What happens when our most vulnerable generation — children between birth and age five — don’t have access to health care?
While the problem of coverage gaps has come to a head in California as the state faces a major budget crisis, it reflects a danger nationwide.
At a Friday, April 5 Ethnic Media Services briefing, a state Assemblymember and children’s health care experts discussed the threat to continuous coverage of Medi-Cal, the state’s version of Medicaid, for children ages zero to five; the national impact of reinstating annual Medicaid eligibility reviews; and the potential impact of coverage gaps for children’s health.
A nationwide view
Half of U.S. children get health coverage through Medicaid and the Children’s Health Insurance Program (CHIP), a similar state-administered program that provides health insurance for children whose household income is too high for Medicaid but too low for marketplace coverage.
“Federal researchers estimate that three out of four children who would lose their Medicaid during redetermination would still be eligible — this is much higher than for adults, because children have higher income eligibility, and likely don’t have another coverage source,” explained Joan Alker, executive director of Georgetown Center for Children and Families.
“We are about to hit 5 million fewer children on Medicaid nationwide. In 2023, we had 4 million total uninsured children nationwide. Even if half of these children are becoming uninsured for procedural reasons, this is a national crisis,” she said.
The two states with the most children losing coverage are Texas, with 1.3 million fewer children on Medicaid since redetermination — comprising nearly one in four of the children losing coverage nationwide — and Florida, with nearly half a million fewer children on Medicaid.
“The good news is that we’re seeing a national breakthrough in policies that allow continuous coverage,” said Allker. “Oregon, Washington and New Mexico are now implementing a Section 1115 waiver from the federal government to cover children from birth to age six. Eight other states, and the District of Columbia, are also pursuing this.”
“In this year’s budget and his State of the Union speech, President Biden proposed to Congress that states be offered an option to cover infants from birth through age six” as well as an option to allow three years of continuous coverage after that through age nine, she continued.
Currently, continuous coverage like this is only possible if states undergo the complicated process of applying for a Section 1115 waiver.
“California was earlier to pass continuous coverage, but hasn’t implemented it. These states are catching up,” Alker added. “Let’s not fall behind. Children and families shouldn’t have to worry about losing health care.”
Keeping Medi-Cal
Against a deficit estimated at $73 billion, continuous coverage for children is at risk of being cut, said California Assemblymember Tasha Boerner (D-77): “I’ve been fortunate to be elected to the Assembly since 2018, and we’ve had ever larger budgets, and this is the first time many of us have had to cut it.”
While in 2022 the Legislature approved multi-year continuous Medi-Cal, the state’s version of Medicaid, for children ages zero to five, it has yet to greenlight the funding.
The Legislature has until June 15 to pass the state budget, while the greenlight may not be determined until August.
Meanwhile, a nationwide annual redetermination of Medi-Cal eligibility, temporarily suspended during the COVID-19 federal emergency, resumed in April 2023. Since then, hundreds of thousands of Californians are being disenrolled. A third of these are youth.
92% of these disenrollments are due to procedural or paperwork reasons as of November 2023, compared to a nationwide average for procedural disenrollment of 71%.
“Oftentimes, families that still qualify for coverage but lose it due to procedural reasons — like missed renewal notices due to old contact information, inadequate language assistance, difficulty gathering all required documentation, and timely renewal applications not marked as received due to staffing shortages — find out about their lack of coverage while having a medical emergency, or going in for basic necessary services. This is unacceptable,” said Boerner.
Out of 40 million Californians, 40%, or over 15 million, relied on Medi-Cal when redetermination began.
Nationwide, over 90 million Americans — over one in four — were on Medicaid.
Boerner said she was pushing the Department of Finance to certify multi-year continuous Medi-Cal enrollment for children aged zero to five.
“When we cut the red tape, people get the preventative care they need, and they’re not just ending up in the ER, with sick children that may have lasting, costly impacts from those illnesses,” she explained.
Those who lose Medi-Cal for procedural reasons have 90-day retroactive coverage, i.e. can have medical bills paid for if issued within the 90 days before their coverage starts again.
The impact of losing coverage
5.2 million Californian children — over half of the state’s 9 million children — had Medi-Cal or CHIP as of October 2023, and three-fourths of these were children of color.
Since redetermination began, over a million Californians of all ages have lost coverage, including 284,000 children.
“Babies see a doctor up to seven times in the first year of life alone. Health during those first few years of life, when 90% of brain development occurs, requires frequent and timely visits and screenings, and even short gaps in health coverage — known as ‘churning’ — can disrupt that care,” said Mayra Alvarez, president of The Children’s Partnership.
During the pandemic, when redetermination froze, churn rates for California children dropped from 7.5% to 1%.
“The numbers don’t capture the true impact of lost coverage. Last year, we held focus groups statewide where we heard directly from parents. One Spanish-speaking parent in Fresno described their confusion and shock when they took their sick daughter to the doctor and were told they weren’t covered,” she continued. “Other families said their children didn’t have any coverage for months, and all visits had to stop. No child should be without that coverage.”
“Without greenlighting continuous coverage, the commitments our state has made to deliver on the promise of healthy early development for all children are broken promises,” Alvarez added.
“As a practicing community pediatrician, I’ve seen what happens when we cut down the opportunity in that zero-to-five age gap, with the brain developing, to help those children grow to be the healthiest they can,” said Dr. Ilan Shapiro, chief health correspondent and medical affairs officer at AltaMed, a community clinic network which serves about 500,000 patients, including 120,000 children.
“Many children I see come with chronic problems that create a wave through the entire community. If they have asthma and low oxygen, or developmental delays, the parents need to take care of them, the kid misses out on school and social development,” he continued. “If we don’t give proper vaccine protection, we see what’s happening now — problems with infectious diseases we have not seen in decades, like measles.”
“If we continue opening that coverage gap, we can’t be there for them,” Shapiro said. “If we want to have a healthy California and a healthy country, it’s in our hands to protect the base and future of our community by ensuring continuous coverage. These are our children.”
