Georgetown University Health Policy Institute Covering All Introduction The nation made remarkable progress in reducing Children the rate of uninsured children, following decades of coverage expansions and policy changes that made it easier for children and their families to by Kelly Whitener and Joan Alker get and stay covered.1 But, in 2018, the rate of uninsured children increased for a second year in a row to 5.2 percent.2 Early warning signs pointed to a large increase in the uninsured rate in 2018, such Ninth in a series of papers from the as the historic decline of over 1 million children Georgetown University Center for enrolled in Medicaid and CHIP between December Children and Families on the future of 2017 and May 2019.3 children’s health coverage. Policymakers must renew their efforts to regain momentum on children’s coverage and strive February 2020 to reach all children, because research shows that having coverage as a child leads to better educational outcomes, higher-paying jobs as an adult, and improved health over the lifetime.4 Coverage for parents and caregivers is also critical to child health. When parents are healthy and insured, their families are more financially secure, and their children are more likely to be enrolled in health coverage and have their health needs met.5 This brief focuses on the remaining 4 million uninsured children and makes recommendations for policy changes to reach them as well as to simplify and improve children’s coverage overall. A menu of options is included that can be contemplated separately or in combination. If the number of uninsured children continues to grow, the need for bolder action by policymakers becomes increasingly urgent. CCF.GEORGETOWN.EDU cover all children 2 Who Are the Remaining Uninsured Children? Uninsured children are more likely to fall into certain reach demographic groups are covered. For example, of demographic groups. For example, children living in and the remaining uninsured children, 56.5 percent are eligible near poverty have higher uninsured rates than children for Medicaid or CHIP but not enrolled (see Figure 1).11 with family income above 250 percent of the federal Clearly, policy solutions aimed at increasing Medicaid and poverty level (FPL).6 The uninsured rate also varies by CHIP participation rates would make significant strides race and ethnicity, with American Indian/Alaska Native toward covering all children. For the remaining uninsured children having the highest rate at 13.2 percent in 2018.7 children, policy changes are needed to make coverage more Latino children, who can be of any race, also have higher affordable and more accessible to all, regardless of income or uninsurance rates, climbing up to 8.2 percent in 2018.8 immigration status. School-aged children are also more likely to be uninsured than children under 6 years old, but the uninsured rate for young children jumped an alarming 13 percent to 4.3 Figure 1. Share of Uninsured Children Eligible percent in 2018. Finally, children are more likely to be for Medicaid/CHIP in 2017 uninsured in certain states, especially states that have not adopted the Medicaid expansion to cover more parents Medicaid/CHIP-eligible and other adults.9 Half of the nation’s uninsured children Family income exceeds reside in just six states (Texas, Florida, California, Georgia, 32.8% eligibility thresholds Arizona, and Ohio).10 Meets income requirements but ineligible Building on the strong foundation of Medicaid and 56.5% because of immigration 10.7% status CHIP, policymakers could achieve universal coverage for children by setting national standards for children’s Source: Urban Institute analysis of coverage, expanding insurance affordability programs 2017 American Community Survey data from the Integrated Public Use to reach more children, and targeting outreach and Microdata Series. enrollment efforts to make sure even the hardest to Create a National Children’s Coverage System U.S. children are significantly more likely to have health coverage if they happen to reside in certain states. Figure 2. Most notably, uninsured children disproportionately live National Continuum of Children’s Coverage in the South.12 Children are almost twice as likely to be uninsured in states that have not adopted the Medicaid expansion to cover more parents and other low-income adults.13 Some states have been able to make progress in reducing the percentage of uninsured children by All newborns All children All children adopting policies that make it easier for children to get leave the receive continuous get the health and stay covered—the only two states to cover more hospital with health care coverage they insurance card during critical need to attend than 98 percent of children cover all children regardless development stage school ready of immigration status—but states have not been able ages 0-6 to learn to achieve 100-percent coverage on their own. In order to have universal coverage for children, states need a stronger federal partner, and children need equal access to coverage regardless of where they live. CCF.GEORGETOWN.EDU Cover all children 3 1. Create a national continuum of XX Medicaid and CHIP eligibility, once established at birth, children’s coverage should be extended for several years to ensure that children maintain continuous coverage during the first Policymakers should strive to improve technology and data critical years of growth and development. This would systems to create a universal coverage system that begins establish continuous, reliable coverage during early at birth and continues through adolescence. Newborns childhood when children are developing very quickly should have coverage before leaving the hospital, and as and early interventions are