HHS: 'Children's Health Coverage Trends – Gains in 2020-2022 Reverse Previous Coverage Losses'

WASHINGTON, March 3 (TNSrep)-- The U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation issued the following report (No. HP-2023-07) on March 2, 2023, entitled "Children's Health Coverage Trends - Gains in 2020-2022 Reverse Previous Coverage Losses."

The report was written by Ann B. Conmy, Christie Peters, Nancy De Lew and Benjamin D. Sommers.

Here are the excerpts:

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KEY POINTS

* Recent national survey data show that the uninsured rate among children (ages 0-17) fell from 6.4 percent in late 2020 to 4.5 percent in the third quarter of 2022. These gains have nearly erased the loss in children's coverage that occurred between 2016 and 2020.

* By income, coverage gains were greatest among children living in households with incomes between 100 and 200 percent of the Federal Poverty Level (FPL).

* Federal policies such as the Medicaid continuous enrollment provision in the Families First Coronavirus Response Act (FFCRA), expanded Marketplace premium tax credits under the American Rescue Plan (ARP), an extended Marketplace special enrollment period (SEP) in 2021, and robust enrollment outreach have potentially contributed to families and children gaining and retaining health coverage since 2020.

* While there has been growing health care coverage for children, there has also been a general decline in utilization of services, especially pediatric preventive services, during the pandemic. There are growing income and race-related disparities in use of preventive care services among children, suggesting the pandemic may have had a greater impact on children in lower income households and Black, Latino, and Asian children.

* Older children (age 12-17) received the lowest rates of preventive care. Preventive care in this age group typically includes depression and suicide risk screenings, so this decline is particularly concerning given rising burdens of mental illness and suicide attempts among adolescents.

* A new provision in the Consolidated Appropriations Act, 2023 (CAA), requires 12-month continuous eligibility for all children enrolled in Medicaid and CHIP, which may improve access to preventive and other types of care. The Inflation Reduction Act (IRA) extended enhanced premium subsidies for Marketplace coverage, resulting in record-high enrollment in 2023. The elimination of the "family glitch" for Marketplace subsidies will improve affordability of coverage for many families with children.

* Under the CAA, the Medicaid continuous enrollment provision will come to an end on March 31, 2023. Many children who lose Medicaid coverage as eligibility redeterminations resume may be eligible for CHIP, zero-premium or low-premium plans through the Marketplace, or employer sponsored coverage.

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DISCUSSION

Recent health coverage gains among children reduced their uninsured rate from 6.4 percent in late 2020 to 4.5 percent in the third quarter of 2022, resulting in 1.4 million children gaining coverage./51 This occurred after a 4-year period from 2016 to 2020 where the uninsured rate among children had increased from its previous levels. After the implementation of the ACA's Marketplace plans and Medicaid expansion, the uninsured rate among children decreased from 7.8 percent in 2010 to 4.5 percent in 2015. Research shows that Medicaid expansion for parents resulted in increased coverage for their children as well./52/53/54/55

Beginning in 2017, administrative and state-based policy changes were implemented that made enrolling and maintaining Medicaid coverage more difficult. Policy changes included reduced funding for Marketplace outreach and enrollment, administrative changes to Medicaid eligibility and enrollment, and immigration- related policies. Specifically, the changes in immigration-related policy were associated with declines in Medicaid and CHIP enrollment and adverse consequences for maternal and child health, particularly among Latino children who have the highest rates of being uninsured./56/57/58/59/60

Despite the renewed progress increasing health coverage for children by 2022, substantial disparities in health coverage remain by income, race, and ethnicity. Children living in households with incomes between 100 and less than 400 percent of the FPL and Latino children have disproportionately high uninsured rates./61 Although many Latino individuals are eligible for coverage, these immigrant groups face a range of potential barriers to enrollment, including confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. Culturally-tailored outreach and marketing for the ACA Marketplaces are important in closing the gaps in coverage among Latino children and families, particularly among Latinos who reside in predominantly Spanish-speaking households and who are eligible for Marketplace subsidies./62 Additionally, there are growing income-related disparities in preventive care utilization, suggesting a greater pandemic impact for children in low-income households than for children in higher income households.

There are various factors and policy changes that may explain the decrease in the children's uninsured rate beginning in 2020. The FFCRA implemented a 6.2 percentage point-increase in state's FMAP in exchange for maintaining Medicaid continuous enrollment from January 2020 through the end of the quarter in which the PHE ends. With the passage of the CAA, the continuous enrollment requirement is no longer tied to the end of the PHE and will end March 31, 2023. As shown above, this policy has resulted in significant growth in Medicaid and CHIP enrollment among children. In addition to continuous Medicaid and CHIP enrollment throughout the COVID-19 PHE, administration efforts to promote affordable coverage include increased funding for Marketplace outreach, an extended 2021 Marketplace Special Enrollment Period (SEP) and increased and expanded eligibility of Marketplace subsidies under the American Rescue plan of 2021 (ARP) and the Inflation Reduction Act of 2022 (IRA). Under the increased and expanded premium subsidies, ASPE estimated that in 2021 61.7 percent of non-elderly adults without health insurance had access to zero- premium plans and 73.3 percent had access to low-premium plans (less than $50 per month)./63

