Prevention is better than cure, especially for children. Maintaining access to affordable health care coverage empowers them to thrive. However, as a result of Medicaid unwinding, children are losing health care coverage at alarming rates. As of February 1, 2024, 2,898,000 children across the United States have lost access to Medicaid through the unwinding process. In some states, such as Texas, nearly two-thirds of the children enrolled lost their coverage, putting their families at risk of incomprehensible amounts of medical debt should their child become sick. We’re just barely over halfway through unwinding — 48% of enrollees are still awaiting their determinations, meaning that the country likely will see another onslaught of coverage losses over the next few months.
Many children lost coverage not because of their eligibility, but because of procedural issues such as incorrect phone numbers, old addresses, or paperwork mistakes. On average, states have disenrolled almost three-quarters of recipients during unwinding due to these procedural reasons. In some states, these rates are as high as 94%. This means that millions of children no longer have access to health care, all because their parents missed a form in the mail.
While unwinding has been terrible for kids’ health coverage, another policy has stepped in to help keep kids covered — 12-month continuous eligibility. As of January 1, 2024, all states are required to provide one year of continuous coverage for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). This means that children enrolled in Medicaid or CHIP are guaranteed 12 months of continuous coverage even if their household’s circumstances change, preventing gaps in coverage and periods of uninsurance due to income fluctuations or missed paperwork. Though it cannot undo the harms already done by the unwinding, 12-month continuous eligibility is a boon for children’s coverage.
Experience has shown that continuous eligibility works — many states already had this policy prior to the new national requirement, and their child disenrollment rates were about half the rate of states without continuous eligibility. Unwinding highlights how arduous and ineffective the current renewal process is for millions of families, and the success of continuous eligibility policies highlights the benefits of keeping kids enrolled.
Keeping kids covered is a cost saver for both families and states. On average, states lose $400-$600 in administrative costs for each child that rotates in and out of Medicaid coverage, a process called “churn.” Research also shows that Medicaid enrollment significantly reduces families’ medical debt. This stability helps support a family’s overall financial health, making them less likely to carry non-medical debt as well. Both of these factors allow parents to purchase other necessities for their children such as food, clothing, and housing.
While 12 months of continuous eligibility is a great start, it’s not enough to keep our kids covered. KFF reports that after the 12-month window passes, child churn more than doubles. Children need consistent access to health care coverage to receive the routine and emergency medical care that they need during their earliest years. The American Academy of Pediatrics recommends that children visit their physicians at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months to ensure that they are developing properly. Most churn gaps last 3-9 months, meaning that young children could miss nearly half of these critical appointments. This means that doctors may not detect emerging conditions or developmental delays in a timely manner, delaying diagnosis and treatment.
To keep kids covered Congress must pass five-year continuous eligibility, which keeps kids covered during the most important years for their development. Continuous eligibility eliminates churn in early childhood, ensuring that children can receive all of their vaccines, screenings, and routine checkups at an affordable cost to their parents. With five-year continuous eligibility, children, regardless of their socioeconomic background, can receive the care they need to be successful as they begin school. This simple extension also reduces administrative burdens for both families and state governments by reducing the frequency of the redetermination processes.
First Focus Campaign for Children supports Rep. Joe Neguse’s (D-CO) Save Children’s Coverage Act (H.R. 1316), which allows states to implement continuous eligibility for children through age 5 via a state plan amendment (SPA) rather than submission of a Section 1115 waiver, which requires negotiation and approval from the federal government. Rep. Neguse’s legislation reduces the administrative burden of deciding to provide early childhood continuous eligibility, making it easier for states to implement.
Unwinding has been devastating for children, and the ramifications of this political failure will be evident for years to come. However, continuous eligibility offers an opportunity to ensure that no child or family will have to constantly navigate these bureaucratic hurdles that keep kids from coverage. Implementing five-year continuous eligibility will help keep kids worrying about important kid things — like quicksand and mall Santas — instead of spending their childhoods sick.
With food insecurity rising and summer on the way, 14 states have rejected a program that would keep students fed while school is out.
In a rare bipartisan agreement, Congress recently approved a Summer Electronic Benefit Transfer (EBT) program that would provide $40 per month to families with children enrolled in the free or reduced-price school meal programs during most of the year. The additional assistance would help families bridge the three-month gap in school meals and keep their children from going hungry over the summer. The federal government funds all of the Summer EBT benefit costs and half of the administrative cost, creating a fiscally feasible program that ensures students are better supported.
