Connecting state and local government leaders
COMMENTARY | More than 5 million children could lose their Medicaid benefits during the public health emergency’s Medicaid “unwinding.” The U.S. has the data and experience to prevent this.
The U.S. pandemic response, while imperfect, demonstrated the power of investing in and supporting families and children.
The expanded child tax credit cut child poverty by nearly half, and continuous coverage for Medicaid has led to the lowest uninsured rate in our nation’s history. Yet as the Covid-19 public health emergency officially ends this week, what should be a moment to exhale is instead a moment of peril for millions of families, as pandemic-era policies and lifelines begin to recede.
As a pediatrician and public health practitioner (Dr. Besser) and a researcher and children’s health coverage expert (Alker), we are deeply concerned that more than 5 million children could lose their Medicaid benefits during the public health emergency’s Medicaid “unwinding.” The majority of these children risk losing coverage not because they aren’t eligible or don’t need Medicaid, but because automatic enrollment is ending, and states must now determine who still qualifies for benefits. According to federal researchers, children and families of color are at greatest risk of losing coverage while remaining eligible.
Parents and caregivers could lose coverage for their kids simply because of a language barrier, a recent move or something as innocuous as a new phone number. Administrative hurdles—from lost mail and out-of-date addresses to long wait times at call centers, computer glitches or inadequate communication—could end benefits for these families. As a result, parents may be faced with the impossible decision of seeking expensive, out-of-pocket care or deferring care altogether.
Imagine finding out your child doesn’t have health coverage when you show up at the pharmacy to fill a prescription for an asthma inhaler or EpiPen. The administrative labyrinth, which varies state by state, is a structural barrier to health care for too many families. The unwinding stands to particularly harm children of color, families with low incomes, families who speak English as a second language and people living in rural parts of the country.
Fortunately, despite the public health emergency ending, states have some discretion in how quickly and equitably they move through the renewal process, and they should take the time to get this right. Governors should do everything in their power to protect children from falling through the cracks and becoming uninsured. They must not let the system fail our children.
This is a moment, and issue, that should unite policymakers. Federal estimates project that 3 out of 4 children who will lose Medicaid coverage during the unwinding still will be eligible for Medicaid or the Children’s Health Insurance Program (CHIP). So if, in the months ahead, we see large numbers of children losing their benefits, that’s a problem—as it’s unlikely the parents or caregivers of these children have another option outside of the government programs, such as affordable employer-sponsored coverage.
We all want to live in a United States where everyone has a fair and just opportunity to reach their best health and well-being, no matter one’s age, race, ethnicity, class or geography. Maintaining coverage for these children is an important step toward achieving that aspiration. What should be done now? States must prioritize the following steps:
Protect the children every step of the way. Governors must keep an eye on the data reflecting the unwinding, make it public and proactively pause disenrollment if large numbers of children are losing coverage, since most will still be eligible for Medicaid. If a state doesn’t get this right, and families are inappropriately losing their benefits, U.S. Department of Health and Human Services Secretary Xavier Becerra can use his authority to pause the unwinding.
Communicate clearly and find families where they are. Families with high levels of residential instability, limited English proficiency or limited internet access are at a greater risk of losing coverage. It is essential that families receive notices that clearly explain the steps required to maintain coverage or to receive help to transition to other sources of coverage. States must engage all family-facing systems—schools, child care centers, Headstart programs and community-based organizations—to connect with families.
Keep what works. When Dr. Besser led emergency preparedness and response at the Centers for Disease Control and Prevention in 2005, just after Hurricane Katrina, he learned that the United States too often enters crises ill-equipped and exits the crisis without adapting, no better prepared for the next one.
The pandemic ushered in some practices and policies that worked well and should be maintained. States should consider permanently adopting effective policies, such as eliminating premiums for CHIP, a change that helps families struggling with high food and housing costs. More states should follow the lead of Oregon and Washington, which offer young children continuous coverage from birth to age 6. This policy ensures that bureaucratic barriers or small fluctuations in income don’t prevent infants and young children from accessing the regular care they need to grow and thrive.
If states don’t take these necessary steps during the unwinding, the uninsured rate among children could double, and we as a nation will not have learned an important lesson. This is an inequitable and costly possibility that would cause real harm. According to KFF, uninsured children in 2021 were more likely than insured children to go without needed care because of costs. One-third of the uninsured kids had not seen a doctor in the prior year, compared with about 8 percent of insured children. We can and must do better.
Taking a deliberate, humane approach to the public health emergency unwinding is in everyone’s best interest. We have the data and experience to know which actions states need to take to protect our children. There are plenty of tough calls to be made as we transition out of the pandemic toward our new normal. This isn’t one of them.
Richard E. Besser, MD, is the president and CEO of the Robert Wood Johnson Foundation in Princeton, New Jersey. Joan Alker is the executive director of Georgetown University’s Center for Children and Families and a research professor at the McCourt School of Public Policy in Washington, D.C.