Advancing Health Equity for Children and Adults with a Critical Tool: Medicaid and Children’s Health Insurance Program Continuous Coverage Kelly Whitener and Matthew Snider Key Takeaways: z Latino children disproportionately receive their health coverage through Medicaid or CHIP. Together, these programs provide coverage for more than one-third (37.6 percent) of all children, but more than half (52.1 percent) of Latino children. z Adopting Medicaid and CHIP policies that remove barriers to participation and reduce gaps in coverage would narrow inequities in health coverage and access for Latino children. z 12-month continuous coverage advances health equity by promoting continuity of treatment for low-income children who experience disproportionate rates of health disparities. z Additionally, research shows that continuous eligibility policies significantly improve the continuity of children’s enrollment in Medicaid and are cost- effective. z Without policies like 12-month continuous eligibility in place, higher COVID-19 case rates and lower vaccination rates could lead to even longer-term inequities in access to care. OCTOBER 2021 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US 1 Introduction The COVID-19 pandemic underscores the need for universal While health inequities are leading to disproportionate access to health care and exposes the ways that systemic suffering among Latinos2 and other communities of color, racism diminishes access to both coverage and care.1 policymakers have an opportunity to learn from, and correct Maintaining affordable health coverage is essential to both for, this failure. More specifically, policies that support reduce transmission of the virus and ensure that those continuous coverage for low- and moderate-income children impacted by COVID-19 have access to vaccinations and covered by Medicaid and CHIP are an essential tool for treatment now and in the future. minimizing disruptions in care and promoting health equity. The Time is Now to Guarantee Continuous Coverage for Children and Adults Since January 2020, the Secretary of Health and Human at the end of the PHE.5 In addition to possible state action, Services (HHS) has declared a COVID-19-related public health Congress has considered various bills in recent years that would emergency (PHE), which was recently extended to January 16, provide for 12 months of continuous coverage for children in 2022, and may be extended again. During the PHE, the federal Medicaid and CHIP.6 The measure is also included in the House government is paying an additional 6.2 percentage points for Reconciliation bill currently being considered in Congress. state Medicaid costs. As explained below, it is also important that adults with In exchange for this additional federal money, states may Medicaid have continuous coverage. Under current law, states not disenroll those who were enrolled as of March 18, 2020 may adopt 12-month continuous eligibility for adults. However, or were subsequently enrolled.3 This “disenrollment freeze” they must do so through a more burdensome waiver process, has ensured continuous coverage for nearly all Medicaid which only two states have done to date. To encourage more beneficiaries. Yet the unwinding of this policy at the end of states to implement 12-month continuous eligibility for adults, the PHE could lead to thousands of eligible beneficiaries losing Congress should update the Medicaid statute to give states the health insurance.4 option to adopt this policy through a simpler process. Adopting 12 months of continuous eligibility for all children in Medicaid would help to mitigate potential coverage losses Policy Recommendations Continuous eligibility State Plan Amendment for all children in (SPA) option for Medicaid/CHIP continuous eligibility for adults in Medicaid 2 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US OCTOBER 2021 Health Coverage is Critical to Children’s Healthy Development, Yet Latino Children Lag Behind Children with health coverage are more likely to show Moreover, Latino children have long had higher uninsured rates improved health, lower rates of disability, higher educational than non-Latino children, but between 2017 and 2019 this attainment, and greater financial security in adulthood.7 gap started to widen further and the uninsured