States Leading the Way on Connecting All Children with Health Coverage – Will Congress Follow?

According to the Urban Institute, over half of the remaining uninsured children are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) but unenrolled. About a third of uninsured children are ineligible for Medicaid or CHIP because their family income exceeds the eligibility thresholds. Another 10% are ineligible for Medicaid/CHIP because of their immigration status, or immigration status plus income.

Reaching these groups of uninsured children will take different strategies. For those who are eligible but unenrolled, outreach and enrollment assistance plus administrative simplifications could go a long way. Adopting policies such as 12-months continuous eligibility or multiyear continuous eligibility would also help by reducing churn. For those children who are over income for Medicaid/CHIP, the increased financial support in the Marketplace makes private coverage more affordable and the recent fix to the family glitch will help more families access subsidized coverage. In some states, raising the CHIP income eligibility level up to at least the national median is key.

But for the relatively small share of uninsured children who are ineligible for Medicaid/CHIP because of immigration status, different policy changes are required. Ultimately, Congress should change the rules to make all children regardless of citizenship status eligible for Medicaid/CHIP if they meet the other requirements (income, state residency). As an interim step, Congress could lift the 5-year waiting period for lawfully residing immigrant children. Thirty-five states have already done so through the CHIPRA 214/ICHIA option in Medicaid, along with 24 of 35 separate CHIP programs.

In the absence of federal action, states have stepped in to provide Medicaid/CHIP to income-eligible children regardless of citizenship status using state-only funds. For many years, 6 states (CA, IL, MA, NY, OR, and WA) and DC were the only states to do so. But in the past year or two, several other states have jumped in to fill these coverage gaps. In Maine, Rhode Island, and Vermont, child coverage expansions took effect earlier this year. And Connecticut (limited to children age 12 and under) and New Jersey will implement their coverage expansions in January 2023. More states may adopt similar coverage expansions next year. There’s growing interest in Delaware, Pennsylvania and Utah, just to name a few.

Immigration status is a barrier for a relatively small share of the remaining uninsured children because most children (97.4%) in the US are citizens. But even though noncitizen children make up only a small group, they merit special attention because their coverage disparities are large. For example, the uninsured rate for citizen children with citizen parents is just 4%, compared to a 28% uninsured rate for undocumented children. State policymakers are increasingly interested in adopting inclusive coverage policies, hopefully federal policymakers are taking notice.

Policy decisions that improve children’s access to health care are smart investments that provide long-term benefits for children, families and society. Research finds public health coverage is associated with improved health, reduced disability, greater educational attainment, and better financial outcomes when children reach adulthood. State and federal policymakers interested in doing more to help children thrive should focus on connecting more children with Medicaid and CHIP.

Kelly Whitener is an Associate Professor of the Practice at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.