Lessons from the Pandemic: Children’s Coverage Improvements

As readers of SayAhhh! know, Medicaid and CHIP enrollment is at an all-time high with close to 86 million people – covering half of the country’s children. Children and adults on Medicaid are protected by the continuous coverage provision including in the Families First Act (link to explainer) that prevents states from disenrolling anyone involuntarily. This provision was a key aspect of preventing large increases in the number of uninsured Americans during the pandemic. Prior to the pandemic, the number of uninsured children was on the rise from 2016 to 2019 – particularly for Latino children.

When the public health emergency lifts – (Secretary Becerra just extended it to July 15th) states will begin the process of “unwinding” by checking eligibility for everyone on Medicaid. This is a big deal with the potential for millions of adults and children to lose coverage in the process. As we have written about previously, we estimate that as many as 6.7 million children could be at very high risk of losing coverage.1 This could have the effect of more than doubling the number of uninsured children, which stood at 4.4 million in 2019.

In general, enrollment increases have been higher in percentage terms for adults (28.1%) than children (12.8%), — although both have seen large increases. In any state, children are the largest single eligibility group in Medicaid; but in the 12 states that have not expanded Medicaid (mostly in the South) under the ACA to cover adults; of course children constitute an even larger percentage of those covered by Medicaid.

When looking at children’s enrollment, the non-expansion states have significantly larger percentage point increases in child Medicaid enrollment than expansion states. With thanks to my colleague Aubrianna Osorio for running the numbers, here is what has happened:

So what this means is that Medicaid’s continuous coverage protection has been even more important for children’s coverage in these non-expansion states – the largest of which are Texas, Florida, and Georgia.  All three have uninsured child rates higher than the national average – with Texas having the highest rate and number of uninsured children in the country. Texas and Florida alone accounted for 41% of the nation’s uninsured children in 2019. We should know more when the American Community Survey releases data this fall, but uninsured rates for children in these states likely stabilized during the pandemic as a consequence of the continuous coverage provision.

This is good news, but only temporarily so because we have the unwinding ahead. Our recent report identified states where children are more at risk of losing coverage with red flags. All three of these states had five red flags meaning policies and structures in place that put children at higher risk of losing coverage.

Since states run Medicaid and CHIP, governors will hold the cards when it comes to determining how many children become uninsured. Governors in states that have not expanded Medicaid have seen larger increases in the number of children enrolled in Medicaid as described above.

Congress could ameliorate the situation by requiring twelve months of continuous coverage for children in Medicaid and CHIP as the House did in the Build Back Better bill passed last fall. Of the twelve non-expansion states, most of the smaller states do have this policy enacted, but the big three Florida, Georgia, and Texas do not have it in place for all children in Medicaid and CHIP.

Gaps in coverage cause problems for children and their families such as more medical debt and less access to needed care. And they are more likely to impact children of color. The silver lining of the pandemic has been that lower-income families have been assured of stable Medicaid coverage for their children. Policymakers should build on this success and not allow children to slip backwards.

Governors, Members of Congress, and other elected leaders have paid a lot of lip service to the plight of children during the pandemic. Now they have an opportunity to help children by protecting their access to health care.

  1. People can lose coverage in one of two ways – either getting lost on the way to a new source of coverage because their income has gone up since they enrolled (most likely the subsidized marketplaces for adults and CHIP for children); or they remain eligible but lose Medicaid due to a “procedural denial.”

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