While much progress has been made in health care coverage for children, there is still more to do to ensure that the more than 4.3 million uninsured U.S. children have access to health insurance. According to census data, children of color were hit hardest in 2020, with 9.5% of Hispanic children and 6% of Black children lacking health insurance. In states that have not expanded Medicaid, the rate of uninsured children is more than twice as high. The COVID-19 pandemic has taken a serious toll on the mental and physical health of all of our nation’s children, and especially the uninsured. 

Research confirms that coverage for kids matters. Ensuring that a child has adequate health care coverage from birth helps them to grow and develop into healthy, productive adults. By investing in the health of children, we can ensure no child has to live in pain or go without preventive care like vaccinations and annual check-ups just because their parents have lost their job or simply can’t afford health insurance.

Below are policy recommendations that will help to cover the 5.6% of American children that did not have health insurance in 2020. 

1. Make the Children’s Health Insurance Program (CHIP) Permanent

For almost 25 years, CHIP has been an essential source of children’s coverage, ensuring access to high-quality, affordable, pediatric-appropriate health care for children in families whose parents earn too much to qualify for Medicaid but too little to purchase private health insurance on their own. CHIP has played a critical role in reducing the number of uninsured children by more than 68%, from an uninsurance rate of nearly 15% in 1997 to less than 5% in 2016, while improving health outcomes and access to care for children and pregnant women. CHIP, together with Medicaid, plays a particularly important role for children of color: In 2019, more than half of American Indian/Alaska Native, Black, multi-racial, and Hispanic children relied on Medicaid and CHIP for health care coverage. Making CHIP permanent is critical so families, medical providers, and governors can depend on it to always be there. By making CHIP permanent, the recurrent funding dilemma would be eliminated, allowing states to develop their programs in ways that best serve children and families.

2. Expand CHIP income eligibility to 300% of Poverty in All States 

The CHIP income eligibility level varies across the country. Some states provide CHIP for children in families at or just above 300% of the federal poverty level (FPL) and some states have an eligibility level as low as 175% (North Dakota). Current rules don’t allow states to expand their CHIP eligibility level even if their legislature and governor want to. Making CHIP income eligibility levels a true state option would better serve children and provide consistency across the country. 

3. Eliminate Waiting Periods for CHIP

Currently, 12 states enforce waiting periods for children who apply to a CHIP. These waiting periods require children to “go bare” without any insurance through CHIP even though they meet income and other eligibility requirements. These waiting periods are an archaic standard that means children are uncovered while they are growing, developing, and, over the last two years, living through a pandemic.

4. Provide 12-Month Continuous Eligibility for Children in Medicaid and CHIP

Children in low-income families need to be continuously covered under Medicaid or CHIP for a full year. Many families experience some income fluctuation, but their income does not change substantially or for the long term. Keeping children covered leads to improved health status and well-being, promotes health equity, and alleviates the impact of seasonal work, overtime, and variable work hours on low-income families. For states, continuous coverage for 12 months reduces administrative costs and labor while helping to promote more efficient health care spending. When children with chronic conditions have consistent access to medications and their medical home, and when all children can access care when needed without interruptions, health care costs go down.

5. Provide Continuous Eligibility from Birth to Age 6 in Medicaid and CHIP

Having uninterrupted health care coverage from birth to age 6 allows children to have consistent access to well-child visits, vaccinations, and specialty care. During these first five years, children need regular, routine checkups. The American Academy of Pediatrics suggests such visits occur at birth, three to five days after birth, at 1, 2, 4, 6, 9, 12, 15, 18, and 24 months and that they continue once a year until adulthood. Young children need these visits to ensure any social, emotional, or developmental delays are detected early and before beginning school. If a pediatrician notices a concern at a visit, they can make referrals to a specialist for advanced care, such as speech therapy or cancer screening. Without these checks and referrals, care may be delayed until it is too late, and children may suffer unnecessary, long-term harm. Medicaid and CHIP specifically provide comprehensive coverage for children through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit — with little or no cost to families. 

A child who churns in Medicaid and/or CHIP will experience gaps in both coverage and access to care that can be detrimental to their development; even a short gap in coverage can harm a child by reducing their access to necessary care. If a coverage gap is prolonged, families may face expensive medical bills or may put off their child’s care due to high out-of-pocket costs. Maintaining Medicaid and/or CHIP coverage through age 5 provides children with a long-term medical “home,” where care is coordinated, efficient, and consistent. Continuous eligibility will also ensure children have access to the same provider networks and benefits. Churning or fluctuating from Medicaid and/or CHIP to private coverage due to income changes forces families to search for new in-network providers and navigate new cost-sharing rules, burdening families and complicating a child’s access to necessary care. 

Continuous eligibility to age 6 is a proven investment in children’s health and well-being, and it would pay off down the line. Children are one of the most vulnerable populations, and, from birth to age 6, their brains are developing at a rapid pace. Having health care coverage ensures children will access and receive necessary preventive and diagnostic care and will be prepared to enter school and contribute to society. It is vital that every child in the U.S. has consistent and continuous coverage as they develop.

