Recent figures show that approximately 31 million (or 42%) of U.S. children receive health insurance through Medicaid or CHIP.^1,2 These programs have been critical in improving access to pediatric care, which studies show improves medical utilization and leads to better personal, educational, and societal health outcomes. Thus, as healthcare providers, it is critical that we understand how these systems function if we hope to advance our nation’s health.

Continued support for children’s health care through the Patient Protection and Affordable Care Act (ACA or PPACA, March 2010) and MACRA (Medicare Access and CHIP Reauthorization Act, April 2015) has contributed to unprecedented improvement in the rate of our uninsured children nationwide (from approximately 14% in 1997 to 6% in 2014).^3,4 Nonetheless, despite this improvement, 9% of Texas’ children remain without coverage. Thus, as home to 1 out of every 11 children in the U.S., Texas has the greatest number of uninsured children at 685,900.^{2, 3}

Estimates are that more than half of these uninsured children (and perhaps as many as 70%) are actually eligible for Medicaid or CHIP.^5,6 The reason for why these children are unenrolled is multifactorial but includes complicated eligibility rules, lack of awareness, citizenship status of family members, linguistic barriers, and general difficulty navigating bureaucratic processes.^7,8

Encouragingly, pediatric providers can take several steps to promote increased enrollment in Medicaid/CHIP:

• At the state legislative level, we can stand in line with the AAP (State Legislation Report of 2015)⁹, the federal government¹⁰ and many Texas businesses¹¹, by supporting ACA Medicaid expansion to adults. In addition to newly providing low-income parents with healthcare coverage, this change would likely spur a “welcome-mat” effect in bringing greater awareness/know-how of the application process for already-eligible children.^{12, 13}

• Furthermore, we can support legislation that creates efficient enrollment.¹⁴ Two key strategies include Express Lane Eligibility and Continuous Eligibility (which have shown tremendous benefit in several states)^{15, 16}; these are addressed in U.S. House Bill 919 – encompassing a wide spectrum of pediatric quality issues – which physicians should consider encouraging their U.S. Representative and Senators to co-sponsor.¹⁷

• Dr. Rachael Johnston previously offered us an insightful view of outreach campaigns in cities around the U.S. (including Dallas), illustrating innovative examples of community interventions which aim to increase rates of health care coverage and facilitate a culture of health.
  • Highlighting the importance of continued advocacy at this level, CMS has continued its fourth cycle of grant funding ($32 million) to support local organization efforts to enroll eligible children. (Anticipated award date is May 20, 2016)¹⁸

• In our individual practices, we can educate ourselves and staff, screen for important social determinants of health (particularly access to healthcare services and insurance), and create systems to inform and empower our patients and their families with knowledge of community/state/federal resources which may benefit themselves or their neighbors.
  • One study demonstrated the significant effectiveness of training parent mentors within a primary-care practice to serve as sustainable agents of outreach (especially within minority populations, when compared with traditional Medicaid/CHIP outreach approaches).¹⁹

As healthcare providers, each one of us has tremendous capability to advocate at many of these levels. Please take at least one approach to heart.

Find out how to contact your elected officials (by State or ZIP code) here.

Peter Hong, MD

References:
1 – “Medicaid – By Population” https://www.medicaid.gov/medicaid-chip-program-information/by-population/by-population.html

2 – U.S. Census Bureau “Quick Facts” http://www.census.gov/quickfacts/table/PST045215/00

3 – “Health Insurance Coverage of Children 0-18” kff.org/other/state-indicator/children-0-18/

4 – “Health Insurance Coverage: 2000” https://www.census.gov/library/publications/2001/demo/p60-215.html

5 – “The Uninsured in Texas” https://www.texmed.org/uninsured_in_texas/

6 – “New Estimates of Eligibility for ACA Coverage among the Uninsured” http://kff.org/health-reform/issue-brief/new-estimates-of-eligibility-for-aca-coverage-among-the-uninsured/

7 – Kenney, GM, JM Haley, N Anderson, and V Lynch. 2015. “Children Eligible for Medicaid or CHIP: Who Remains Uninsured, and Why?” Academic Pediatrics 15(3S), S36-S43.

8 – “Despite Progress, Texas Leads in Uninsured Hispanic Kids” http://www.texasobserver.org/hispanic-children-insurance-highest-texas/

9 – “AAP State Government Affairs – State Legislation Report 2015” https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/2015SLRFINAL_Web.pdf

10 – “More than Halfway There: New Opportunities to Expand Medicaid and Level the Playing Field” https://www.whitehouse.gov/blog/2016/01/14/more-halfway-there-new-opportunities-expand-medicaid-and-level-playing-field

11 – “Texas Politicians And Businesses Feud Over Medicaid Expansion” http://www.npr.org/sections/health-shots/2015/05/29/410520561/texas-politicians-and-businesses-feud-over-medicaid-expansion

12 – Dubay L, Kenney G. Expanding Public Health Insurance to Parents: Effects on Children’s Coverage under Medicaid. Health Services Research. 2003;38(5):1283-1302.

13 – “Total Monthly Medicaid and CHIP Enrollment” http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/

14 – “Enrollment Strategies” https://www.medicaid.gov/medicaid-chip-program-information/by-topics/outreach-and-enrollment/enrollment-strategies.html

15 – “Express Lane Eligibility Has Proven Its Effectiveness – Time to Make it a Permanent Policy Option” http://ccf.georgetown.edu/all/express-lane-eligibility-has-proven-it-effectiveness-time-to-make-it-a-permanent-policy-option/

16 – “Texas Medicaid & CHIP Programs” http://ccf.georgetown.edu/programs/tx-mcp/

17 – “CHIP Extension and Improvement Act of 2015 Summary” https://www.childrenshospitals.org/issues-and-advocacy/childrens-health-insurance-program/fact-sheets/2015/chip-extension-and-improvement-act-of-2015-summary

18 – “Connecting Kids to Coverage Outreach & Enrollment Funding” https://www.insurekidsnow.gov/professionals/funding/index.html

19 – G. Flores, C. Walker, H. Lin, M. Lee, M. Fierro, M. Henry, K. Massey. “A Successful Program for Training Parent Mentors to Provide Assistance With Obtaining Health Insurance for Uninsured Children” Academic Pediatrics, 2015;15(3):275-281