By Phil Galewitz
Republican lawmakers in Florida and Texas snubbed the Affordable Care Act’s Medicaid expansion for adults, but their states did broaden the program this year -- for school-age children.
Those states were among 21 – including some big Democratic-led states, such as California -- that were required to widen Medicaid eligibility for children between the ages of 6 and 18 by 2014. That little-known provision of the health law is a key reason hundreds of thousands of kids gained coverage in the state-federal health insurance program for the poor, according to a Kaiser Health News survey of a dozen states.
While many of those kids were previously enrolled in another government insurance program, children are typically better off in Medicaid because it offers broader health benefits at lower cost to their families. The higher eligibility level was already in effect for children younger than 6.
California led the way, increasing Medicaid enrollment by 715,000 children age 6 to 18. Five other states — Texas, New York, Florida, Georgia and Colorado — accounted for about 750,000 additional enrollees, according to data measuring growth through this summer.
Several other factors helped drive the increases: Some of those kids might have been eligible under the old rule, but enrolled this year because of the focus on the health law’s open enrollment. California, meanwhile, shifted into Medicaid all kids previously covered by the Children’s Insurance Program (CHIP), the federal-state program that helps children from families with incomes too high to qualify for Medicaid but too low to afford insurance on their own.
More Kids Might Have Enrolled
Consumer advocates say they welcome the expansion of eligibility to children in families making 138 percent of the federal poverty level, or $32,913 for a family of four— raised from the poverty level, or $23,850 for a family of four.
But they say more children would be enrolled had more states expanded the program for adults. That’s because parents who sign up themselves are more likely to sign up their kids.
“It’s a lost opportunity for Texas to cover the kids and teens, but not their parents.” said Anne Dunkelberg, associate director of the left-leaning Center for Public Policy Priorities in Austin, Texas.
Much attention has been paid to the 23 GOP-led states, including Florida and Texas, which have not expanded Medicaid for adults since the Supreme Court made that optional in 2012. Republican critics have said expansion would strain state budgets and increase dependency on government programs. Yet there’s been little publicity about the law’s mandatory Medicaid expansion for school-age children.
One reason is that the change affected fewer than half the states — those that had not raised eligibility levels for school-age kids before the 2010 health law passed. The law required states to expand by 2014. California, Colorado and New York started earlier.
In addition to those three and Texas and Florida, the other states that broadened eligibility for children in Medicaid are Alabama, Arizona, Arkansas, Delaware, Georgia, Kansas, Mississippi, Nevada, North Carolina, North Dakota, Oregon, Pennsylvania, Tennessee, Utah, West Virginia and Wyoming. Eleven of these states expanding kids’ coverage opted against expanding it for adults, after the Supreme Court gave them that option.
Many Kids Shifted From CHIP
In most of those states, between half and two-thirds of the children joining Medicaid were previously covered by CHIP. About 562,000 children were expected to shift from CHIP to Medicaid as a result of the law, according to a study by the Georgetown Center for Children and Families.
Experts say the benefits are generally richer in Medicaid. For instance, families had to pay monthly premiums for their kids’ CHIP coverage in six states that expanded Medicaid for children —Alabama, Arizona, Delaware, Florida, Georgia and Utah, according to Joan Alker, executive director of the Georgetown program.
“Having [to pay] premiums depresses enrollment” in CHIP, she said.
Medicaid requires that children receive comprehensive services, including physical exams, immunizations, laboratory tests and dental, vision, and hearing services. CHIP benefits are not as broad in some states.
Still, state officials and advocates in California and Pennsylvania worry that families may have to find new doctors for their kids because Medicaid does not have as many participating providers as CHIP in some places.
“It’s a mixed bag, as Medicaid has lower costs but possibly fewer providers,” said Kelly Hardy, senior director of health policy for the California advocacy group, Children Now.
But Hardy said the expansion makes life easier for parents who will no longer have to deal with having one child in CHIP and another in Medicaid because income eligibility varied by age. Siblings in different programs might have different benefits, provider networks and cost-sharing.
Unlike Medicaid expansion for adults, the federal government is not paying the full cost of expanded eligibility for the first three years. Instead, states will get the higher federal matching rate for CHIP—about 71 percent of the costs.
‘Welcome Mat’ Effect
In Texas, nearly 2.9 million children were signed up for Medicaid as of August 2014—up about 254,000 school-age kids from December 2013. In the same period, Texas’ CHIP enrollment fell by nearly 160,000.
“There is no doubt we are seeing a welcome mat effect,” involving children who were previously eligible but not enrolled and who were signed up because of the publicity about the ACA’s open enrollment, said Dunkelberg of the Center for Public Policy Priorities.
In Florida, enrollment of school-age children in Medicaid rose by 137,000 this year, which included more than 62,000 kids who transferred from the state’s CHIP program, according to Florida Healthy Kids Corp., the nonprofit that runs CHIP in the state. That switch saved families money, since they previously had to pay a $15- or $20-a-month premium for CHIP coverage.
In Georgia, meanwhile, Medicaid enrollment for school-age kids rose by 81,000 to about 632,000 since last December. At same time, the state’s CHIP enrollment fell by about 25,000.
Georgia Medicaid Director Jerry Dubberly said the state did little to publicize the expansion for children. He attributes the higher enrollment to the change in eligibility, along with a reduction in dropouts as a result of the need to renew coverage for children only once a year under the health law.
Pennsylvania officials won federal approval to delay shifting children from CHIP to Medicaid until the end of the year because of concerns that families would have to find new doctors. About 32,000 children in that state’s CHIP program now qualify for Medicaid.
Still, the number of Medicaid-enrolled children over six in Pennsylvania rose by about 18,000 this year to 668,000, which could include children who were uninsured or who switched from private insurance.
Officials in Florida, Georgia and Texas discount concerns about the availability of providers.
Greg Mellowe, policy director of the consumer group, Florida CHAIN, said he hopes the expansion of Medicaid to tens of thousands of children doesn’t go unnoticed by state lawmakers.
“While Florida continues to have the option to reject expansion for adults in the legal sense,” he said, “this is yet another reminder that doing so isn't sensible or justifiable in any other sense.”
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.