Starting in plan year 2023, the Administration closed the "family glitch," which will increase availability of premium tax credits to help cover the cost of Marketplace plans, particularly among children and families. Previously, consumers were ineligible for premium tax credits to help cover the cost of Marketplace coverage if they had access to affordable employer coverage, determined affordable if the cost of employer coverage for an individual (i.e., employee-only coverage) did not exceed a percentage of household income, determined annually. Under the final rule published by the Internal Revenue Service, eligibility for premium tax credits is based on the cost of a family plan./64

Moreover, Administration policy changes are aiming to not only make coverage more affordable, but to reduce disruptions or churning in coverage for children in Medicaid and CHIP. HHS recently approved Medicaid demonstrations in Massachusetts and Oregon expanding children's Medicaid coverage. In Oregon children enrolled in Medicaid have continuous eligibility until they reach the age of 6./65 In Massachusetts, children enrolled in Medicaid or CHIP have 12 months of continuous eligibility after release from a correctional facility, and children enrolled in Medicaid with chronic homelessness have 24 months of continuous eligibility. However, the end of the Medicaid continuous coverage provision under FFCRA starting in April 2023 means millions of children will be at risk for coverage loss due to the resumption of eligibility redeterminations./66

Meanwhile, in terms of access to care, early evidence of children's utilization trends during the COVID-19 pandemic shows disruptions in preventive care, namely routine vaccination rates and recommended well child and physical visits. Among older children (age 12-17), who received the lowest rates of preventive care, these visits typically include depression and suicide risk screenings. The possibility of disruptions in these behavioral health screenings is particularly concerning given rising burdens of mental illness and suicide attempts among adolescents./67

In addition to mental health, vaccinations are another key area of concern. Administered by the CDC, the Vaccines for Children program, program (VFC) is a federal vaccine distribution program for children enrolled in Medicaid, without comprehensive health insurance, underinsured, or are AI/AN./68 While health care staff and provider shortages remain an on-going problem to circumvent physician shortages, increased pharmacy enrollment in the VFC could help address the decrease rates of routine vaccinations among children during the COVID-19 pandemic and existing disparities in vaccination rates./69/70

Telehealth was an important tool to help maintain health care access during the pandemic for people of all ages; however, delivery of preventive pediatric services via telehealth is limited as vaccinations and certain screenings cannot be completed virtually./71/72 Additionally, adults are more likely to use telehealth than children.73 Similar to adults, telehealth use for pediatric care helped mitigate the decrease in utilization but did not completely offset the decrease in utilization./74 Some potential factors explaining the decrease in utilization among children attributed to the COVID-19 pandemic include, physician office closures, limited available appointments, concerns about COVID-19 exposure at physician offices, COVID-19 vaccine hesitancy among parents, virtual school, and children becoming eligible for the vaccine after adults./75/76

A growing body of research evidence shows that providing stable coverage to children improves health care access, quality of care, and both health and economic outcomes in the short and long term.77/78/79 Permanent, mandatory, 12-month continuous eligibility in Medicaid and CHIP for children up to age 19 is included in the Consolidated Appropriations Act, 2023 and coverage begins in 2024. This provision may mitigate some of the coverage losses as the Medicaid continuous coverage provision comes to an end.

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CONCLUSION

Insurance coverage among children has increased substantially since the implementation of the ACA and policies implemented since 2020, including those in response to the COVID-19 pandemic. These gains in health insurance coverage since 2020 may help address the pandemic-related disruption in access for children's health care utilization services, specifically among preventive care services. In addition, provisions in the IRA will continue increased and expanded availability of premium subsidies established in ARP to help families access affordable coverage through Health Insurance Marketplaces. HHS recently approved Medicaid demonstrations in Massachusetts and Oregon expanding continuous eligibility for children enrolled in Medicaid with certain circumstances and until children reach the age of 6 in Oregon./80 In addition, the Consolidated Appropriations Act, 2023 will for the first time require all states to implement 12-month continuous eligibility for children enrolled in Medicaid and CHIP. These policies will be particularly important as the pandemic-era continuous coverage provision in Medicaid comes to an end and people of all ages begin to experience coverage transitions. The coverage gains of the past two years - combined with policies designed to improve continuity of Medicaid and CHIP coverage going forward - are important steps toward the goal of improving the health and well-being of children.

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ABOUT THE AUTHORS

Ann B. Conmy is an Analyst in the Office of Health Policy in the Office of the Assistant Secretary for Planning and Evaluation.

Christie Peters is the Director of the Division of Health Care Access and Coverage for the Office of Health Policy Office of the Assistant Secretary for Planning and Evaluation.

Nancy De Lew is the Acting Deputy Assistant Secretary for for the Office of Health Policy Office of the Assistant Secretary for Planning and Evaluation.

Benjamin D. Sommers is a Senior Counselor in the Office of the Assistant Secretary for Planning and Evaluation.

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CITATION: Conmy AB, Peters C, De Lew N, Sommers BD. Children's Health Coverage Trends: Gains in 2020-2022 Reverse Previous Coverage Losses. (Issue Brief No. HP-2023-07). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. March 2023.

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The footnotes and report are posted at: https://aspe.hhs.gov/sites/default/files/documents/77d7cc41648a371e0b5128f0dec2470e/aspe-childrens-health-coverage.pdf