rate for Latino Unfortunately, following decades of progress, children’s children rose from 7.9 percent to 9.2 percent, which was the coverage trends are now going in the wrong direction. After largest increase in the uninsured rate for any racial or ethnic reaching a low of 4.7 percent in 2016, the uninsured rate for all group.9 children rose to 5.7 percent by 2019.8 Medicaid and CHIP provide critical support for working Latino families. Medicaid and CHIP Policies that Remove Barriers to Participation would Narrow Inequities for Latino Children Although Latinos have a higher labor force participation than The data also show that states with lower Medicaid and CHIP the general population, many Latino families still struggle to participation rates overall have higher rates of uninsurance for cover basic needs due to factors such as insufficient wage Latino children.11 growth and the lack of affordable employer-sponsored For these reasons, adopting Medicaid and CHIP policies that insurance.10 Medicaid and CHIP are therefore critical supports remove barriers to participation and reduce gaps in coverage for working Latino families. would narrow inequities in health coverage and access for Latino children disproportionately receive their health coverage Latino children. The sections below describe how state policy through Medicaid or CHIP. Together, these programs provide decisions impact access, particularly for Latino children, as coverage for more than one-third (37.6 percent) of all well as how policies to improve continuous coverage for Latino children, but more than half (52.1 percent) of Latino children. children can advance health equity. OCTOBER 2021 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US 3 State Policy Decisions Have a Major Impact on Access to Coverage There are many strategies that states could use to reduce Federal law requires states to use annual renewal periods for coverage inequities for Latino children (see Figure 1). A most populations, including children, but there is no federal key strategy is to adopt 12-month continuous eligibility requirement to provide 12 months of continuous coverage which allows states to cover children for a full year without today.14 Twenty-four states have adopted 12-month continuous interruption. eligibility for children in Medicaid, plus 26 of 35 separate CHIP programs.15 The policies work: children living in these states are Adoption of 12-month continuous eligibility allows a state less likely to be uninsured and to have a gap in coverage in the to keep children enrolled in coverage even if their family previous year.16 experiences a temporary change in income between renewals.12 States can adopt this policy for children through a In the remaining states without such policies, children straightforward amendment to their Medicaid and CHIP state frequently lose coverage between annual renewals, for a plans (known as a “State Plan Amendment” or SPA).13 variety of reasons. One common cause for loss of coverage is periodic data checks. Figure 1. Strategies States Could Use to Reduce Coverage Inequities for Latino Children Eliminating barriers to Increasing Medicaid/ coverage such as CHIP Adopting 12-month CHIP income eligibility premiums, waiting periods, continuous eligibility for children and families and lockouts Tailoring outreach and Waiving the 5-year waiting Covering all children enrollment campaigns to mixed period for lawfully residing regardless of citizenship status families who are more immigrant children status likely to be uninsured 4 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US OCTOBER 2021 In 30 states, agencies conduct periodic data matches by checking state databases for changes that could impact eligibility.17 If a data check shows an income discrepancy, the “Families do not receive the renewal notices on state sends a letter to the family – often with a tight, ten-day time. They do not understand the information response deadline – requesting paystubs or other paperwork on the notices. Their [online] account gets to verify ongoing eligibility. Sometimes the state’s data is out- closed, and they cannot get back in. Sometimes of-date, due to lags in data reporting, but unless the family they cannot get into the system prior to the responds right away with all the right documents, the child