Yet governors in 14 states have rejected this relatively easy — and extremely effective — money. Many objected to what they characterized as “irresponsible” government spending. Others offered shocking ignorance of the way poverty, food insecurity, and children’s health all work together. Iowa Governor Kim Reynolds, for example, said there was no need for the program “at a time when childhood obesity has become an epidemic.” The United States’ child obesity epidemic is a symptom of pervasive food insecurity, which often results in children consuming high-calorie, low-nutrition foods. Food assistance programs have proven to create better health outcomes for kids.
The governor of Nebraska initially rejected this money as well, simply stating “I don’t believe in welfare.” He recently reversed this decision due to political pressure, especially from state legislators representing rural areas that are far from many community resources. While the carelessness in his initial decision-making is clear, it also proves the importance of pressuring policymakers to prioritize kids. Since children are often on the back burner for policymakers, this recent reversal proves that advocating for them is essential.
Ensuring kids are fed should not be a political game. Politicians are using child hunger for political gain, despite the Summer EBT program reducing long-term spending and providing necessary food support. The decision to reject funding for student meals highlights the lack of emphasis our policymakers put on ensuring children have what they need to thrive. One-in-5 children don’t have enough to eat and families with children are more likely to face hunger. This should be a priority issue for policymakers across the country, but the decision to decline federal support for student meals proves otherwise.
The decision of these governors leaves millions of students without summer meals. While federal lawmakers took an appreciated step to prioritize spending to keep children fed, state-level officials are putting politics over kids.
Images of Flint Michigan’s water are hard to forget. For months in 2016, residents drank from taps running gasoline-colored liquid and water bottles filled with murky sludge, but one contaminant grabbed the headlines: lead. Blood lead levels (BLLs) among Flint’s children doubled citywide and even tripled in certain neighborhoods just months after the crisis began. These children suffered from rashes, behavioral issues, and learning delays, which could potentially follow them for life.
As Flint pediatrician Dr. Mona Hanna-Attisha said, “Lead is one of the most damning things you can do to a child in their entire life-course trajectory.” However, America’s lead problem isn’t isolated to just one town. An estimated 500,000 children have dangerous levels of lead in their blood, which can lead to serious health complications. But, as in Michigan, contaminated water may be one of the most prominent sources.
Lead seeps into our drinking water via lead pipes, which corrode over time and release lead particles into passing water. These pipes are most prevalent in older homes and buildings, which often are occupied by low-income families or families of color, a situation that has created a decades-old disparity in BLLs. Across the country, Black children and children in low-income households have higher levels of lead in their blood than their white and/or wealthier peers.
Aging school buildings often serve as a significant source of lead exposure for children. An estimated 400,000 schools and child care centers may have elevated levels of lead in their water. There’s currently no mandated lead testing for school buildings, and schools know that if they find lead, they have to fix it — so more than half just don’t test at all. Among schools that have tested, more than one-third found elevated lead levels in their water.
The health ramifications of lead exposure are severe and can cause lifelong complications. Children drink more water per pound of body weight than adults, making them more susceptible to smaller levels of lead. Additionally, lower blood levels of lead cause greater impacts on children than in fully-developed adults. Infants are perhaps at the most risk of consuming lead in drinking water, as those who consume formula may receive up to 60% of their lead exposure via water (as compared to 20% for the average person).
The ramifications of lead exposure follow children for a lifetime and severe lead poisoning may lead to lasting behavioral and intellectual disabilities. The academic challenges that they face may lead to poorer economic outcomes in adulthood. Research shows that children who were exposed to lead are more likely to have lower socioeconomic statuses than their parents in adulthood. On all fronts, lead exposure sets children up for failure.
So, how do we get the lead out? We can start by replacing our lead pipes. The Environmental Protection Agency recently proposed a rule that will require all community water systems to replace their lead pipes by 2037, starting with communities that have been disproportionately impacted by lead exposure. If finalized, the rule could eliminate one of the biggest sources of lead exposure for kids. Read our comment to learn more.
