Build Back Better Legislation: What Does It Mean for Children’s Health Coverage and Care?

There has been very little public discussion of the provisions to advance child health in the Build Back Better (BBB) bill. Big ticket items like whether a Medicare dental, hearing, and vision benefit will be added, disputes over drug pricing reforms, and of course, filling the coverage gap in the non-expansion states, have taken up most of the ink. The bill also makes critical improvements in the area of maternal health (as my colleagues and other experts have blogged about) but has gotten less attention.

For children, the BBB offers the nation an opportunity to get back on track and reverse the health coverage loss trends we saw during the Trump years. Importantly, it promises low-income kids more stability of public coverage no matter where they live – by requiring 12 months of continuous coverage in Medicaid and CHIP, permanently protecting income eligibility levels for kids, and making CHIP permanent. And by offering parents a path to coverage through the Marketplaces (the majority of uninsured children live in non-expansion states), a “welcome mat” effect is likely to result in more eligible kids getting enrolled in Medicaid and CHIP when their parents gain access to a new affordable coverage option. Given that more than one-third of children in the U.S. (and the vast majority of lower-income kids) get their coverage through Medicaid or CHIP, this is a big deal.

As we have written about many times, the continuous coverage provision will ensure stability of coverage for 12 months in Medicaid and CHIP no matter where a child lives and whether or not the family experiences minor or temporary income fluctuations. This policy has been a state option since 1997, but is currently in place for kids in Medicaid in only 24 states, and in 24 out of 34 separate CHIP programs. With the exception of California, the states with the largest numbers of uninsured children – Texas, Florida, and Georgia – do not have continuous eligibility in place for all kids in both their Medicaid and CHIP programs, so they will have to up their game for kids if the BBB passes.

But the bill does more than that — it makes it easier for states to cover more kids by allowing states to expand income eligibility through a simple state plan amendment rather than having to go through the Section 1115 waiver process. It would also permanently authorize the Express Lane Eligibility option and fund  child-specific outreach and enrollment grants permanently.

States will also not be able to make it harder to enroll by raising CHIP premiums or imposing other new barriers to enrollment. My colleague Edwin Park blogged about most of these provisions here.

If and when these provisions become law, a great deal of effort will be needed to successfully implement these new provisions and to encourage states to take up those that are optional. Bottom line: we should see improvements in the child uninsured rate following the enactment of BBB.

How much will that number go down? It is hard to say – one issue that the Biden Administration and its allies must address separately is the “chilling effect” whereby immigrant and mixed-status families are reluctant to enroll their citizen children in public coverage due to misinformation and rhetoric surrounding the now-repealed public charge rule. And, as regular readers of Say Ahhh! know, the lifting of the Medicaid disenrollment freeze in 2022 could cause large numbers of children and adults to lose Medicaid and become uninsured. So this could be a huge setback.

The BBB establishes a date certain for that unwinding process to begin – April 1, 2022 – and adds a number of protections to the disenrollment process. But how this process will go –especially in states eager to lower their historically high numbers of Medicaid beneficiaries — is very much up in the air. A recent canary in the coal mine situation in Utah yielded disturbing results. The state had initially applied the disenrollment freeze to its separate CHIP program with approval from CMS, but when that was lifted 41 percent of children lost their CHIP coverage during the renewal process. While we don’t know how many of these kids became uninsured, it is highly likely that a significant number of them did.

What about the quality of health care children in public coverage are receiving?

Assuming that the country can get back on track to reduce the number of uninsured children, the BBB jumpstarts the effort in two ways to examine whether they are receiving high quality care in Medicaid and CHIP. This is especially important for kids in communities of color who are disproportionately covered by Medicaid/CHIP.

First, by allowing for 12 months continuous eligibility to be implemented uniformly across the country, the ability of states to measure the quality of care for kids (who are mostly in managed care) is greatly enhanced. Most quality measures exclude children who are not covered for 12 months. The BBB also makes an existing pediatric quality measures program to develop evidence-based measures permanent.

Separately, the most recent CHIP reauthorization mandated all states to report the child health and behavioral health core set in 2024 — which is right around the corner. So policymakers at both the federal and state level will have this issue on their agenda.

It is high time to demand that there is more data about the kinds of care kids are receiving in Medicaid and CHIP – and that the data is disaggregated by race and ethnicity. Easier said than done, however, as there is a long way to go to make this a reality. As our colleagues have demonstrated, the lack of transparency with respect to Medicaid managed care is fairly stunning.  But with coverage stabilizing, stakeholders can beef up their work on these critical issues – essential for all kids but especially necessary to ensure that enduring racial disparities in disease burden and other health outcomes are identified and addressed. While there is clear and consistent research about the value of Medicaid for kids, much more work is needed to drill down on specific managed care plans and the care they are offering to children.

All in all, the package would be a game-changer for children and represent the biggest advance in the world of public coverage specifically for children since 2009 when the Children’s Health Insurance Program Reauthorization Act was enacted.

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.