deadline, [and when] they need to enroll/ will lose coverage even if the state’s data does not reflect the renew online, the website is not user friendly.” family’s current eligibility or income (see Figure 2). – Belisa Urbina, Founder and Executive In contrast, a policy of 12-month continuous eligibility Director, Ser Familia, UnidosUS Affiliate guarantees a full year of coverage (even if income fluctuates) unless the family requests disenrollment or moves out of the state, or the child reaches adulthood. Figure 2. How Data Checks Lead to Loss of Coverage for Families ..... ..... Data check shows The state sends a letter to Family is unable to answer discrepancy, which may family with tight 10-day within timeframe and the or may not reflect family’s deadline verifying eligibility child loses coverage current eligibility Under 12-month continuous eligibility, a child is guaranteed a full year of coverage (even if income fluctuates) unless the child requests disenrollment, reaches adulthood, or moves out of state. OCTOBER 2021 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US 5 Latino Children are More Likely to Experience Harmful Gaps in Coverage, and Continuous Coverage Policies Can Close these Gaps A recent analysis of Medicaid/CHIP enrollment data found that More than half of Latino children live in just five states: Arizona, rates of churn – when beneficiaries lose coverage and re-enroll California, Florida, New York, and Texas. Yet Medicaid and within a year – are higher for Black and Latino beneficiaries CHIP continuous eligibility policies in these states vary widely. compared to non-Hispanic White beneficiaries.18 Furthermore, California and New York have adopted 12-month continuous when the enrollment rates were analyzed in light of the range eligibility for all children, Texas and Florida have done so of state policies, researchers found that there were lower rates for a small subset of children, and Arizona has not adopted of churn in states with 12 months of continuous coverage.19 continuous eligibility for any children.21 More than 1.5 million Looking specifically at children, about 10 percent of all children Latino children who are currently enrolled in Medicaid and experience a gap in coverage at some point during a year or are CHIP in Arizona, Florida, and Texas could benefit from adoption uninsured for the whole year, compared to about 14 percent of of 12-month continuous eligibility.22 Latino children and just over 7 percent of non-Hispanic White children (see Figure 3).20 Figure 3. Children Who Are Uninsured for All or Part of a Year by Race and Ethnicity All Children 9.9% Race/Ethnicity Non-Hispanic White* 7.3% Non-Hispanic Black 11.7% Non-Hispanic Asian 9.9% Non-Hispanic Other/Multiple Races 10.3% Hispanic* 13.9% Source: Georgetown University Center for Children and Families analysis of Agency for Healthcare Research and Quality 2018-2019 Medical Expenditure Panel Survey data. *Estimate is significantly different from the "All Kids" uninsured rate at the 0.10 level. 6 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US OCTOBER 2021 Income Instability Impacts Eligibility, Creating Coverage Gaps for Latinos Families with low and moderate incomes are more likely to experience income instability throughout the year, and this is especially true for Latino families. The Pew Charitable Trusts found that 45 percent of Latino families experience income volatility (defined as a change in monthly income of 25 percent or more).23 These income fluctuations can stem from changes in work such as an increase or decrease in hours or shifts and seasonal work or from changes in household makeup such as a child becoming an adult. The following example demonstrates how temporary fluctuations in income that lead to loss of health coverage can exacerbate financial strain on families. Imagine a Latino family with two children: one parent may work in construction, while the other parent works part-time as a housekeeper.24 Seasonal fluctuation in the construction industry leads the family’s income to increase during the busier summer months.25 This temporary increase in income may make the family appear ineligible on a periodic data check, causing the children to lose their health insurance, while their overall income on an annual basis would render them eligible. During