The Biden-Harris Administration provided $350 billion in the American Rescue Plan for schools and child care centers to replace lead piping. The Bipartisan Infrastructure Law also provides billions for states, tribes, and local governments to begin to update their water systems. It’s up to those governments to take up those funds and begin these projects to protect their children’s health.
In this episode, our hosts Bruce Lesley and Messellech “Selley” Looby chat with Representative Suzanne Bonamici. Rep. Bonamici, who has represented Oregon’s 1st district in Congress since 2012, has been an avid Champion for children throughout her career and achieved the #1 slot on First Focus Campaign for Children’s 2023 Legislative Scorecard. The Congresswoman discusses her legislative priorities, including passing the Child Tax Credit, advocating for a strong public education system, ending child hunger, supporting youth experiencing homelessness, and protecting food programs such as SNAP and WIC. She talks about her belief that funding the health, well-being, and safety of children is the best investment our society can make, and offers advice for listeners on how to affect change themselves.
The United States provides poverty-focused foreign assistance to poor countries to promote global health, security, and democracy, to reduce the worst aspects of poverty, and to respond to disasters and crises. This type of foreign assistance is not only the right thing to do, and represents the best of our American values, but it is the smart thing to do. It promotes national security, global stability, and international trade while reinforcing our diplomatic and strategic priorities by boosting goodwill.
U.S. Foreign Assistance Has Achieved Great Things, But More Is Needed
Thanks in part to U.S. investment in poverty-focused development and humanitarian assistance, deaths of children under five years old due to preventable disease and malnutrition have fallen from more than 12 million a year in 1990 to around 5 million today. Other notable achievements over the past 20 years thanks to U.S. foreign aid include 5.5 million babies being born HIV-free and 25 million men, women and children being saved from HIV.
While these are huge triumphs to be celebrated, recent global setbacks including the COVID-19 pandemic, advancing climate change, new and ongoing conflicts, and mounting global food insecurity are putting these achievements at risk and heightening the urgency of refining our efforts. It is critical that the U.S. do all it can to ensure maximum impact of the limited pot of money spent on foreign assistance, especially the dollars spent on behalf of the most vulnerable children. The fact is, like elsewhere in our U.S. budget, children have never received the attention or share of foreign assistance budget resources they deserve. And it shows.
Children Are in Crisis
According to UNICEF, children are more likely to live in poverty than adults and more vulnerable to its effects.
“Children who grow up impoverished often lack the food, sanitation, shelter, health care and education they need to survive and thrive. Across the world, about 1 billion children are ‘multidimensionally’ poor, meaning they lack necessities as basic as nutritious food or clean water. Worldwide, the poorest children are twice as likely to die in childhood than their wealthier peers.”
Children make up half of those living in absolute poverty worldwide despite being 30 percent of the population. Poverty, and everything that comes with it, has a devastating impact on child development.
In addition to shortening their life spans, absolute poverty means sickness and suffering for children that stunts the growth of their bodies and brains—robbing them, their families, and their nations of their full potential. According to a report in The Lancet
“a staggering 43 percent of children under five years of age—an estimated 250 million—living in low- and middle-income countries are at risk of suboptimal development due to poverty and stunting. The burden is currently underestimated because risks to health and wellbeing go beyond these two factors.”
Congressional Action on Behalf of Children Worldwide
Over the past three decades, Champions for Children in the U.S. Congress have sought to address child mortality and stunting through funding increases in global nutrition and maternal and child health programming. Their leadership contributed to the dramatic drop in deaths of under-five-year-olds from preventable diseases and malnutrition.
Then in 2021, in an effort to make U.S. efforts even more impactful and ensure that kids were not just surviving but thriving, Reps. Joaquin Castro (D-TX), Brian Fitzpatrick (R-PA) and Sens. Chris Coons (D-DE), and Roy Blunt (R-MO) secured passage of the Global Child Thrive Act (GCTA) mandating the integration of Early Childhood Development (ECD) into U.S. foreign aid programs serving kids. By integrating ECD into current interventions, Congressional Champions for Children were following the science and multiplying the positive impacts of already successful U.S. international programming. Incorporating parent training on responsive caregiving into a maternal and child health program, for example, takes that program to the next level and ensures that children not only live beyond their fifth birthday but that their brains and bodies develop to their full potential too.
Where is USAID on Implementation of the Global Child Thrive Act?
