With the outcome of the Congressional midterm elections, the risk of federal legislation to repeal and replace the Affordable Care Act and impose a cap on federal Medicaid funding has receded.  Some federal policymakers are instead renewing focus on how to again make substantial progress towards the goal of universal coverage. This need has become even more pressing with recent survey data showing that the share of children who are uninsured has increased for the first time in at least a decade.  

The health coverage expansion plans now being proposed vary considerably in their approach and scope.  Some proposals establish new universal coverage programs that may replace current coverage sources like employer-sponsored insurance and public programs such as Medicare, Medicaid and the ACA marketplaces.  Others would expand coverage only to targeted populations, such as by lowering the age of Medicare eligibility or allowing a buy-in to Medicare or Medicaid for those not currently eligible.

In the sixth issue brief of our Future of Children’s Health Coverage series, we ask nine key design questions to help assess the relative merits of coverage expansion proposals from the perspective of children, especially the more than 35 million low-income children who rely on Medicaid and the Children’s Health Insurance Program (CHIP).  

That is because expansions of Medicaid and CHIP have been largely responsible for the historic decline in children’s uninsurance rates over the last two decades, with Medicaid covering the vast majority of low-income children today.  Moreover, Medicaid now provides children with critical access to needed care such as well-child visits and a regular source of care at generally no cost, reduces infant and childhood mortality, and results in long-term benefits including higher educational attainment and better health and earnings in adulthood.  It is thus critical to ensure that any coverage expansion proposals, particularly those that would dramatically alter existing health coverage, build on these successes to further advance the goal of affordable, comprehensive health coverage for all children, while avoiding children inadvertently falling through the cracks and being made worse off.  

These design questions include:

1. How would the coverage expansion proposal affect Medicaid and CHIP coverage of children?
2. Would the new coverage expansion’s benefit package be tailored to children’s unique needs?
3. What would be the premium and cost-sharing requirements under the new coverage expansion?
4. How would the coverage expansion measure and ensure quality of care?
5. What would be the health care delivery system under the coverage expansion and how would health care providers be reimbursed?
6. What are the beneficiary access protections under the coverage expansion?
7. How will the coverage expansion be administered?
8. What is the implementation timeline for the coverage and is there a transition period?
9. How will children’s needs specifically be addressed in any new coverage expansion?

Check out our previous briefs in the Future of Children’s Health Coverage series.