when forms and processes are difficult to maneuver. There are a variety of ways states can provide help such as operating high-quality call centers and ensuring that in-person assistance is readily available in local government offices and community-based locations.


From reducing paperwork by streamlining electronic verification of eligibility to building web-based and mobile tools for consumers to apply, renew, and report changes, there are many ways states can maximize technology to support Medicaid and CHIP.

State Processes and Procedures

There are many opportunities for states to improve their processes and procedures. Our favorites include: improving notices; keeping addresses current; following up on returned mail; sending reminders when beneficiary action is required; engaging managed care plans in renewal outreach; and disallowing auto-closures.

While this list is extensive, it is not exhaustive. There are many proven practices that drove our country’s success in covering children until we reversed course in 2017. A key element of that success has been leadership. Having champions at the executive, legislative and administrative levels is key to promoting enrollment and retention. The question is: Do our state and national leaders have the will to do what’s in the best interests of children and the nation’s future?

Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.