Since the passage of the Global Child Thrive Act, the U.S. Agency for International Development (USAID) has released implementation guidance designed for easy use by U.S. missions around the globe. This is a good step in the right direction. However, funding and leadership to successfully implement the law are desperately needed.
Implementation of the act falls to the tiny and vastly under-resourced Children in Adversity Office at USAID. This office is funded each year by a miniscule pot of money (roughly $30 million) called the Vulnerable Children Account within the State, Foreign Operations Appropriations bill. The Children in Adversity Office does some of the most important child-focused work in the world by promoting care for the most vulnerable children, protecting children from violence and neglect, and supporting family care (as opposed to orphanages or institutions which tend to have harmful implications for child well-being and development). But, due to its small staff and lack of resources, the office’s reach has been limited, as is its ability to ensure the implementation of the Global Child Thrive Act all on its own.
What Do the World’s Children Deserve?
What would the world look like for children if Congress, the Administration, USAID, and U.S. foreign assistance funding were to adequately focus on their developmental needs and provide them their fair share of resources?
As mentioned on our Speaking of Kids podcast, the amount of money the U.S. provides for foreign aid is modest to begin with. When polled, Americans estimate that 25 percent of the federal budget goes to international assistance. The truth is that just 1 percent of the U.S. federal budget goes toward foreign assistance—and within that, less than half is devoted to poverty-focused development and humanitarian programs. The remainder goes toward economic and security or military funding.
And when it comes to children in the foreign aid budget, we treat them the same as everywhere else: Children are always last and receive the least. Children have specific developmental needs and investing in them delivers an outsized return on investment. Yet our spending on kids is minuscule.
The U.S. budget currently skews investment toward adults, both domestically and globally. First Focus on Children works to make children the priority in federal budget and policy decisions, not only because it is the right thing to do, but because children are inherently vulnerable. Kids are more fragile than adults—unable to withstand periods of malnutrition or bouts of extreme heat or unclean water for as long as a grownup—so focusing on their needs first, rather than last or not at all, would save more lives—thereby more successfully achieving a top objective of U.S. poverty-focused foreign assistance. Additionally, it is the smart thing to do. Investing earlier in the human life cycle produces a bigger bang for the buck in terms of human brain growth, future health, and economic success.
First Focus on Children’s 2023 Children’s Budget documents that just 9 cents of every $1 of U.S. foreign assistance goes to babies and kids worldwide despite the fact that they make up a third of the population globally. So out of the one-half of one percent of the U.S. budget that goes to poverty-focused development assistance, just 9 percent of that modest pot of funding goes to kids.
With such meager funding provided for children, and such a tiny, under-resourced office dedicated to their well-being, it is no wonder that the Congressional mandate included in the Global Child Thrive Act to integrate early childhood development interventions into current programs serving vulnerable children has been so slow to take hold at the country-level. Indeed, three years after its passage, most U.S. missions worldwide are still minimally aware of the law’s existence.
And USAID leadership has thus far been silent on the importance of implementing the GCTA. Communication from the top down that the GCTA is a priority would move its enactment along, as would adequate funding for USAID missions to be able to follow through successfully.
Implementing and successfully funding the GCTA’s early childhood development mandate also would help break down some of the funding siloes inherent in U.S. foreign assistance. For instance, Congress generally provides U.S. foreign aid separately for schooling or health services or clean water, or nutritious food. But children are multi-dimensional and have physical, emotional, and cognitive needs that require a combination of all of those supports to achieve their full potential. Supporting children holistically with a “whole child” approach that takes into account their developmental stages and intersecting needs ensures better outcomes.
A Call to Action for Vulnerable Children
Children need the people in charge to prioritize their needs. Children all over the world face more challenges than ever. First Focus Campaign for Children calls on Congress to significantly expand resources for vulnerable children in the Fiscal Year 2025 State, Foreign Operations Appropriations bill to at least $35 million. USAID leadership must prioritize the Children in Adversity Office and its work to ensure effective and rapid implementation of the Global Child Thrive Act.
In addition, the Biden-Harris Administration must do all in its power to prioritize children globally and here at home. First Focus on Children recently called on President Biden to make children a cross-agency priority through the Office of Management and Budget and to implement child impact statements across agencies to assess the U.S. government’s impact on child well-being. Governments use child impact statements to build child well-being into policy design. As with environmental impact statements, this approach would require government agencies to address the potential positive and negative effects on children posed by regulations, rules, policies, programs, and guidance.
