The number of uninsured Colorado kids has been on the decline. That could change.

Colorado is among the states that made the most progress in a nationwide effort to connect kids with health insurance coverage during the pandemic, according to a report published Wednesday by the Georgetown University Health Policy Institute's Center for Children and Families.

The number of uninsured children in Colorado dropped by about 12,000 between 2019 and 2021 — to 61,000 from 73,000 — and the rate of uninsured kids in the state decreased by 0.9 percentage points to 4.6% in 2021 from 5.5% in 2019, according to the report. Nationally, the number of uninsured kids dipped by 210,000 — a 5% decline to 4.165 million in 2021 from 4.375 million in 2019. The rate of uninsured kids dropped to 5.4% from 5.7%, the report notes, with kids from families earning between $30,305 and $54,900 per year (for a family of three) experiencing the biggest declines.

Those figures mark a turnaround from 2016-19, when the number of uninsured kids across the country had been increasing, the report states.

The gains in helping kids access health insurance over the past few years have largely been made possible by federal protections put in place during the federal public health emergency declared at the start of the coronavirus pandemic. Those protections barred states from releasing anyone from Medicaid rolls during the health crisis. The protections, once enacted, quelled fears that uninsurance rates in Colorado would be on the rise amid widespread job loss and an economic downturn.

But when the federal government ends the emergency order — it has repeatedly been extended, most recently to April 11 — about 220,000 Colorado kids could lose access to government-subsidized health insurance.

They're part of a group of about 700,000 Colorado residents who could lose access to Medicaid and Child Health Plan Plus, a public health insurance option for people whose income exceeds limits that would make them eligible for Medicaid. An estimated 6.7 million children across the country could lose their coverage, meaning the rate of kids uninsured could more than double if states fail to keep eligible kids enrolled in their government health insurance plans, the report notes.

And most of the children at risk of being dropped from their coverage will still be eligible, with administrative issues standing in the way of maintaining coverage as states work to redetermine who is eligible for Medicaid and Child Health Plan Plus. For instance, states may not have a child's correct address on file to send them a renewal package or families might submit incomplete forms or neglect to return forms at all.

"We know that kids having steady, reliable access to the care that they need is very important for their health and development, so it's something we're watching very closely," said Zach Zaslow, interim vice president of population health and advocacy at Children's Hospital Colorado.

When children don't have stable insurance coverage, it impacts their access to care, Zaslow said, making it harder for them to fill prescriptions, get immunizations and be seen for regular wellness checks. The stakes are even higher for children who have significant mental health needs or those born with chronic or genetic medical conditions.

"Their lives literally depend on having access to high-quality health care," he said, adding that losing access to insurance would be "devastating" for those children and their families and could cause them to suffer long term.

"The sooner we intervene in a child's life, the better their trajectory is going to be," said Zaslow, who was in Washington this week to talk to members of the congressional delegation about his concerns around kids' welfare at the end of the public health emergency. "If we let those conditions fester, they are going to struggle into adulthood potentially."

Access to health insurance is key to receiving all kinds of care — whether preventive, emergency or other medical services, said Shoshi Preuss, a senior policy analyst for the Colorado Community Health Network, a membership association for 20 community health centers that care for low-income residents in the state.

"Generally, outside of community health centers and other safety net clinics, the system is really built on having access to an insurance that will pay for whatever services a person needs," Preuss said.

Zaslow also worries about the possibility of the public health emergency ending at a time the country is facing challenges with multiple respiratory viruses, including COVID-19, influenza and respiratory syncytial virus (RSV). That will drive up administrative costs for states that will inflate uninsurance rates when health care has become particularly critical for kids.

A push to adopt state policies to keep kids insured

The report also illuminates policies to build on, said Erin Miller, vice president of health initiatives at the Colorado Children's Campaign.

People have secured health insurance coverage and stayed insured in recent years "because these burdensome enrollment processes have been paused during the pandemic," Miller said. This includes simplifying the way families apply for and maintain their insurance coverage. During normal times, Colorado adults and children using Medicaid have to be re-evaluated for their eligibility every year.

"It's a silver lining of the pandemic and hopefully a lesson we can carry forward," she said. "The time that families don't have to spend filling out paperwork they can instead devote to getting preventative health services and other health services they need."

Preuss is encouraged by the number of Colorado kids covered by health insurance throughout the pandemic.

"This has been a really great demonstration just of the power of continuous coverage or continuous eligibility," she said. "We know just by the numbers that it is a successful policy lever to keeping folks enrolled."

The Colorado Department of Health Care Policy & Financing, which oversees the state's Medicaid program and Child Health Plan Plus, has already rolled out proactive measures to try to keep eligible families enrolled in their plans.

One strategy is an "update your address" campaign so the state can contact families to inform them about the renewal process. And the department will automatically renew anyone whose information they can verify and who demonstrates they still qualify for a government health insurance plan. But more can be done — by both state and federal lawmakers, Miller said.

Oregon has received approval for a waiver from the federal government to allow kids to be covered by Medicaid until age 6 without their families having to prove eligibility every year, Miller said.

Once a Colorado child is determined eligible for coverage, they are guaranteed coverage for one year. Colorado could pursue a waiver from the federal government, but the process takes a long time, Miller said.

If the federal government does end the public health emergency, Miller and the Colorado Children's Campaign are advocating for more efficient options that would help states keep more eligible kids covered. For instance, Congress could allow a state plan amendment, which would empower individual states to help specific groups of people maintain coverage, such as children from birth to age 6.

There is also some momentum ahead of the next legislative session to create state policies that streamline the process of applying for government-subsidized insurance, Miller said. That could include making sure kids have continuous coverage in their early years and extending coverage periods for underserved populations of adults, including people who are homeless.

State and national leaders must find a way to keep children insured, she said.

"We've learned that we can," Miller said. "We've learned that it's been hugely successful in Colorado, and so we've got to find a path forward to keep kids enrolled in their coverage."