Stopping the churn: Why some states want to guarantee Medicaid coverage from birth to age 6

Before the covid-19 public health emergency began in 2020, millions of children churned on and off Medicaid each year — an indication that many were losing coverage because of administrative problems, rather than because their family's income had increased and made them ineligible.

Spurred by pandemic-era lessons, several states are rethinking their enrollment policies for the youngest Medicaid members. Oregon is leading the way after getting federal approval to implement a new continuous-enrollment policy.

In 2023, when the public health emergency is expected to end, Oregon will become the first state to allow children who qualify for Medicaid to enroll at birth and stay enrolled until they turn 6, regardless of changes in their household's income and without having to reapply.

"This is really a no-brainer in terms of supporting kids," said Jenifer Wagley, executive director of Our Children Oregon, an advocacy group. She said that keeping kids insured — particularly at the youngest ages, when their bodies and minds are still developing — will ensure they don't miss important checkups and care because of gaps in coverage.

Three other states are moving to implement similar policies for their Medicaid plans, which provide health coverage to people with low incomes and are funded by states and the federal government. Washington state in July asked the Biden administration for permission to provide continuous coverage to kids until age 6, and a decision is likely in the next few weeks. California lawmakers have approved a proposal for kids to stay covered until age 5, starting in 2025, pending federal approval. And New Mexico has sought public comments on a plan to keep kids enrolled until age 6 and is expected to seek federal consent later this year.

Medicaid enrollment nationally is at a record high after the federal government prohibited states from dropping members during the public health emergency unless they died or moved out of state. That rule has helped push the country's uninsured rate to a record low.

Of the nearly 90 million people on Medicaid and the Children's Health Insurance Program — a federal-state program that covers children in households with incomes above Medicaid eligibility — about 41 million are children.

Joan Alker, executive director of Georgetown University's Center for Children and Families, called states' moving to longer periods of continuous coverage for children "a silver lining of the pandemic for children."

She noted that from the fourth quarter of 2020 through the first quarter of 2022, the share of uninsured children in the U.S. fell from 6.7% to 3.7%, largely because of the emergency rule that has blocked states from dropping Medicaid enrollees.

"States will have to do a lot of outreach about this new policy so that every baby leaves the hospital with health insurance and the parents don't have to worry about coverage until the child goes to kindergarten," she said.

If the public health emergency ends next year, nearly 5.3 million children could lose Medicaid coverage, according to a federal analysis that was released in August. About 1.4 million of them would be moved off the rolls because they no longer qualify, but nearly 4 million eligible kids would lose coverage for administrative reasons, such as failing to submit paperwork on time.

Because Medicaid's household income eligibility thresholds are typically higher for children than adults, kids are less likely to lose coverage because of small changes in income. But children can lose their eligibility if parents fail to renew the coverage each year or don't respond when a state seeks information to confirm that a family's income has remained low enough to qualify.

Medicaid enrollees generally must report any changes to household income or other criteria that may affect their eligibility during the year, and states must act on these changes. That's challenging for Medicaid beneficiaries and state agencies because people's incomes often fluctuate. As a result, enrollees may lose coverage, be forced to switch between Medicaid and subsidized marketplace coverage on the Affordable Care Act insurance exchanges, or experience coverage gaps if the paperwork proves difficult to complete.

To address that problem, about half of states give children one year of continuous Medicaid eligibility regardless of changes in their household's income. That group includes both Republican- and Democrat-controlled states, including some states — such as Alabama and Mississippi — that have not expanded Medicaid under the ACA.

Before moving toward continuous coverage for kids up to age 6, Oregon offered 12 months of continuous eligibility for children. Nonetheless, state Medicaid officials estimate that in 2019, prior to the pandemic's start, more than 70,000 children younger than 6 — one-third of those enrolled — churned in and out of Medicaid. About 29,000 of those kids had coverage gaps that exceeded six months, state officials told KHN.

Oregon officials estimate that after four years in place, the new enrollment policy will benefit more than 51,000 children in 2027, at a cost of $177 million.

"The public health emergency has clearly demonstrated the value of having continuous health insurance, particularly for populations that experience health disparities and have had historical barriers to health care access," said Elizabeth Gharst, a spokesperson for the Oregon Health Authority, which oversees the state's Medicaid program.

The six-year guarantee will also reduce administrative costs for the state, since it won't have to process some applications each year. And officials hope it will reduce the program's medical costs, as children who stay on Medicaid will have access to preventive and primary care services that can reduce the need for treatments related to delays in seeking care.

Oregon provides Medicaid and CHIP coverage to children from families with incomes of up to 300% of the federal poverty level, which is $83,250 for a family of four.

Lori Coyner, Oregon's senior Medicaid policy adviser, said the change will reduce health inequities because it will help children of color retain coverage and access to care.

In addition to keeping children on Medicaid longer, Oregon won federal approval in October to become the first state to give children 6 years and older and adults two years of continuous eligibility regardless of changes in their household's income.

Nationally, KFF estimates that about 11% of children enrolled in Medicaid lost their coverage for at least one day in 2019 before having it restored. Washington state also reports 11%.

In California, where a continuous-coverage policy is being considered, Medicaid officials estimate that of the nearly 1.2 million children younger than 5 who are covered, about 64,000 — or 6% — were dropped from the rolls and then reenrolled in the same year

Mike Odeh, senior director of health for the California advocacy group Children Now, believes the state's churning estimate is too low. He thinks 89,000 children a year are affected. The California legislature included the continuous eligibility provision in the budget approved in June. California would cover children in Medicaid from birth until age 5 starting in 2025 as long as the state can afford it.

The California Medicaid agency estimates the policy change would cost $39 million in 2025, assuming a January implementation, and $68 million for the 2025-26 fiscal year. The state is still weighing when to seek federal approval.

Odeh hopes the state moves ahead soon. "We would rather see the state pay for kids getting care than paying for paperwork," he said. Having to reenroll every year, he added, can be a barrier for low-income families. "We want them healthy and ready for school," Odeh said.

Medicaid officials in Washington state said that they have long considered giving children continuous eligibility for multiple years. "Families on Medicaid are really busy, and the last thing they can think about is renewing their coverage — and so this gets dropped to the bottom of their priority list," said Amy Dobbins, section manager of the Office of Medicaid Eligibility and Policy.

She said the covid public health emergency, during which more children have had coverage and received health services, only strengthened the case for continuous eligibility.

Dianne Hasselman, interim executive director of the National Association of Medicaid Directors, predicts that some states may be cautious about following Oregon's lead. "State legislators might also be concerned about increasing Medicaid program enrollment, particularly during a time when enrollment has already grown significantly," she said. In addition, lawmakers could be leery of extending coverage to people with other insurance options, such as from a parent's workplace, she said.

While pleased to see some states keeping children on Medicaid until age 6, Georgetown's Alker emphasized that Oregon's new policy will go into effect — at the public health emergency's end — just as millions of children lose coverage.

"States that are inattentive to the needs of children when the public health emergency ends will likely see a massive increase in uninsured children," Alker said. "So very different outcomes lie ahead."