critical. It would also ensure children grow and income or other family circumstances families have affordable access to coverage during change, that coverage should continue without gaps even the early years when children are expected to have if the source of coverage changes (i.e., from Medicaid to frequent doctor’s visits to be immunized and have CHIP or CHIP to Marketplace). (See Figure 2 above.) developmental milestones assessed. In order to create XX Babies born to mothers covered by Medicaid and CHIP a seamless coverage system, continuous eligibility are automatically eligible for one year, but systems periods in Medicaid and CHIP should extend from birth to need to be improved to make sure all such newborns kindergarten entry. are enrolled. Oklahoma uses an automated newborn enrollment system, which allows hospital staff to enter Recommendation Federal: Allow states to newborn information and receive an assigned Medicaid test longer periods of continuous Medicaid and number before the mother and baby are discharged.14 CHIP coverage, such as for a five- or six-year period In New Jersey, private insurance plans are required to beginning at birth through kindergarten entry. cover their member’s newborns from birth to 60 days.15 Similar systems should be developed and implemented XX Upon entering school and each school year thereafter, to ensure newborns enroll in coverage, regardless of the the school enrollment process should include information source, before leaving the hospital. Parents can indicate about enrolling in available health coverage programs. that their newborn will be covered on their private plan Using streamlined applications and partnerships with or the baby will be enrolled into Medicaid by default. community health organizations, schools should be able This would create a simple, national system with an to connect children to Medicaid, CHIP and Marketplace expectation that no baby should leave the hospital coverage as applicable. Older children are more likely without insurance. to be uninsured than their younger counterparts, so additional efforts should be made to reach adolescents Recommendation State: Ensure that every with specialized outreach programs. In Michigan, a health newborn leaves the hospital with health plan worked with schools to connect families who qualify coverage by improving technology and processes for free and reduced-price meals to health coverage. to immediately enroll them in available Medicaid, In Oregon, school-based health clinics asked students CHIP, or Marketplace coverage if they don’t have whether they had coverage and helped eligible students employer-sponsored insurance. apply or referred them to someone who could assist them. Some communities used back-to-school night and parent- teacher conferences to reach out to parents of teens.16 Recommendation Federal: Enroll newborns without alternative coverage in Medicaid Recommendation State: As children automatically. enroll in school and at regular checkpoints throughout the school year, such as the beginning of a new sports season, states should ensure that all students are covered and facilitate enrollment for eligible children as needed. CCF.GEORGETOWN.EDU cover all children 4 2. Strengthen Medicaid and CHIP gaps in eligibility remain. For example, in 1996, the Personal Responsibility and Work Opportunity Reconciliation Act Over 40 percent of uninsured children are ineligible for (PRWORA, P.L. 104-193), added a requirement that lawfully Medicaid/CHIP because family income exceeds the present immigrants have a “qualified” immigration status and applicable eligibility thresholds (32.8 percent) or because wait five years after obtaining qualified status before being of immigration status (10.7 percent).17 Targeted coverage eligible to enroll in Medicaid. These rules were applied to CHIP expansions to reach these two groups would help the U.S. at its creation in 1997. These restrictions continue to apply achieve higher rates of insurance for children. today, but states have the option to waive the five-year waiting Once eligible for Medicaid and CHIP, children can receive period for qualified, lawfully residing children and pregnant affordable coverage because federal rules limit out-of- women.21 As of 2019, 34 states have waived the five-year pocket costs significantly. In general, states may not impose waiting period for children.22 premiums or cost-sharing in Medicaid for children with With the exception of emergency Medicaid services, federal family income below poverty, and only very limited cost- funds are not available for undocumented children who sharing is allowed for children with higher family incomes. would otherwise be eligible for Medicaid, CHIP, or subsidized Federal rules allow more premiums and cost-sharing in Marketplace coverage but for their immigration status. Six separate CHIP programs but only up to an overall cap of states (California, Illinois, Massachusetts, New York, Oregon, 5 percent of household income. As the cost of dependent and Washington) and the District of Columbia (D.C.) use state- coverage for employer-sponsored insurance continues to only funds to cover Medicaid/CHIP income-eligible children grow,18 expanding Medicaid and CHIP income eligibility regardless of immigration status.23 These states have children’s would give more children access to affordable coverage. coverage rates well above the national average (ranging from Recommendation Federal: Enact a new, 96.4 percent to 98.8 percent in 2018).24 Though funded largely national standard setting the minimum income with state-only dollars (federal funds can continue to pay for eligibility level for children in Medicaid at 200 percent emergency Medicaid services), these coverage programs look of the FPL