Child Medicaid Enrollment Decline Reaches 3 Million: How Many Kids are Moving to CHIP?

Our tracker of net child Medicaid enrollment declines during the unwinding period just reached, and then quickly exceeded, 3 million with the release of October data by Texas – the undisputed national leader in dumping kids off Medicaid. In February 2022, Georgetown CCF researchers projected that as many as 6.7 million children could experience a gap in coverage – the number as we write today is 3.24 million fewer kids on Medicaid with about half of the renewals nationwide processed. The final number is entirely dependent on state actions – and Governors have a moment of reckoning right now with respect to protecting children; our colleague Tricia Brooks has blogged about how to earn a gold star.

Prior to the beginning of the process, researchers projected that a majority (57%) of children losing Medicaid would move to CHIP because for families whose income went up this would be the next stop on the public coverage train. We’ve been tracking net enrollment changes for separate CHIP programs, hoping to see this movement from Medicaid to CHIP so that children don’t become uninsured. Unfortunately, this projection is far off as we reach the halfway point of unwinding, and separate CHIP enrollment increases only represent a small share (8%) of child Medicaid enrollment declines nationwide as discussed below.

The majority of “CHIP children” are actually enrolled in Medicaid but financed by CHIP, and those children were protected by the continuous coverage protections, so the real question is what is happening with movement to separate CHIP. We’re tracking net enrollment changes for separate CHIP programs in 34 states. Just as with our child Medicaid enrollment and state Medicaid enrollment trackers, these are net enrollment numbers, meaning they account for newly enrolled children, or children who lost then regained coverage. The table below compares separate CHIP enrollment changes to child Medicaid enrollment changes within the same month for each state. As we’ve previously noted, these Medicaid numbers are an underestimate of the total number of children who may have experienced a gap in coverage because it is a net number, and because of data lags between when states report unwinding disenrollments and when they report their current enrollment.

Since our last blog on separate CHIP enrollment, new data has allowed us to add thirteen states to our tracking. The situation has not improved. While child Medicaid enrollment declined by more than 2.3 million across these states, separate CHIP enrollment increased by less than 190,000 which equates to 8% of child Medicaid enrollment declines.

In eight states (AZ, ID, KS, ME, MT, NJ, WA, WI), separate CHIP enrollment data continues to show declines. The largest numeric CHIP increases are seen in Florida (41,429), Pennsylvania (51,693), and Texas (57,967), but in Florida and Texas, these increases represent less than 11% and 7%, respectively, of their child Medicaid enrollment declines (Florida and Texas alone account for one-third of the total three million child Medicaid enrollment decline). Pennsylvania’s separate CHIP increase equates to 42.5% of their child Medicaid enrollment, one of the higher shares we’ve seen, but that is still well below the estimated 57% of children losing Medicaid who would move to CHIP.

We should note in states where we’re seeing separate CHIP enrollment increase shares equates to more than 100% of child Medicaid enrollment declines (such as Delaware), data is from early in their unwinding processes. Because every state prioritized Medicaid renewals differently, we can see losses for different populations at different times in their unwinding processes (for example, Rhode Island is waiting until January 2024 to begin renewals for children and their families).

This small growth in separate CHIP enrollment is particularly concerning as kids are less likely to go to marketplace or employer-sponsored health coverage. Our colleague Edwin Park noted that marketplace growth so far has only constituted a small part of Medicaid coverage losses due to the unwinding, and children likely only account for a small portion of new marketplace enrollees. As we previously wrote about, low-wage workers are rarely offered affordable coverage for their dependents. We don’t know how many of the 3+ million children are becoming uninsured but there are many reasons to worry – especially when so few of them are making it to CHIP.

Even if kids who are losing Medicaid coverage are eventually making it to separate CHIP programs, they may be experiencing gaps in coverage. Although CHIP eligibility should be integrated into the Medicaid eligibility system, additional steps often need to be taken before a child is enrolled in coverage. These gaps in coverage are particularly harmful for kids, who need frequent routine care and exposes their families to large medical bills and debt. Some states have taken action to alleviate barriers to separate CHIP enrollment, such as eliminating premiums. New CMS guidance reiterated and encouraged that, in cases where a child enrolled in Medicaid appears eligible for separate CHIP via ex parte, the state may enroll the child in CHIP, even if the family does not return a renewal form for separate CHIP. Starting on January 1, 2024, states cannot terminate CHIP coverage due to non-payment of premiums under mandatory 12-month continuous eligibility requirements.

We’ve seen two states, Kentucky and North Carolina, opt to keep all children currently enrolled in Medicaid for another year, which allows the state to focus on other populations and fix problems in their renewal systems before moving on to children. And ten states are moving towards a system of continuous coverage for young children from 0-6 which is a national breakthrough and moves the country towards a new day. However, where a child lives is becoming increasingly and starkly important for their chances of a healthy future.

A note on methods: CHIP and Medicaid enrollment changes are based on the first month that unwinding terminations in the state commenced. For the separate CHIP numbers, we use either state reported or CMS data. State reported data is often much more recent than CMS data, however, many states do not publicly post data on their separate CHIP programs. The latest CMS data on separate CHIP enrollment is from June, so for the states where we use CMS data, these numbers are from early in their unwinding processes, meaning it is possible that more kids have made their way back to coverage. The child Medicaid enrollment numbers are the same data used in our “What is happening with Medicaid renewals in each state?” and “How many children are losing Medicaid?” pages.

An additional note: Our analysis of Florida's separate CHIP program includes children enrolled in the state's full-pay Healthy Kids and MediKids plans, which means these families are paying the full cost of coverage which is not subsidized by federal or state CHIP funding.