this gap in coverage, the family would have to pay 100 percent of the costs of any needed medical services out of pocket. In addition to being more likely to experience income information and services needed to make appropriate health fluctuations, Latino families may also be more likely to lose decisions.28 Low health literacy makes it more difficult to coverage due to frequent eligibility reviews compared to other participate in the health care system and maintain good health. groups given the broader immigration policy and political Families with lower incomes, racial and ethnic minorities, and context. While nearly all Latino children are citizens, almost immigrants and refugees are all more likely to have low health half live in mixed-status families in which at least one parent literacy.29 Hispanics and individuals enrolled in public health is a noncitizen.26 More frequent eligibility reviews could insurance programs are especially at risk, leaving many Latino produce greater anxiety for a mixed status family already children vulnerable at this intersection due to factors entirely wary of enrolling. Research shows that the changes to public beyond their control.30 This is compounded by language access charge rules during the Trump Administration, among other issues, which are ubiquitous despite requirements for states to immigration-related policy changes and anti-immigrant provide language assistance services.31 The health care system rhetoric, created a chilling effect, leading eligible families can help by reducing the demands placed on individuals, to avoid public programs such as Medicaid out of fear and providing culturally competent care, and ensuring that system confusion.27 defaults provide support for continuing care, rather than burdening families.32 Moreover, a large share of adults in the U.S. have low health literacy, defined as the degree to which individuals have the capacity to obtain, process, and understand basic health Research shows that the changes to public charge rules during the Trump Administration, among other immigration-related policy changes and anti-immigrant rhetoric, created a chilling effect, leading eligible families to avoid public programs such as Medicaid out of fear and confusion. OCTOBER 2021 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US 7 Continuous Coverage Policies Have Clear Benefits for Adults As Well Under current law, states may only offer 12 months of continuous eligibility to adults by requesting a waiver from the Centers for Medicare & Medicaid Services (CMS) through a section 1115 demonstration project. The section 1115 approach involves a more onerous application and public comment process than the SPA process that permits policy changes on continuous coverage that apply to children. To date, only two states have implemented 12-month continuous eligibility for adults.33 Yet research suggests that adults would benefit from broader implementation of continuous eligibility too. The Medicaid and CHIP Payment and Access Commission (MACPAC) issued a recommendation in 2013 to allow for 12 months of continuous eligibility for adults through a SPA process, highlighting the benefits for people with chronic conditions such as diabetes and depression.34 Congress should amend the Medicaid statute to permit 12-month continuous coverage for adults through a SPA. Continuous Coverage Policies Promote Health Equity As described above, a full year of continuous coverage has $147 for a child enrolled for only six months (see Figure 4).39 many benefits. Medicaid continuous eligibility policies reduce Costs related to continuous eligibility are also reduced by state the unmet need for specialty care and lead to more preventive savings in administrative costs (to repeatedly review eligibility, care visits.35 On the other hand, children with interruptions in terminate children, and then re-enroll them) and increased coverage are more likely to have delayed care, unmet medical preventive care, which in turn reduces expensive acute and needs, and unfilled prescriptions.36 Continuous eligibility is also emergency care. associated with a 31 percent reduction in the risk of application problems, suggesting that the policy is effective in reducing paperwork barriers.37 Figure 4. Average Monthly Cost for a Child Enrolled in Medicaid