and in CHIP at 300 percent of the FPL. just like Medicaid/CHIP to the family, maximizing efficiency and offering the same scope of child-specific benefits.25 Uninsured rates are higher for children in immigrant families. Despite efforts to streamline program operations, states Four percent of citizen children with citizen parents were are limited in what they can do because of complicated uninsured in 2017, compared to 7 percent of citizen children funding limitations and the federal rules requiring citizenship with a noncitizen parent, 19 percent of lawfully present documentation. Covering all kids, regardless of citizenship immigrant children, and 31 percent of undocumented status, would reduce program complexity and improve the children.19 About 385,000 uninsured children who met the insurance rate for children. Most children living in immigrant Medicaid/CHIP income requirements in 2017 were ineligible families are citizens, and the share of undocumented children because of immigration status.20 Some ineligible immigrant is small. However, extending coverage to all children regardless children are lawfully residing but do not meet the specific of immigration status would make the overall system more immigration requirements for health coverage, while some efficient, eliminating the need for a citizenship documentation are undocumented. Moreover, while it is hard to quantify process that all children are currently subjected to and the losses of coverage due to immigration enforcement streamlining funding. A simple message that all children are fears such as public charge, the chilling effect of current welcome makes outreach efforts far more effective and as a immigration policies decreases the likelihood that eligible result, more currently eligible children would be likely to enroll children will enroll in Medicaid and CHIP. through the “welcome mat” effect. Medicaid and CHIP coverage for noncitizens is limited Recommendation Federal: Remove eligibility to certain lawfully present immigrants, such as legal restrictions based on citizenship status so that all permanent residents (LPRs or “green card” holders), children who meet the income eligibility requirements refugees, and asylees; and such coverage is subject to for Medicaid and CHIP are able to enroll. restrictions. Thus, even among lawfully present immigrants, CCF.GEORGETOWN.EDU Cover all children 5 Many of the proposals included in this brief would increase federal and state spending on Medicaid and CHIP and federal spending on subsidized Marketplace coverage. Under current law, state spending on Medicaid and CHIP is matched by the federal government through a formula known as the Federal Medical Assistance Percentage (FMAP), and in the case of CHIP, the enhanced-FMAP (E-FMAP). The matching rates vary from state to state, with states that have per-capita income below the national average receiving more federal funds. Matching rates may also differ by population, service, or type of expenditure such as administrative costs versus the cost to deliver benefits. Though outside the scope of this paper, policymakers may want to consider increasing the share of costs borne by the federal government in order to support more uniform coverage nationwide. 3. Reduce gaps in children’s coverage where they live. Providing families with continuous coverage Once enrolled, it is critical that children stay covered will help reduce school absenteeism for children and, without unnecessary administrative red tape. Even a short potentially, lost work days for their parents.27 gap in coverage can result in a child missing needed Recommendation Federal: Set a national care such as treatment for a chronic condition like standard of at least 12 months of continuous asthma—which left untreated is likely to result in visits to coverage for children in Medicaid and CHIP. the emergency room and missed school days. Gaps in coverage can also create financial hardship. Even if just one Finally, it is important to allow states to expand coverage family member is uninsured, the whole family’s economic for children beyond these new federal minimums to reflect security is at risk. Coverage expansions for children and state and local needs. For example, states may want to adults decreased the percentage of poor and near poor cover all children at higher income levels to keep up with families with trouble paying their medical bills by almost 30 higher costs of living. Or, a state may want to expand percent.26 coverage to a subgroup of particularly vulnerable children, States have the option under current law to provide 12 like those with special health care needs. Currently, most months of continuous coverage for children in Medicaid states cannot expand their CHIP programs without a and CHIP so that even as their family income fluctuates Section 1115 waiver, which is cumbersome, time-limited, from month-to-month, children can remain covered. Almost and requires a budget neutrality test. half of all states have adopted this option in Medicaid, and more than two-thirds of states with separate CHIP programs Recommendation Federal: Create a state plan apply it to CHIP, too. However, all states should be required option to cover children at higher income levels to provide at least 12 months of continuous coverage in (i.e., without a waiver). order to avoid gaps in children’s coverage regardless of M edicaid plays a unique role for many vulnerable groups including low-income parents and adults, pregnant women, and people with disabilities. For children to grow up into healthy, productive adults, they need the support of healthy parents and caregivers and a safe, secure community. Children’s positive development relies on healthy parents, and health coverage improves parents’ health and access to needed care. Covering parents also provides financial security for the whole family, as having even one uninsured family member could lead to major medical debt. Moreover, as children age into adulthood, they will continue to have health care needs over their lifespan. Though not within the scope of this report, policymakers should also consider setting national standards to reduce state variation and improve coverage for everyone. CCF.GEORGETOWN.EDU cover all children 6 4. Improve affordability in the Marketplace Even for families who do qualify for premium tax credits, and expand access to subsidized private the expected contribution to premiums and other out-of- pocket costs can be so high that coverage remains out coverage for immigrants of reach. An earlier brief in this series identified policy Over 1 million children remain uninsured because family options to make Marketplace coverage more affordable, income exceeds the Medicaid/CHIP eligibility thresholds, including decreasing the expected premium contribution and yet private coverage is still out of reach. Families amounts and making cost-sharing protections more ineligible for Medicaid and CHIP may rely on employer- robust and available to families with higher incomes.34 A sponsored insurance (ESI) coverage if available, or they Commonwealth Fund analysis found that allowing families may purchase coverage through the Marketplace, but these above 400 percent of the FPL to purchase subsidized coverage options may be unaffordable even for middle- Marketplace coverage would decrease the number of income families. Premiums for ESI increased 55 percent, people without insurance by 1.2 million.35 twice as fast as workers’ earnings, in the past decade.28 Marketplace plans offer subsidized coverage for families Recommendation Federal: Decrease the with income below 400 percent of the FPL, but for many expected premium contributions for all families families the cost of coverage is still a major barrier.29 and make premium tax credits available to families Additionally, some families are unable to access subsidized with incomes above 400 percent of the FPL. coverage under the current application of the test to determine whether the family has access to “affordable” Recommendation Federal: Require insurers coverage, also known as the “family glitch.” operating in the Marketplace to reduce deductibles and other cost-sharing so that total out- Approximately 460,000 children live in families where ESI of-pocket costs are reasonable. is available, but very expensive, and yet they are ineligible for premium tax credits in the Marketplace due to the There are fewer immigration-related eligibility restrictions family glitch.30 Regulations define employer coverage for premium tax credits in the Marketplace compared to as “affordable”—making the employee, spouse and/or Medicaid and CHIP. In order to be eligible for premium tax children ineligible for premium tax credits—if the cost to the credits, immigrants must be lawfully present but do not employee for individual coverage is less than 9.86 percent have to have “qualified” status and are not subject to the of family income.31 However, family coverage is generally five-year waiting period. This creates confusion because far more expensive than coverage for the employee only.32 certain groups, like those with temporary protected status, The result is that families who have access to affordable are lawfully present but not “qualified” and therefore individual coverage are excluded from premium tax credit ineligible for Medicaid and CHIP but eligible for premium eligibility even if the cost of family coverage exceeds the tax credits in the Marketplace under current law. affordability thresholds.33 Recommendation Federal: Remove eligibility Recommendation Federal: Congress or the restrictions based on citizenship status so Administration should redefine the affordability that all children who meet the income eligibility test based on the cost of family coverage not individual requirements are able to purchase subsidized coverage, thereby eliminating the “family glitch.” Marketplace coverage. A s policymakers work to provide health coverage for all children, it is also important to make sure such coverage is affordable and comprehensive. Medicaid and CHIP have important affordability protections already built-in, and Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit guarantees that children have access to all pediatrician-recommended services. Children whose coverage comes from other sources—like the Marketplace or employer-sponsored insurance—may need additional protections to ensure their coverage is affordable and comprehensive, too. CCF.GEORGETOWN.EDU Cover all children 7 Interim Steps to Cover More Children While the broader, more systemic policy changes outlined Despite prior enrollment improvements, the Urban Institute above would achieve universal coverage for children, data show that 2 million uninsured children were eligible political challenges and time and resource constraints for Medicaid or CHIP but unenrolled in 2017. Over half may present insurmountable barriers. Thankfully, there of eligible but unenrolled children lived in just eight large are interim steps that could be taken immediately or in states (California, Florida, Georgia, Illinois, Indiana, New the nearer term. For example, research by the Urban York, Pennsylvania, and Texas).39 Moreover, certain Institute has found that following implementation of the socioeconomic and demographic subgroups are not only ACA, children’s participation rates in Medicaid and CHIP more likely to be uninsured, they are also more likely to improved dramatically—from 88.7 percent of eligible have lower participation rates in