Why do some states still require long waits before kids can get health insurance?

A handful of American states still mandate that kids must be uninsured as long as 90 days before they can enroll in a public health insurance program that covers nearly 10 million children.

Health policy experts say this requirement is unnecessary because many, if not most, kids qualify for exemptions to the waiting period for the Children’s Health Insurance Program. They argue this provision leads to missed health care for children, mistakenly denied coverage and unnecessary administrative work for states.

“I think (states) should remove the barrier,” said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families who studies CHIP, a program for lower-income families who earn too much money to qualify for Medicaid. “It’s not good for kids to have gaps in coverage.”

Brooks said that while it’s difficult to estimate exactly how many kids are affected by the CHIP waiting periods in the 14 states that still have them, it’s undeniable the policy is having an impact. “If you think about how you pile on the red tape … people just get tired of trying to get in and stay in,” she said. “The more barriers you put up to coverage, the worse it is terms of getting and keeping kids enrolled.”

The CHIP waiting periods are yet another obstacle to kids getting health coverage at a time when the children's uninsured rate is on the rise, clocking in at 5.2% in 2018, up from a historic low of 4.7% in 2016. More than 4 million children lack insurance nationwide. 

I had my own experience with CHIP recently when I got laid off from my newspaper job and my kids and I were cut off from our insurance. At more than $1,000 a month, I couldn’t afford the COBRA continuation coverage my employer offered. So I went to the federal health insurance marketplace to see if I qualified for subsidized coverage.

The site told me I could get private health insurance with premiums lowered by tax credits, but that my children may be eligible for CHIP and their information was being forwarded to the state of Illinois, where we live. I eventually found out the state had automatically enrolled my kids in temporary CHIP (though I didn’t get the notification letter in the mail until a month later).

Around that time, I was talking to a children’s health policy expert in Indiana, where we used to reside. He told me Indiana was one of a handful of states that still required a 90-day waiting period for CHIP.

“We’ve got a lot of families in this danger zone,” said Mark Fairchild, director of policy and communication for Covering Kids & Families of Indiana. He estimated that thousands of Indiana children are affected by the policy annually.

He said the waiting period puts them at risk for missing well-child checkups with pediatricians who can identify developmental issues that could be corrected. The waits can also lead families to turn away from public coverage. “Families might get frustrated and feel the system’s not working for them and not come back to it, which is the most dangerous thing that could happen,” he said.

Phew, I thought, thank goodness I no longer live in Indiana.

But then I started researching the issue and realized that Illinois, in fact, also had a waiting period (although it differs from Indiana in that it exempts families making less than 209% of the federal poverty level).

Then I learned that no matter where in the United States I lived, my kids would have still qualified for immediate CHIP coverage.

In 2014, the Affordable Care Act limited states’ waiting periods to no longer than 90 days and imposed a number of exemptions. For instance, there are exceptions for kids who don’t have coverage because their parents — like in my case — lost a job, divorced or died; who are transitioning from Medicaid or marketplace insurance; or whose parents’ job-based health plan is considered too expensive. In response, most states that had waiting periods got rid of them, in the name of administrative efficiency or to clear another barrier in the way of insuring children.

Yet more than a dozen predominantly conservative states still make kids wait up to three months before they can enroll in CHIP.

Children’s health advocates in Texas have put eliminating CHIP waiting periods on their legislative agenda in the past but have since moved on to more pressing concerns, said Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Austin. That state has the highest rate of uninsured children in the country (11.2% in 2018, up from 9.8% two years earlier).

“The CHIP waiting period is a policy that makes no sense, and we would love to find ourselves in a legislative and administrative landscape more receptive to the common-sense validity of how useless a CHIP waiting period is in an ACA world,” Dunkelberg said. “Because we have much more serious policies that affect a much larger number of kids, it doesn’t really get to the top of anyone’s list.”

For instance, her organization estimates that about 50,000 Texas kids are kicked off Medicaid every year because of a state policy that requires families to recertify their eligibility monthly in the second six months of every year they’re signed up for the program.

The waiting periods — they could extend up to a year in some states — were put into place during the passage of the original CHIP legislation, in 1997, to appease lawmakers worried that families would drop their kids’ employer-based coverage and enroll them in CHIP. The ACA, in an effort to implement near-universal coverage, reduced those waiting periods and largely made them obsolete.

As for me, I’m happy my kids have insurance. But health policy in America never ceases to confound me. I write about this stuff for a living; I can’t imagine how difficult it must be to navigate for the average person. What if a family heard their state had a CHIP waiting period and just didn’t bother to apply, even if they (likely) qualified for an exemption? 

Brooks, from Georgetown, has been in the field for a quarter-century and says she’s still discovering new complexities. She called the American health care system “a big thick onion we keep rolling back layers on.” She wonders why any restrictions remain in place that might leave children uninsured.

“We’ve taken an approach in this country where more than 99% of our seniors have coverage. We should take the same approach with our kids,” she said. “When kids have gaps in coverage or are uninsured, we know that impacts success in school, that impacts their productivity and health and adults.

“We keep focusing on trying to figure out how to manage costs for people who have multiple, chronic conditions in adulthood. Most of those chronic conditions are rooted in childhood. If we ever want to bend the cost curve and improve population health in the United States, we have to start with the kids. We have to make sure that all kids have access to health care throughout their childhood.”