Perhaps most importantly, continuous coverage advances health equity by promoting continuity of treatment for low-income children who experience disproportionate rates for 1 month of health disparities. For example, delayed care and unfilled prescriptions that arise from gaps in insurance coverage can be detrimental to children with chronic conditions such as $163 diabetes and asthma and put all children at greater risk of preventable childhood diseases, such as measles. for 6 months $147 Additionally, research shows that continuous eligibility policies significantly improve the continuity of children’s enrollment in Medicaid and are cost-effective.38 While keeping more children covered continuously has higher costs because enrollment is higher overall, such spending is also for 12 months more efficient: research shows that monthly per person costs decrease over time and decrease the most when the coverage period is the longest. For example, in Medicaid, the average $107 monthly cost for a child enrolled for 12 months was $107, compared to $163 for a child enrolled for only one month and 8 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US OCTOBER 2021 Access to Equitable Care is Particularly Important for Resilience in a Pandemic The COVID-19 pandemic has hit Latino communities particularly Health coverage is an essential aspect of care in a pandemic, as hard: Latinos are nearly twice as likely to die from the virus and it may support higher rates of COVID-19 testing, vaccination, represent approximately one-third of COVID-19 deaths among and/or treatment for Latino children. While COVID-19 children.40 Moreover, the long-term consequences of infection vaccinations are free, uninsured people are less likely to have are still unknown.41 COVID-19 also led to increased income received the vaccine and proof of insurance is still seen by volatility for many families, with nearly 30 percent of Latinos some Latinos as necessary for access.43 Without policies like reporting that they have been furloughed, had their hours 12-month continuous eligibility in place, higher COVID-19 case reduced, or lost income six months after the pandemic.42 rates and lower vaccination rates could lead to even longer- term inequities in access to care. Innovative Approaches to Continuous Coverage While more innovative approaches have yet to be enacted, some states are considering implementing longer periods of continuous coverage to reduce churn even further.44 For example, California, Oregon and Washington are considering multi-year continuous eligibility policies. California and Washington are aiming for five years of continuous coverage for the youngest children, ages 0 to 5. Oregon is also considering five years of continuous coverage, but for children of all ages. Multi-year continuous eligibility would provide stable insurance coverage during critical years of child development and further mitigate the impact on access to coverage and care from small, temporary fluctuations in family income. About the Authors Kelly Whitener is an Associate Professor of the Practice at the Georgetown University McCourt School of Public Policy’s Center for Children and Families. Matthew Snider is a Senior Health Policy Analyst at UnidosUS. Acknowledgements The authors thank Alexandra Corcoran, Cathy Hope, Leo Cuello, Melissa McChesney, and Laura MacCleery. Design and layout provided by Oyinade Koyi. OCTOBER 2021 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US 9 Endnotes among-children-and-parents-2019. 12 “Continuous Eligibility for Medicaid and CHIP Coverage,” Center for Medicaid and CHIP Services, https://www.medicaid.gov/medicaid/ 1 Systemic racism describes a system in which public policies, enrollment-strategies/continuous-eligibility-medicaid-and-chip- institutional practices, cultural representations, and other norms work coverage/index.html. in various, often reinforcing ways to perpetuate racial group inequity. “Glossary for Understanding the Dismantling Structural Racism/ 13 T. Brooks & A. Gardner, “Continuous Coverage in Medicaid and Promoting Racial Equity Analysis,” The Aspen Institute, available at CHIP,” (Washington, D.C.: Georgetown University Center for Children https://www.aspeninstitute.org/wp-content/uploads/files/content/ and Families, July 2021), available at https://ccf.georgetown.edu/wp- docs/rcc/RCC-Structural-Racism-Glossary.pdf. content/uploads/2021/07/Continuous-Coverage-Medicaid-CHIP-final. pdf. 2 The terms “Hispanic” and “Latino” are used interchangeably by the U.S. Census Bureau and throughout this document to refer to 14 The only federal requirements related to the duration of coverage persons who self-identify as being of Mexican, Puerto Rican, Cuban, are for deemed newborns (1 year) and post pregnancy (60 days). Central and South American, Dominican, Spanish, and other Hispanic 15 T. Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Cost descent; they may be of any race. This document may also refer to this Sharing Policies as of January 2020,” Kaiser Family Foundation (March population as “Latinx” to represent the diversity of gender identities 2020), available at https://files.kff.org/attachment/Table-11-Medicaid- and expressions that are present in the community. and-CHIP-Eligibility-as-of-Jan-2020.pdf (Table 11). Data on South 3 T. Brooks & A. Schneider, “Families First Coronavirus Response Carolina is based on 2019 survey. Act Medicaid and CHIP Provisions Explained,” (Washington, D.C.: 16 L. Ku & E. Brantley, “Continuous Medicaid Eligibility for Children and Georgetown University Center for Children and Families, March Their Health,” (Washington, D.C.: Milken Institute School of Public 22, 2020), available at https://ccf.georgetown.edu/2020/03/22/ Health Center for Health Policy Research, May 2020), available at families-first-coronavirus-response-act-medicaid-and-chip-provisions- https://www.communityplans.net/wp-content/uploads/2020/06/GW- explained/. continuous-eligibility-paper.pdf. 4 T. Brooks, “Tips for Advocates on Preparing for Unwinding of the 17 T. Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Cost PHE Continuous Eligibility Provision,” (Washington, D.C.: Georgetown Sharing Policies as of January 2020,” Kaiser Family Foundation (March University Center for Children and Families, August 31, 2020), available 2020), available at https://files.kff.org/attachment/Table-10-Medicaid- at https://ccf.georgetown.edu/2021/08/31/new-tips-for-advocates-on- and-CHIP-Eligibility-as-of-Jan-2020.pdf (Table 10). preparing-for-unwinding-of-the-phe-continuous-eligibility-provision/. 18 Medicaid and CHIP Payment and Access Commission, “An Updated 5 Ibid. Look at Rates of Churn and Continuous Coverage in Medicaid and 6 Patient Protection and Affordable Care Enhancement Act, H.R. 1425, CHIP,” MACPAC (October 2021), available at https://www.macpac.gov/ 116th U.S. Congress, 1st Session (February 28, 2019), available at wp-content/uploads/2021/10/An-Updated-Look-at-Rates-of-Churn- https://www.congress.gov/bill/116th-congress/house-bill/1425. and-Continuous-Coverage-in-Medicaid-and-CHIP.pdf. 7 E. Park, J. Alker, & A. Corcoran, “Jeopardizing a Sound Investment: 19 Ibid. Why Short-Term Cuts to Medicaid Coverage During Pregnancy and 20 J. Alker and A. Osorio, “Why is Medicaid/CHIP Continuous Eligibility Childhood Could Result in Long-Term Harm,” (Washington D.C.: The So Important for Kids?” Say Ahhh! Health Policy Blog, Georgetown Commonwealth Fund, December 8, 2020), available at https://www. Center for Children and Families (October 8, 2021), available at commonwealthfund.org/publications/issue-briefs/2020/dec/short- https://ccf.georgetown.edu/2021/10/08/why-is-medicaid-chip- term-cuts-medicaid-long-term-harm. continuous-eligibility-so-important-for-kids/. 8 These estimates come from the U.S. Census Bureau American 21 T. Brooks, Op cit. 15. Community Survey (ACS). Given the significant pandemic-related 22 Estimate based on data from the 2019 American Community Survey disruptions to data collection, the Census Bureau announced that it (ACS) Public Use Microdata Sample (PUMS). Estimate should be will not be releasing 2020 one-year estimates comparable to prior treated as a ballpark figure, given that there is a known undercount of years. The U.S. Census Bureau Current Population Survey Annual children on Medicaid and CHIP in ACS data. Further, the data do not Social and Economic Supplement (CPS ASEC) has released 2020 health disaggregate children covered by Medicaid from children covered by insurance coverage estimates (5.6 percent uninsured rate for all CHIP; household income is used as a rough proxy for the Texas share children and 9.5 percent for Hispanic/Latino children), however these of the estimate, where children with CHIP have 12-month continuous should be interpreted with caution given the high non-response rate eligibility, but children with Medicaid do not. the CPS experienced during the pandemic. 