Children are falling off the public insurance rolls — here's why advocates are worried

If children are increasingly falling off the public insurance rolls, as recent enrollment figures suggest, where are those kids getting coverage, if anywhere?

That’s a question children’s health groups are still trying to answer. But they’re alarmed nonetheless.

“We’ve had for years now an effort to reduce the number of uninsured children, a bipartisan effort started decades ago with the passage of Medicaid, then the Children’s Health Insurance Program, then the Affordable Care Act,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. 

“It’s been a very welcoming climate to insuring children,” she added. “That welcome mat has been pulled back.”

In 2018, more than 800,000 fewer kids were on Medicaid or CHIP, public health insurance programs for low-income children, than the year before, according to data released by the Centers for Medicare and Medicaid Services.

A report from the Center for Children and Families released Thursday looked at enrollment data going back to the year 2000. The 2.2% drop in 2018 is only the second time that enrollment declined — the other was in 2007 — and the largest decrease in that time period.

For its part, CMS promised to further analyze the decline but contended that the strong economy may have played a role.

“It’s always been clear that as the economy improves, unemployment drops and incomes grow, people move off of public assistance programs like Medicaid,” CMS Administrator Seema Verma stated on Twitter.

“What is clear is that under (President) Trump’s leadership, the American economy is thriving,” she added. “Unemployment remains low, wage growth is up, and we now see fewer people relying on public assistance. That’s something to celebrate.”

Children’s groups — including the American Academy of Pediatrics, Children’s Hospital Association and March of Dimes — are particularly concerned because 2017 marked the first drop in the youth uninsured rate in a decade. Seven of the nine states with statistically significant declines that year also had large Medicaid/CHIP enrollment decreases in 2018: Georgia, Florida, Massachusetts, Ohio, Tennessee, Texas and Utah, the Georgetown report noted.

Tennessee, for instance, had the biggest drop: 10.1%, or 88,305 kids losing their public coverage from the year prior, according to the Georgetown analysis. 

State officials there contribute the decline to big enrollment increases in the years leading up to 2018 and a reconfiguring of the eligibility process for the insurance programs.

“In fact, there are 195,00 more members enrolled in TennCare and CoverKids now than in December 2013,” said Sarah Tanksley, a spokeswoman for TennCare, the state’s Medicaid program.

She noted that Tennessee, like most states, paused its yearly eligibility checks for Medicaid and CHIP after the passage of Obamacare, but in 2016 reversed that decision. She said that caused many ineligible members to drop off the rolls.

Some states require eligibility verification more than once a year, including Texas, which had more than 145,000 kids drop off Medicaid and CHIP in 2018. Efforts to make those eligibility checks an annual process were unsuccessful during the state’s recent legislative session.

In Iowa, the state Senate passed a measure to make Medicaid members show they qualify on a quarterly basis. The state House didn’t vote on the bill.

That state had the largest percentage increase in Medicaid and CHIP enrollment in 2018: 3.3%.

“Iowa is bucking the trend,” said Mary Nelle Trefz, health policy associate with the Child and Family Policy Center of Iowa. “But we know there is turbulence on the horizon.”

She was referring to the quarterly eligibility verification push, as well as another unsuccessful legislative measure that would have required adult Medicaid recipients to work. 

“We are seeing states wanting to impose work requirements, check income more frequently, impose waiting periods,” said Kathleen King, deputy director of child health policy for the Children’s Defense Fund. “Those are things over the years that were eliminated or at least were significantly reduced, and we had more kids getting coverage.”

“It’s a disconcerting trend to see a lot of these things come back,” she added.

Trefz noted that Iowa’s success in boosting enrollment could be a result of the state continuing to invest heavily in efforts to enroll residents in Medicaid and CHIP.

On the national level, however, the Trump administration has cut outreach and enrollment funding for the Affordable Care Act marketplace, where many Americans find out they qualify for Medicaid. 

Children’s health advocates blame that, as well as the administration's anti-immigrant rhetoric, for the drop in Medicaid and CHIP enrollment. They say immigrant parents are increasingly fearful their green card status may be affected by signing their children up for public benefits.

These advocates worry what effects the enrollment declines will have on the health of the nation’s youth.

“The ultimate cost of this to individuals is children can die,” said Dawn Garzon Maaks, president of the National Association of Pediatric Nurse Practitioners.

She gave as an example a teen she was treating at the federally qualified health center where she practices in Washington state: He came in suicidal, was stabilized with medication, and went back to school. But when his family lost their health coverage, he stopped coming in for care.

“Suicide is the second-leading cause of death in our country for kids. They can die, just like if they couldn’t get penicillin,” Garzon Maaks said.

She said that when kids lack coverage, it adds costs to the health care system overall, as many of those children end up seeking care in expensive settings like the emergency room. 

“The reason you get charged $100 for that aspirin is your insurance is paying the cost for people who don’t have insurance,” she said.

Many children also get their dental care through public programs like Medicaid and CHIP — about 40 percent, according to the most recent available data, from 2015.

“If we’re seeing declines writ large, you can count on similar declines for dental,” said Colin Reusch, policy director for the Children’s Dental Health Project. “It’s unlikely those children are somehow maintaining coverage while losing their public benefits.”

He said untreated childhood dental problems can adversely affect a person’s entire life. He pointed to a 2012 study in the American Journal of Public Health that found that children with pain in their teeth were six times more likely to miss school and four times more likely to have below-average GPAs than students without toothaches.

“As kids age, those dental problems, if left untreated, don’t go away on their own,” Reusch said. “As children become adolescents, there’s research indicating it continues to affect them in various ways, including self-confidence and mental health. Kids with dental problems become adults with dental problems. It affects their ability to seek and maintain employment.”

Georgetown’s Alker said we won’t know for sure whether the children falling off Medicaid and CHIP are gaining coverage elsewhere until the fall, when the U.S. Census Bureau will release new data on the uninsured rate. But she’s not hopeful.

“This data is waving a huge red flag … that we’re going to continue to see an increase in our uninsured kid population,” she said. “So I hope that this will raise concerns and that elected officials can take some action to fix this.”