Medicaid and CHIP (see children in 2013 to 93.7 percent in 2016. However, in Figure 3). In 2017, some gains in the participation rates 2017, the Medicaid and CHIP participation rate for were reversed. For example, participation rates for the eligible children fell back to the 2015 level of 93.1 lowest income children—family income below 100 percent percent.36 This was the first time the participation rate has of the FPL—and citizen children with noncitizen parents declined since the Urban Institute first began measuring declined significantly between 2016 and 2017.40 participation in 2008. Efforts to improve the rate in the Implementing policies and procedures that facilitate 2013 to 2016 period—such as streamlining Medicaid and enrollment and retention as well as maximize use of CHIP enrollment processes and enhancing outreach and technology would help reach eligible but unenrolled enrollment efforts, together with the welcome mat effect of children. providing affordable coverage options to parents through the ACA—paid off. Returning to a “culture of coverage” that includes policies to make it easier to enroll in Medicaid Figure 3. Demographic Groups with Higher and CHIP and affirms the value and importance of covering Uninsurance Rates and Lower Medicaid/ children would help participation rates get back on track CHIP Participation Rates, 2017 and help cover more children. • Children between the ages of 13 and 18 Higher State Focus uninsurance • American Indian/Alaska rates Native children Though Nevada still has a high percentage of • Children living in states that uninsured children relative to the national average Lower have not adopted the ACA’s Medicaid/CHIP (8 percent versus 5 percent), the state had the particiption rates Medicaid expansion sharpest decline in the rate of uninsured children • Citizen children with noncitizen parents during the ACA implementation period from 2013 to 2016.37 Over that same period, the Medicaid Source: Urban Institute tabulations of 2013-2017 American Community and CHIP participation rate increased from 74.3 Survey data from the Integrated Public Use Microdata Series. percent to 91.3 percent, the biggest jump across the country.38 CCF.GEORGETOWN.EDU cover all children 8 In the absence of new federal requirements described above, Interim Steps to Improve Coverage there are several options states may adopt under current law that have proven effective in expanding eligibility and Recommendation State: Adopt the option to promoting continuity in coverage. For example, all states provide 12-month continuous coverage for should opt to provide 12 months of continuous coverage for children in Medicaid and CHIP. children so that even as their family income fluctuates from month-to-month, children can remain covered. Twenty-four Recommendation Federal: Allow states to states have already adopted this option in Medicaid, along with provide 12-months continuous coverage for 26 of 36 separate CHIP programs.41 Extending the 12-months parents and adults in Medicaid as a state plan continuous coverage option to parents and other adults would option (i.e., without a waiver). also help ensure more children have coverage as research has shown that when parents are covered, the whole family is more Recommendation Federal: Remove the likely to have coverage and be more financially secure.42 requirement to have qualified status in addition to As noted above, federal rules generally require immigrant being lawfully residing so that all lawfully residing children to have a qualified status for five years before children may be eligible for Medicaid and CHIP. becoming eligible for Medicaid and CHIP. However, states may opt to waive the five-year waiting period for children and Recommendation State: Adopt the option to pregnant women. cover all lawfully residing children at current Additionally, federal agencies could streamline eligibility rules eligibility levels without requiring a five-year for immigrant groups and help more youth obtain coverage waiting period in Medicaid and CHIP. by allowing Deferred Action for Childhood Arrivals (DACA) recipients to be eligible for Medicaid, CHIP, and premium tax Recommendation Federal: End the DACA credits in the Marketplace. Though children’s use of Medicaid exclusion from federally funded health coverage is exempt from the recent public charge policy changes, if affordability programs, including Medicaid, CHIP federal agencies rescinded the regulations it would allow all and subsidized Marketplace coverage. eligible children to enroll without fear.43 As noted, six states and D.C. have opted to cover all children Recommendation Federal: Rescind the recent regardless of citizenship status; for those in the Medicaid changes to public charge policy. income eligibility range, the state pays all of the costs beyond what emergency Medicaid covers. Other states should Recommendation State: Cover all children consider adopting this same approach, and CMS should regardless of immigration status, using state-only streamline the process to make it easier for states to continue funds as needed. to draw down federal funds for emergency Medicaid expenses. Finally, states have the option under current law to increase Recommendation Federal: Make it easier for income eligibility for children in Medicaid and CHIP through states to cover populations with state-only funds a section 1115 demonstration waiver. The waiver process by streamlining cost allocation processes. can be cumbersome, which is why it would be better in the long term to make eligibility expansions an option through Recommendation State: Expand income the state plan amendment (SPA) process instead. Waivers are eligibility to cover more children in Medicaid also subject to budget neutrality