23 The Pew Charitable Trust, “How Income Volatility Interacts With 9 J. Alker & A. Corcoran, “Children’s Uninsured Rate Rises by Largest American Families’ Financial Security” (March 9, 2017), available Annual Jump in More Than a Decade,” (Washington, D.C.: Georgetown at https://www.pewtrusts.org/en/research-and-analysis/issue- University Center for Children and Families, October 2020), available briefs/2017/03/how-income-volatility-interacts-with-american- at https://ccf.georgetown.edu/wp-content/uploads/2020/10/ACS- families-financial-security. Uninsured-Kids-2020_10-06-edit-3.pdf. 24 The most common occupations for working Latino parents with 10 Unidos US, “Latinos Jobs Report: Latino Unemployment Rate At children covered by Medicaid are construction laborers and maids/ 7.3%” (Washington, D.C.: Unidos US, May 2021), available at https:// housekeepers. Georgetown University Center for Children and Families www.unidosus.org/publications/2167-latinos-jobs-report-latino- analysis of US Census Bureau American Community Survey (ACS) 2019 unemployment-rate-at-7-3/. Integrated Public Use Microdata Sample (IPUMS). 11 J.M. Haley, et al., “Uninsurance Rose among Children and Parents 25 M. Geremew and F. Gourio, “Seasonal and Business Cycles of in 2019,” (Washington, D.C.: Urban Institute, July 15, 2021), available U.S. Employment,” Economic Perspectives 42, no. 3 (2018): 1-28, at https://www.urban.org/research/publication/uninsurance-rose- available at https://www.chicagofed.org/publications/economic- 10 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US OCTOBER 2021 perspectives/2018/3. Continuous Eligibility Policies Reduce Unmet Need for Specialty Care, 26 K. Whitener & A. Corcoran, “Getting Back on Track: A Detailed Look Lead to More Preventive Care Visits,” (Washington, D.C.: Association at Health Coverage Trends for Latino Children,” (Washington, D.C.: for Community Affiliated Plans, June 23, 2020), available at https:// Georgetown University Center for Children and Families, June 8, www.communityplans.net/study-medicaid-continuous-eligibility- 2021), available at https://ccf.georgetown.edu/2021/06/08/health- policies-reduce-unmet-need-for-specialty-care-lead-to-more- coverage-trends-for-latino-children/#heading-10. preventive-care-visits/. 27 J.M. Haley et al., “One in Five Adults in Immigrant Families with 36 L. Ku & E. Brantley, Op cit. 16. Children Reported Chilling Effects on Public Benefit Receipt in 2019,” 37 E. Brantley and L. Ku, “Continuous Eligibility for Medicaid Associated (Washington, D.C.: Urban Institute, June 18, 2020), available at https:// with Improved Child Health Outcomes,” Medical Care Research www.urban.org/research/publication/one-five-adults-immigrant- & Review (pre-print, September 2021), available at https://doi. families-children-reported-chilling-effects-public-benefit-receipt-2019. org/10.1177/10775587211021172. 28 Center for Health Care Strategies, Inc., “Fact Sheet #1: What is 38 L. Ku, E. Steinmetz, & B. Bruen, “Continuous Eligibility Policies Health Literacy?” (Hamilton, NJ: Center for Health Care Strategies, Stabilize Medicaid Coverage for Children and Could be Extended to Inc., October 2013), available at https://www.chcs.org/media/What_ Adults with Similar Results,” 32, no. 9, September 2013: 1576-1582, is_Health_Literacy.pdf. available at https://doi-org.proxy.library.georgetown.edu/10.1377/ 29 National Hispanic Council on Aging, “Health Literacy,” (Washington, hlthaff.2013.0362. D.C.: National Hispanic Council on Aging, April 10, 2015), available at 39 L. Ku, E. Steinmetz, & T. Bysshe, “Continuity of Medicaid https://nhcoa.org/our-work/nhcoa-programs/health-literacy/. Coverage in an Era of Transition,” (Washington, D.C.: Association 30 J. Edward et al., “Significant Disparities Exist in Consumer Health for Community Affiliated Plans, November 1, 2015), available at Insurance Literacy: Implications for Health Care Reform,” Health http://www.communityplans.net/Portals/0/Policy/Medicaid/GW_ Literacy Research and Practice, 3, no. 4 (2019): e250-e258, available