Can a Biden Administration Reverse the Rise in Uninsured Children?

A few weeks ago I blogged about how a Biden Administration could go about unwinding Medicaid Section 1115 work reporting requirement waivers. Since Section 1115 demonstrations are clearly in the purview of the Secretary of Health and Human Services, a Biden Administration is in the driver’s seat (within the confines of the statute of course!)  with respect to Medicaid waiver policy.

But what about reversing the growing number of uninsured children and families? We have been documenting the increase in uninsured children every year for the past three years. In 2019, approximately 4.4 million children lacked health insurance – an increase of approximately 726,000 since 2016 when the number reached an all-time low.  No doubt the number of uninsured children has gone up in 2020 given the large job losses associated with the pandemic recession. And the rise in uninsurance is not limited to children – all non-elderly adults have seen an increase.

The Biden Administration will face many challenges on January 20th – including most prominently a raging pandemic and a struggling economy. Children – especially those in communities of color – are suffering greatly on many fronts due to the twin health and economic crises. Our colleagues at the Urban Institute released a great report recently on the need for a national strategy to address children’s health needs in the pandemic. So reversing the slide in the number of uninsured kids is just one of many issues facing the new Administration.

But given the uncertainty of Senate control, and Congressional logjams in general, the question arises as to what can a Biden Administration do in the absence of any legislative action to ensure more children are covered? Moreover, since Medicaid/CHIP are administered by the states, what role can the federal government play?

The answer is not everything, of course, but there are many things that a Biden Administration can do. Let’s review a few biggies.

First and foremost, a Biden Administration can (and I believe will) roll out the welcome mat for public coverage programs – Medicaid, CHIP and the ACA marketplaces. An essential goal of the Trump Administration has been to repeal the Affordable Care Act and limit access to Medicaid. Since the majority of uninsured children are eligible but not enrolled in Medicaid/CHIP reaching these “eligible but unenrolled” kids is a critical piece of the puzzle. President-elect Biden has run on a message of extending coverage and protecting the Affordable Care Act, not to dismantle it. Having high level messengers reinforcing the availability and importance of public coverage will be a welcome change from the repeated messages to families that the Affordable Care Act was being repealed or that new barriers (such as Medicaid work requirements) were being erected.

What else does rolling out the welcome mat mean? Families, especially those who have recently lost jobs or income, must be made aware of their options. This could include outreach and advertising efforts that highlight public coverage options – many have called for opening up the federal Marketplace for a special enrollment period for example which would generate momentum. While the Marketplace is not a primary source of coverage for kids, their parents often find out that their kids are eligible for Medicaid or CHIP when they sign up for Marketplace coverage. It will be important, however, to clarify in public messaging to families that Medicaid and CHIP are open for enrollment all year round and not limited to any special enrollment periods. And funding for community-based navigators to assist consumers and educate families about their options should be restored to 2016 levels — with particular attention to reinvigorating culturally competent consumer assistance.

Another critical piece of rolling out the welcome mat will be withdrawing the Trump Administration’s public charge rule which has contributed to a “chilling effect” for mixed-status families who are afraid to enroll their mostly citizen children in public benefits. As we have highlighted with our colleagues at UnidosUS, Latino children have seen particularly large increases in their uninsured rate. Withdrawing the public charge rule is critical, and must be accompanied by efforts to support and resource community-based, trusted messengers. It won’t be easy to undo the damage and fear that has been created in the immigrant community.

Finally, coverage losses due to inappropriate red tape are currently on hold as a consequence of the Medicaid disenrollment freeze tied to the increase in federal Medicaid matching funds for the duration of the public health emergency (PHE). There is a real danger that significant numbers of children and families may lose coverage inappropriately at the end of the PHE. The PHE, unfortunately, is likely to be with us for a while (the Congressional Budget Office predicts that it won’t end until 2022), but the new CMS Administrator should issue guidance to states about how and when to redetermine eligibility so that state eligibility systems are not overwhelmed and beneficiaries are not erroneously terminated. This should include flexibility for states to stagger renewals  that are past due for up to 12 months and to ensure that all beneficiaries are screened for all insurance affordability programs prior to disenrollment.

We released a report early on in 2020 with a slate of federal and state actions that could be taken to cover all children without gaps. In the meantime, we will continue to blog about more specific actions that a Biden Administration can take to protect and improve children’s health coverage.

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