rules, so it may be difficult to and CHIP through a section 1115 demonstration do larger expansions. However, states may want to consider waiver. some eligibility expansions through the waiver process in the absence of statutory change. CCF.GEORGETOWN.EDU Cover all children 9 Improve Outreach and Enrollment Interim Steps to Improve Outreach Programs and Enrollment Some coverage gains could also be achieved by simply Recommendation Federal: Restore navigator doing a better job to make sure existing coverage options funding to 2016 levels and increase funding for and related systems work well for children and families. other forms of in-person, culturally competent Many such strategies are outlined in a separate report consumer assistance for Medicaid, CHIP, and and blog series on the decline in Medicaid and CHIP Marketplace coverage. Funding should also enrollment.44 For example, an important tool to reaching be reinstated for marketing and outreach, so eligible children is in-person, culturally competent that families are aware of their options. All such consumer assistance. The ACA created “navigator” funds must be comprehensive, such as explicitly programs to provide outreach, education and enrollment allowing in-person assistance for any of the assistance for Medicaid, CHIP, and Marketplace coverage. insurance affordability programs. However, in 2018, the Trump administration reduced navigator funding to just $10 million, a reduction of 84 percent from full navigator funding in 2016.45 Free, in- Recommendation Federal and State: Ensure that person assistance is especially important for underserved community-based organizations and providers communities—African Americans and Latinos were 43 who serve hard-to-reach, low-income families are percent more likely to seek in-person help than their white involved in outreach and enrollment efforts. counterparts. And consumers with in-person assistance are twice as likely to successfully enroll compared to those who attempt to enroll online without help.46 Recommendation State: Expand and maximize Medicaid enrollment sites, especially in schools, In addition, states are required to provide opportunities Indian health clinics, and family resource centers for pregnant women, children, and parents to apply for in order to enroll harder to reach children. Medicaid at certain locations such as hospitals, federally qualified health centers, and Indian health clinics. States Recommendation Federal: Devote new resources also have the option to establish other enrollment sites to the national children’s coverage campaign, with in locations such as schools or family resource centers. a particular emphasis on increasingly marginalized These outstation locations and functions should be populations such as children in immigrant families. maximized to make it easier for eligible children to enroll.47 Conclusion The nation has made incredible progress in improving the arise when accidents happen, such as a child falling on the uninsured rate for children, but since 2016, policy changes playground and breaking a bone. When an ear infection and a lack of national focus on children’s health coverage goes undiagnosed and untreated, it can lead to hearing loss have undermined that success. Between 2016 and 2018, the and speech and language delays with life-long health and number and rate of uninsured children grew for the first time educational consequences for the child. This devastating in nearly a decade. With a strong foundation of coverage impact could be prevented through health coverage providing in Medicaid, CHIP and the Marketplace, it is time to revisit access to care and early intervention. These financial and national priorities and get back to the sustained progress health burdens can have long term consequences even if that came about through a strong, bipartisan commitment the period without coverage is short. There are many issues to children’s health. Insurance coverage is the price of facing a child’s successful trajectory, but without continuous admission to the nation’s health care system, and without affordable coverage it is hard to equip the next generation to it, children are condemned to worse health and educational address the complex challenges they and our nation will face outcomes in the short and long term. Their families face in the future. It’s time to redouble efforts to ensure that all the threat of medical debt and even bankruptcy that can children are insured. CCF.GEORGETOWN.EDU cover all children 10 Acknowledgments The authors would like to thank Sonya Schwartz for her thoughtful work writing an earlier version of this paper. The authors also thank Edwin Park for his review and Tara Mathias-Prabhu and Phyllis Jordan for editing assistance. Design and layout provided by Nancy Magill About this Series This issue brief is ninth in a series of papers from Georgetown University Center for Children and Families on the future of children’s health coverage. Other briefs in the series include: Promoting Health Coverage of American Indian and Alaska Native Children. Focuses on improving access to health care for American Indian and Alaska Native children. (September 2019) How Medicaid and CHIP Can Support Student Success through Schools. Examines how Medicaid can help schools better serve children and families and how schools can help students get the health care they need. (April 2019) The Questions to Ask When Assessing the Impact of Coverage Expansion Proposals on Children. Focuses on a number of key questions to help assess the relative merits of coverage expansion proposals from the perspective of children. (February 2019) How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs. Focuses on the effectiveness of the Medicaid Drug Rebate