Much more can and should be done for our children. Our kids are in crisis and now is the time to act on their behalf.
One of the most joyful times in the life of parents is the birth of their first child. Meeting a tiny baby for the first time is a life-changing moment. That baby will bring grandparents, aunts, uncles, and friends together in a special way. Everyone celebrates and supports the first-time parents in their new journey.
The last thing that should ruin this joyful experience is “surprise billing,” but for some first-time parents, that is exactly what happens. It usually happens to new parents whose baby is born with medical issues that require time in the hospital, and possible tests and/or surgeries before the baby can go home. When babies cannot go home as planned, it is often a stressful event for the new parents. They worry about their baby’s health, how to care for them upon discharge, and the normal anxiety of new parents. And while new parents are especially vulnerable to getting caught in the “birthday rule,” anyone can get caught.
For these new parents who picked between their two health insurance plans ahead of time to identify which insurance plan to add the baby to, they are probably fine. They likely picked the insurance plan with more generous primary care coverage for the baby. For parents who had not yet identified which plan to select (maybe the baby arrived early, or they were unaware that they needed to select between the two plans, or they were simply too busy to pick one plan), health care becomes a game of chance.
Under current law, when parents both have individual health insurance coverage but have not yet decided which plan to use for their new child, a default kicks in: The parent whose birthday comes first in the calendar year covers the new baby with their health insurance plan, regardless of whether it’s the best plan. This default is known as the “birthday rule.”
If the baby needs expensive medical care at birth — and in the days and weeks afterward — the parents could receive surprise medical bills in the tens or hundreds of thousands of dollars. Families across the country have experienced this issue, but it is rarely discussed. Needless to say, excessive medical debt incurred because of this arbitrary “birthday rule” can add damaging stress to these families.
To support these parents and fix the birthday rule, the Empowering Parents’ Healthcare Choices Act introduced by Rep. Sharice Davids (D-KS), would give parents up to 60 days after the birth of their child to choose which insurance policy will cover their new baby. The bill also would give the Administration authority to instruct insurers on how and when to notify parents of their rights.
This bill would give new parents more control over their health care and would offer them peace of mind. The 60-day window would give them time to compare premium rates and plan benefits, including what deductibles are required from each plan.
Let’s let our parents focus on the birth of their child with peace of mind. They know they have health insurance, but if this bill passes, they will also know that they will have just a bit more time to decide which of the two health plans is a better fit for their new family.
Written by Elaine Dalpiaz, Vice President, Health Systems and Strategic Partnerships with special thanks to Megan Condon for her contribution to this blog.
In this episode, we chat with Dr. Mona Hanna-Attisha and Professor Luke Shaefer about “Rx Kids,” their innovative program to support pregnant women and infants in Flint, Michigan. Dr. Hanna-Attisha is a pediatrician and activist best known for leading studies that exposed the deadly levels of lead in Flint’s water supply. Dr. Shaefer leads Poverty Solutions, an interdisciplinary initiative at the University of Michigan that partners with communities and policymakers to find new ways to prevent and alleviate poverty. Their conversation with our hosts centers on the importance of “Rx Kids,” which gives pregnant moms a prenatal allowance and support during the first 12 months of a child’s life. By supporting families during their most vulnerable window, the program aims to address a root cause of health equity and opportunity.
Child hunger does not have to exist. Incredibly, policies that could keep children from going hungry are staring lawmakers at the federal and state levels in the face, and yet, they are failing to act and failing kids.
Congress Should Enact an Expansion of the Child Tax Credit
First, in 2021, Congress failed to extend the improved Child Tax Credit, and this contributed greatly to the increase in child poverty from 4 million, or 5.2%, in 2021 to 9 million, or 11.4%, in 2022. This has led to an increase in food insecurity, particularly among our nation’s children. In fact, according to survey data from the U.S. Census Bureau at the close of 2022, the U.S. Department of Agriculture reports:
Children and adults were food insecure at times during 2022 in 8.8 percent of U.S. households with children, up from 6.2 percent in 2021 and 7.6 percent in 2020.