Providing continuous eligibility up to age 6 in Medicaid and/or CHIP would relieve low-income families from having to constantly complete paperwork to ensure their children are able to continuously have the same coverage that individuals with private insurance and Medicare continuously have. No family should ever have to stress about minor fluctuations in income that could cause their child to lose coverage, and no child should ever have to suffer a gap in coverage that could cause health care needs to go unaddressed. Families have been stretched thin during the COVID-19 pandemic and ensuring children under the age of 6 remain covered in Medicaid and/or CHIP after the public health emergency ends will allow families to recover faster. 

6. Enroll All Eligible Children

The majority of uninsured children in this country are eligible for Medicaid or CHIP but are not enrolled. Approaches to improve enrollment should include a combination of ways to enroll, retain, and renew coverage, including expanded outreach to families with children, such as enhanced use of culturally competent navigators, community health workers, and parent mentors; enrollment at key moments and places such as at birth and during enrollment in WIC, Head Start, early childhood, and education programs; simplified paperwork and elimination of bureaucratic barriers; and allowance of presumptive and express lane eligibility and a streamlined renewal of coverage.

7. Eliminate Barriers to Health Coverage for Children in Immigrant Families

All children should have access to health care, regardless of their immigration status. The COVID-19 pandemic and its economic fallout have affected our nation’s children and every child and family needs support to recover. Congress must eliminate structural barriers in our immigration system and other systems to protect all children’s healthy development, including the five-year waiting period for those with legal permanent status to access certain federal programs and determinations of public charge for children.

8. Improve ACA Affordability by Eliminating the “Family Glitch”

The ACA offers tax credits to make private, employer-sponsored health insurance more affordable for working families. The law bases eligibility determinations on a comparison of the cost of the insurance and the family’s income. However, the Treasury Department bases that assessment on the cost of insuring the employee alone, not the cost of family coverage. While individual-only employer-sponsored health insurance premiums average around $7,470 a year, annual premiums for family coverage average $21,342– nearly triple.

More than 5 million people fall into this “family glitch,” and the vast majority of them (4.4 million people or 85%) are currently enrolled through employer-sponsored health insurance. These families likely spend far more for health insurance coverage than individuals with similar incomes eligible for financial assistance on the ACA Marketplaces.  They could spend less on premiums if they could enroll in Marketplace plans and qualify for subsidies. One study estimated that those impacted by the family glitch are spending on average 15.8% of their incomes on employer-based coverage. 

If not clarified by the Administration or changed through legislation, this regulation will continue to leave millions of children as well as their non-employee parents ineligible for tax credits or subsidized coverage in the ACA Marketplaces. More than half of those who fall in the ACA family glitch (about 2.8 million people) are children under the age of 18. These are children who do not qualify for CHIP. About 500,000 people in the family glitch are ages 18-26. The ACA requires employers to offer coverage to dependents up to age 26, but that coverage does not need to meet affordability standards set elsewhere in the ACA.

9. Allow Families to Buy Into Coverage through Medicaid, CHIP, or the Federal Employees Health Benefits Program (FEHBP) for Their Children

For families who are self-employed, work part-time, or work for small businesses that may not offer health benefits, these options would offer the chance to provide their children with coverage that will meet their needs and be cost-effective. Allowing all families regardless of income and immigration status to buy into coverage through these programs will improve coverage and access to care for families who remain in the coverage gap.

10. Expand Medicaid in States That Haven’t

Medicaid is the largest insurer of children, covering more than 35 million children in 2020. It serves as an important source of coverage for children of all races and ethnicities and is a primary source of coverage for many children of color. From well-baby and well-child visits to vaccines, cancer treatment, dental services, and speech therapy, Medicaid plays a significant role in keeping kids healthy, in school, and on track to becoming healthy and productive adults. Children are the least expensive beneficiary group in Medicaid, yet they have the most to gain from comprehensive and affordable Medicaid coverage. Children who receive Medicaid coverage are more likely to graduate high school, have better health outcomes, and pay more taxes as adults.

In 2014, the Affordable Care Act gave states the option to expand Medicaid to low-income adults who had not previously been eligible for coverage. With the passage of the ACA, all children up to 138% of the federal poverty level (FPL) — a total of $30,305 for a family of three in 2021 — were eligible for Medicaid.

According to data from the Census Bureau, children living in states that have not expanded Medicaid were more likely to be uninsured compared to children living in expansion states. States that have expanded Medicaid have experienced a “welcome mat” effect where children gain coverage alongside their parents and other low-income adults newly eligible for coverage.

In 2019, more than half of all uninsured children resided in six states (Texas, Florida, California, Georgia, Arizona, and North Carolina). Only Arizona has since expanded Medicaid. By expanding Medicaid in the remaining 12 states that haven’t, millions of uninsured children would gain coverage. 

Special Note: All Reforms Must Meet the Unique Health Care Needs of Children

Any approach to cover all children must recognize that children have unique health and developmental needs that are vastly different from adults. Pediatric medicine, pediatricians, pediatric nurses, and children’s hospitals better meet the special health care needs of children and need to be integral to any reform proposal.

Conclusion

Covering all children will require a comprehensive, multi-pronged strategy aimed at closing the gaps in the children’s health insurance system. Continuous coverage, parent mentors, community health centers, increased affordability and other approaches must be applied together to address the crisis of uninsured children. Policymakers must therefore offer unique solutions to serve this population.

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