ContinuityInAnEraOfTransition_11-01-15.pdf at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831506/pdf/ 40 Centers for Disease Control, “Hospitalization and Death by Race/ hlrp1119edward.pdf. Ethnicity,” (September 9, 2021), available at https://www.cdc. 31 M. Mirza et al., “Medicaid Redetermination and Renewal gov/coronavirus/2019-ncov/covid-data/investigations-discovery/ Experiences of Limited English Proficient Beneficiaries in Illinois,” hospitalization-death-by-race-ethnicity.html; The COVKID Project: Journal of Immigrant and Minority Health (pre-print, March 2021), Coronavirus in Kids Tracking and Education Project, “Understanding available at https://link.springer.com/article/10.1007/s10903-021- the Disparities Data,” (August 2021), available at https://www. 01178-8; C. Alvarez Caraveo et al., “Barriers to Medicaid and CHIP covkidproject.org/disparities. Coverage for Eligible but Uninsured Latinx Children,” (Washington, 41 Ibid. D.C.: Urban Institute, February 1, 2021), available at https://www. 42 M. Karpman, S. Zuckerman, & G.M. Kenney, “Uneven Recovery urban.org/research/publication/barriers-medicaid-and-chip-coverage- Leaves Many Hispanic, Black, and Low-Income Adults Struggling,” eligible-uninsured-latinx-children. (Washington, D.C.: Urban Institute, October 2020), available at 32 Center for Health Care Strategies, “Health Literacy Fact Sheets,” https://www.urban.org/sites/default/files/publication/103105/ (Hamilton, NJ: Center for Health Care Strategies, Inc., October 2013), uneven-recovery-leaves-many-hispanic-black-and-low-income-adults- available at https://www.chcs.org/resource/health-literacy-fact- struggling.pdf. sheets/. 43 G. Sparks, A. Kirzinger, & M. Brodie, “KFF COVID-19 Vaccine 33 Montana and New York currently operate section 1115 Monitor: Profile of the Unvaccinated,” (Washington, D.C.: Kaiser demonstrations which include 12-months continuous eligibility Family Foundation, June 11, 2021), available at https://www.kff.org/ for adults. (Montana has submitted an amendment to terminate coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor- this policy). Kansas has a pending request for a section 1115 profile-of-the-unvaccinated/; Unidos US, “National Survey of Latino waiver to extend 12-month continuous coverage to parents and Parents,” (Washington, D.C.: Unidos US, August 2021), available at caretaker adults. For more information, see Montana Department https://www.unidosus.org/wp-content/uploads/2021/09/unidosus_ of Public Health and Human Services, “Section 1115 Demonstration parentsurveytopline_91321.pdf. Amendment Application,” (September 3, 2021), available at https:// 44 T. Brooks, “States Move Toward Multi-Year Continuous Eligibility www.medicaid.gov/medicaid/section-1115-demonstrations/ for Children in Medicaid,” Say Ahhh! Health Policy Blog, Georgetown downloads/mt-wasp-pa.pdf; D. Tsai, “New York Medicaid Redesign University Center for Children and Families (June 3, 2021), available at Team Amendment Special Terms and Conditions,” Center for https://ccf.georgetown.edu/2021/06/03/states-move-toward-multi- Medicaid and CHIP Services (October 5, 2021), available at https:// year-continuous-eligibility-for-children-in-medicaid/. www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/ Waivers/1115/downloads/ny/ny-medicaid-redsgn-harp-cmbnd-ltr- stcs-ca.pdf; Kansas Department of Health and Environment, “KanCare Section 1115 Demonstration Amendment Request,” (August 13, 2021), available at https://www.medicaid.gov/medicaid/section-1115- demonstrations/downloads/ks-kancare-pa5.pdf. 34 Medicaid and CHIP Payment and Access Commission, “Eligibility Issues in Medicaid and CHIP: Interactions with the ACA,” (Washington, D.C.: MACPAC, March 2013), available at https://www.macpac.gov/ wp-content/uploads/2013/03/Eligibility-Issues-in-Medicaid-and-CHIP- Interactions-with-the-ACA.pdf. 35 Association for Community Affiliated Plans, “Study: Medicaid OCTOBER 2021 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US 11 Georgetown University UnidosUS Center for Children and Families 1126 16th Street, NW, Suite 600 3300 Whitehaven Street, NW, Suite 5000 Washington, DC 20036 Washington, DC 20057 info@unidosus.org childhealth@georgetown.edu unidosus.org ccf.georgetown.edu 12 GEORGETOWN UNIVERSITY CENTER FOR CHILDREN AND FAMILIES | UNIDOS US OCTOBER 2021