Congress should extend the Child Tax Credit and commit to a goal of dramatically reducing child poverty in this country. Senate Finance Committee Chair Ron Wyden (D-OR) and House Ways and Means Committee Chairman Jason Smith (R-MO) have reached a tentative tax deal that includes an enhanced Child Tax Credit that will take a step toward beginning to reverse the recent increase in the child poverty rate. However, it faces some opposition and procedural hurdles that make its passage in Congress challenging.
A fully refundable Child Tax Credit would substantially help reduce child hunger, and we must strive to make the passage of H.R. 3899, Rep. Rosa DeLauro’s (D-CT) “American Family Act” (209 House cosponsors), or S. 1992, Sen. Sherrod Brown’s (D-OH) “Working Families Tax Relief Act” (42 Senate cosponsors), a reality as soon as possible.
Congress Must Fully Fund WIC…NOW!
Second, for more than a quarter of a century, Congress has adhered to a bipartisan agreement to fully fund the Special Supplemental Program for Women, Infants, and Children (WIC). As First Focus Campaign for Children, the Child and Student Nutrition Alliance, Hunger Free Colorado, the National Association of Pediatric Nurse Practitioners, the National League for Nursing, and UnidosUS explain:
For over fifty years, the WIC program has been one of the most essential federal programs in giving low-income pregnant women, postpartum and breastfeeding individuals, infants, and children at nutritional risk a better start in life. WIC provides over 6.7 million mothers and children access to nutritious foods, counseling on healthy eating, and breastfeeding support. A vast body of research confirms that properly nourishing children not only have better health outcomes but more actively participate at school, and have better focus and information retention.
Unfortunately, WIC is facing a $1 billion shortfall this year and state programs are borrowing against themselves to meet the program’s needs. WIC desperately needs congressional action, or an estimated 2 million pregnant women, infants, and toddlers could be turned away from services this year.
We were pleased to host Nell Melefee-Libey from the National WIC Association to discuss this problem on a recent Speaking of Kids podcast.
🎧 Listen to Speaking of Kids Podcast Episode #7, “The Urgent Need to Protect WIC,” with the National WIC Association’s Nell Menefee-Libey here.
Fortunately, there is a push in Congress to address this problem, as this letter led by Sen. Cory Booker (D-NJ), Senate Agriculture Committee Chairwoman Debbie Stabenow (D-MI), and 168 of their colleagues expressed in this letter.
A fully funded WIC program would reduce and prevent child hunger, particularly among our nation’s babies and toddlers.
States Should Adopt the Summer EBT Program for Children
Third, a lesson learned from the response to the COVID-19 epidemic was the successful creation of a summer debit card program (electronic benefits transfer or EBT) that was provided to families with children to reduce child hunger during the summer months. As part of the 2022 bipartisan budget deal, a summer EBT program was established and made available to states.
One of the bipartisan leaders in establishing the summer EBT program was Sen. John Boozman (R-AR). His weekly column below highlights how this summer program will help children.
This bipartisan deal is critically important because, as Share Our Strength’s No Child Hungry finds, “6 out of every 7 children who participate in free or reduced-price school meals” were unable to access prior summer meal programs. The bipartisan deal provides full federal funding to states for the summer EBT program. All states have to do is agree to pay for half the administrative costs.
It’s just heartbreaking. Many children this summer won’t have access to the food they need. It is really scary and gives me goosebumps just saying it out loud to you.
To help alleviate child hunger:
Please contact your member of Congress and two senators and urge them to pass an expansion of the Child Tax Credit and to provide “full funding” for WIC.
If you live in Alabama, Alaska, Florida, Georgia, Idaho, Iowa, Louisiana, Mississippi, Nebraska, Oklahoma, South Carolina, South Dakota, Texas, Vermont, or Wyoming, contact your governor’s office and legislators to urge them to adopt the summer EBT program.
Stable, affordable healthcare coverage helps ensure children can get the care they need to thrive. Since the Medicaid “unwinding” started in Spring 2023, over 420,000 children have lost their health care coverage in Florida. Many of these children are still eligible for Medicaid but were disenrolled due to administrative issues. Despite encouragement from the federal government to adopt policies that would help reduce unnecessary health care coverage losses, Florida has refused. In fact, Florida has adopted zero of the policies that would help children and families stay better connected to health care coverage as the unwinding continues to unfold. These issues have even led to a lawsuit and civil rights complaint against Florida for its handling of the unwinding.