program and how to improve it. (January 2019) Promoting Young Children’s Healthy Development in Medicaid and the Children’s Health Insurance Program (CHIP). Focuses on ways that state and federal policymakers can use Medicaid and CHIP to more effectively put young children on the best path for success in school and in life. (October 2018) How Medicaid and CHIP Shield Children from the Rising Costs of Prescription Drugs. Focuses on how Medicaid and CHIP protect most children from the rising costs of prescription drugs. (July 2017) Fulfilling the Promise of Children’s Dental Coverage. Focuses on pediatric dental coverage and ways to improve children’s oral health. (August 2016) The Future of Children’s Coverage: Children in the Marketplace. Focuses on ways to improve marketplace coverage and the associated financial assistance for children. (June 2016) CCF.GEORGETOWN.EDU Cover all children 11 Endnotes 1 J. Alker and O. Pham, “Nationwide Rate of Uninsured Children 12 J. Alker and L. Roygardner, op. cit. Reaches Historic Low” (Washington: Georgetown University Center 13 Ibid. for Children and Families, October 2017), available at https://ccf. georgetown.edu/2017/10/22/nationwide-rate-of-uninsured-children- 14 E. Burak, “Promoting Young Children’s Healthy Development reaches-historic-low/. in Medicaid and the Children’s Health Insurance Program (CHIP)” (Washington: Georgetown University Center for Children and Families, 2 J. Alker and L. Roygardner, “The Number of Uninsured Children is On October 2018), available at https://ccf.georgetown.edu/wp-content/ the Rise” (Washington: Georgetown University Center for Children and uploads/2018/10/Promoting-Healthy-Development-v5-1.pdf. Families, October 2019), available at https://ccf.georgetown.edu/wp- content/uploads/2019/10/Uninsured-Kids-Report.pdf. 2018 N.J. Laws P.L. 2017, CHAPTER 361, 2665th Senate and 15 General Assembly, available at https://www.njleg.state.nj.us/2016/Bills/ 3 T. Brooks, E. Park, and L. Roygardner, “Medicaid and CHIP AL17/361_.HTM. Enrollment Decline Suggests the Child Uninsured Rate May Rise Again” (Washington: Georgetown University Center for Children and Families, 16 H. Clapp Padgette, C. Webb, and P. Jordan, “How Medicaid and May 2019), available at https://ccf.georgetown.edu/2019/05/28/ CHIP Can Support Student Success through Schools” (Washington: medicaid-and-chip-enrollment-decline/; and T. Brooks, “Latest CMS Georgetown University Center for Children and Families, April 2019), Data Show Slight Improvement in Decline in Child Enrollment in available at https://ccf.georgetown.edu/wp-content/uploads/2019/04/ Medicaid and CHIP” (Washington: Georgetown University Center Student-Success-Report.pdf. for Children and Families, December 2019), available at https://ccf. 17 J. Haley et al., op. cit. georgetown.edu/2019/12/06/latest-cms-data-show-slight-improvement- in-decline-in-child-enrollment-in-medicaid-and-chip/. 18 S. Collins, D. Radley, and J. Baumgartner, “Trends in Employer Health Coverage 2008-2018: Higher Costs for Workers and Their Families” 4 K. Wagnerman, A. Chester, and J. Alker, “Medicaid is a Smart (New York: The Commonwealth Fund, November 2019), available at Investment in Children” (Washington: Georgetown University Center for https://www.commonwealthfund.org/publications/2019/nov/trends- Children and Families, March 2017), available at https://ccf.georgetown. employer-health-care-coverage-2008-2018. edu/wp-content/uploads/2017/03/MedicaidSmartInvestment.pdf. 19 Kaiser Family Foundation, “Health Coverage of Immigrants” 5 “Covering Parents Helps Kids,” Georgetown University Center for (Washington: Kaiser Family Foundation, February 2019), available at Children and Families, https://ccf.georgetown.edu/2017/03/21/covering- https://www.kff.org/disparities-policy/fact-sheet/health-coverage-of- parents-helps-kids/. immigrants/. 6 J. Alker and L. Roygardner, op.cit. 20 J. Haley et al., op. vit. 7 The Census Bureau does not consider eligibility for IHS services to 21 Children’s Health Insurance Program Reauthorization Act (CHIPRA), be coverage when identifying individuals with health insurance. Those P.L. 111-3, §214 (2009), available at https://www.congress.gov/111/ who respond to the American Community Survey (ACS) or the Annual plaws/publ3/PLAW-111publ3.pdf. Social and Economic Supplement (ASEC) to the Current Population Survey who indicate they are only covered by the IHS are considered 22 T. Brooks, “Hot Off the Press: Annual KFF 50-state Survey on to be uninsured because IHS coverage is not considered to be Medicaid” (Washington: Georgetown University Center for Children comprehensive. The Congressional Budget Office (CBO), in contrast, and Families, March 2019), available at https://ccf.georgetown. defines as publicly insured people who use the Indian Health Service edu/2019/03/27/kff-survey/. for purposes of its coverage analyses. For consistency with health insurance coverage data presented in other CCF analyses, this brief 23 T. Brooks, op. cit. uses the Census Bureau definition. 24 J. Alker and L. Roygardner, op. cit. 8 J. Alker and L. Roygardner, op. cit. 25 The Children’s Partnership, “A Golden Opportunity: Lessons from 9 Under the Affordable Care Act, states may expand Medicaid coverage California on Advancing Coverage for All Children” (Washington: to include parents and other adults up to 133 percent of FPL. States that The Children’s Partnership, January 2018), available at https://www. have not adopted the Medicaid coverage expansion typically limit non- health4allkids.org/wp-content/uploads/2018/01/Golden-Opportunity- disabled adult Medicaid coverage to very low-income parents under Lessons-From-Californias-Journey-to-Advancing-Coverage-for-All- section 1931 of the Social Security Act (median income eligibility for Children-Report.pdf. parents under section 1931 was 49 percent of FPL in 2019). 26 R. Cohen and E. Zammitti, “Problems Paying Medical Bills Among 10 J. Alker and L. Roygardner, op. cit. Persons Under Age 65: Early Release of Estimates from the National Health Interview Survey, 2011-June 2017” (Hyattsville, MD: National 11 J. Haley et al., “Improvements in Uninsurance and Medicaid/CHIP Center for Health Statistics, December 2017), available at https://www. Participation among Children and Parents Stalled in 2017” (Washington: cdc.gov/nchs/data/nhis/earlyrelease/probs_paying_medical_bills_ Urban Institute Health Policy Center, May 2019), available at https:// jan_2011_jun_2017.pdf. www.urban.org/sites/default/files/publication/100214/improvements_in_ uninsurance_and_medicaid_chip_participation_among_children_and_ parents_stalled_in_2017_1.pdf. CCF.GEORGETOWN.EDU cover all children 12 27 Attendance Works, “Connecting School Attendance and Health Care 43 H. Bernstein et al., “One in Seven Adults in Immigrant Families Access” (Washington: Attendance Works, October 2015), available at Reported Avoiding Public Benefit Programs in 2018” (Washington: https://www.attendanceworks.org/connecting-school-attendance-and- Urban Institute, May 2019), available at https://www.urban.org/sites/ health-care-access/. default/files/publication/100270/one_in_seven_adults_in_immigrant_ families_reported_avoiding_publi_6.pdf and Protecting Immigrant 28 L. Hamel, C. Muñana, M. Brodie, “Kaiser Family Foundation/LA Families, “Public Charge: Does This Apply to Me?” (January 2020), Times Survey of Adults with Employer-Sponsored Health Insurance” available at https://protectingimmigrantfamilies.org/wp-content/ (Washington: Kaiser Family Foundation, May 2019), available at http:// uploads/2020/01/Public-Charge-Does-This-Apply-To-Me-Updated- files.kff.org/attachment/Report-KFF-LA-Times-Survey-of-Adults-with- January-2020-ENGLISH.pdf. Employer-Sponsored-Health-Insurance. 44 J. Alker and T. Brooks, “Strategies to Address Alarming Decline in 29 R. Fehr et al., “How Affordable are 2019 ACA Premiums for Middle- Children’s Health Coverage” (Washington: Georgetown University Income People?” (Washington: Kaiser Family Foundation, March Center for Children and Families, September 2019), available at https:// 2019), available at https://www.kff.org/health-reform/issue-brief/how- ccf.georgetown.edu/2019/09/30/regaining-enrollment-momentum-in- affordable-are-2019-aca-premiums-for-middle-income-people/. medicaid-and-chip/. 30 United States Government Accountability Office Report to 45 K. Pollitz, J. Tolbert, and M. Diaz, “Data Note: Limited Navigator Congressional Requesters, “Children’s Health Insurance: Opportunities Funding for Federal Marketplace States” (Washington: Kaiser Family Exist for Improved Access to Affordable Insurance” (Washington: United Foundation, November 2019), available at https://www.kff.org/health- States Government Accountability Office, June 2012), available at reform/issue-brief/data-note-further-reductions-in-navigator-funding-for- https://www.gao.gov/assets/600/591797.pdf. federal-marketplace-states/. 31 Internal Revenue Service, R.P. 2018-34, available at https://www.irs. 46 Enroll America, “In-Person Assistance Maximizes Enrollment gov/pub/irs-drop/rp-18-34.pdf. Success” (Washington: Enroll America, March 2014), available at 32 Employers generally require that workers contribute towards the https://familiesusa.org/wp-content/uploads/2019/09/2014-In-Person- cost of the premium. Annual premiums for employer-sponsored family Assistance-Maximizes-Enrollment-Success.pdf. health coverage reached $19,616 in 2018, up 5 percent from the year 47 42 C.F.R §435.904 (2013). before, with workers on average paying $5,547 toward the cost of their coverage. Kaiser Family Foundation and NORC at the University of Chicago, “2018 Employer Health Benefits Survey” (Washington: Kaiser Family Foundation and NORC at the University of Chicago, October 2018), available at http://files.kff.org/attachment/Report-Employer- The Georgetown University Center for Children and Health-Benefits-Annual-Survey-2018. Families (CCF) is an independent, nonpartisan policy 33 T. Brooks, “Health Policy Brief: The Family Glitch,” Health and research center founded in 2005 with a mission Affairs, (November 2014), available at http://www.healthaffairs.org/ to expand and improve high-quality, affordable health healthpolicybriefs/brief.php?brief_id=129. coverage for America’s children and families. CCF 34 K. Whitener and J. Alker, “The Future of Children’s Health Coverage: is based in the McCourt School of Public Policy’s Children in the Marketplace” (Washington: Georgetown University Health Policy Institute. Center for Children and Families, June 2016), available at https://ccf. georgetown.edu/2016/06/01/future-childrens-health-coverage-children- marketplace/. Georgetown University Center for Children and Families 35 J. Liu and C. Eibner, “Extending Marketplace Tax Credits Would Make Coverage More” (New York: The Commonwealth Fund, July McCourt School of Public Policy 2017), available at https://www.commonwealthfund.org/publications/ Box 571444 issue-briefs/2017/jul/extending-marketplace-tax-credits-would-make- 3300 Whitehaven Street, NW, Suite 5000 coverage-more. Washington, DC 20057-1485 36 J. Haley et al., op. cit. Phone: (202) 687-0880 37 J. Alker and O. Pham, op. cit. Email: childhealth@georgetown.edu 38 J. Haley et al., op. cit. 39 Ibid. www.ccf.georgetown.edu 40 Ibid. 41 T. Brooks, op. cit. facebook.com/georgetownccf 42 Melissa Jenco, “Study: Parents’ Medicaid coverage impacts children’s health,” AAP News, 2017, available at https://www.aappublications.org/ twitter.com/georgetownccf news/aapnewsmag/2017/11/13/MedicaidExpansion111317.full.pdf.