Underlying the issues with the state’s handling of the unwinding is the issue that for many of the children who are truly no longer eligible for Medicaid, Florida should be referring them to their Children’s Health Insurance Program (CHIP), known in Florida as Healthy Kids. A positive development related to this was that in June 2023, the Florida legislature unanimously passed and Governor DeSantis signed into law legislation to increase the income eligibility levels for the Healthy Kids program to 300% of the federal poverty level. This expansion was supposed to go into effect on January 1, 2024. However, Florida officials missed a critical step: the state did not submit a waiver application to the federal government to receive permission to implement the expansion.
With the passage of the Affordable Care Act (ACA) in 2010, there was a technical change to how states are able to make changes to their Medicaid and CHIPs, including expanding their CHIP income eligibility thresholds. Often states can make changes to their Medicaid and CHIPs through state plan amendments (SPAs), a process where a state lets the federal government know of changes it is making to its Medicaid/CHIP (in compliance with federal law). SPAs are deemed approved unless the Centers for Medicare & Medicaid Services (CMS) explicitly disapproves the SPA or requests additional information within 90 days of submission. If a state wants to test novel, innovative ways of providing Medicaid/CHIP coverage – for example, a state wants to provide continuous eligibility for children from birth through age 5 – a section 1115 waiver application is required. This process typically involves more requirements than a SPA such as state and federal comment periods. Also, whereas SPAs generally do not expire, section 1115 waivers are time limited. With language added by the ACA, states must generally submit a section 1115 waiver to expand their CHIP eligibility thresholds.
Florida failed to go through the process for submitting a section 1115 waiver before the end of 2023. This means that the Healthy Kids expansion is currently not in effect and will not be during these critical, final months of the Medicaid unwinding.
Thankfully, Florida is working on submitting its waiver application to the federal government. However, it will take several months before implementation can be approved. While awaiting approval, Florida should adopt available unwinding flexibilities to reduce the number of kids losing health care coverage.
Despite Florida’s mishandling of its CHIP expansion, Congress can help alleviate this issue for other states in the future. Congress has had several opportunities to make a technical fix that would allow states to expand their CHIP eligibility thresholds via a SPA, rather than the waiver process. Language was included in the Build Back Better Act during the 117th Congress, but that legislation was not adopted. Language that would make this fix is currently included in H.R. 4771, introduced by Rep. Barragán, which in addition to making this technical fix would also ensure that CHIP’s funding is made permanent.
We encourage Congress to act on making CHIP funding permanent and improving state flexibility to expand their CHIP eligibility thresholds. Stopping short of making CHIP permanent, however, Congress should adopt the language that would allow states to expand their CHIP eligibility via SPA rather than a waiver. This simple technical fix can reduce mishaps like the one in Florida, streamlining the processing and encouraging CHIP expansion in other states.
For more questions about this issue or other issues related to Medicaid or CHIP coverage, please contact our Vice President for Medicaid and Child Health Policy, Abuko D. Estrada, J.D., at email@example.com.
If you would like to help ensure that children and their needs, concerns, and best interests are no longer ignored by policymakers, please join First Focus Campaign for Children as an “Ambassador for Children” or become a paid subscriber to help us continue our work, including the Legislative Scorecard, on behalf of children. We do not have dedicated support for this work and rely on supporters like yourself to support it. Thank you!
Last night, House Leadership notified members of a potential vote on a bipartisan tax package that would make changes to the Child Tax Credit to benefit millions of struggling families. This crucial vote — which could take place next week, as early as Tuesday — would lift around 400,000 children out of poverty in the first year, rising to half a million children by 2025. Unfortunately, this vote is far from a sure thing — which is why we’re asking everyone to reach out and tell their reps in the House and Senate just how important this deal is for our communities.
It has been 754 days since Congress let the enhanced Child Tax Credit expire. In that time, child poverty in the U.S. has gone from an historic low to the largest one-year increase in the nation’s history. This has made it abundantly clear that child poverty is a policy choice. Inaction on this issue is simply unacceptable.
The package would be an important first step toward meaningfully reducing child poverty — which is why every member of Congress needs to hear from their constituents before it’s too late. Please take a moment to be a voice for the millions of children who stand to benefit — and encourage your friends and family to do the same.