About 146,000 fewer children in Texas were enrolled in Medicaid and the Children’s Health Insurance Program between the end of 2017 and the end of 2018, according to a study released Thursday by the Georgetown University Center for Children and Families.
Nationwide more than 828,000 fewer children were enrolled in Medicaid and CHIP, combined, at the end of 2018. About 70 percent of those losses took place in seven states, including Texas, the report found.
“We are extremely concerned about what we are seeing and what it portends for the uninsured numbers these fall,” said Joan Alker, the executive director of the Georgetown University Center for Children and Families. “For many years there’s been a national bipartisan commitment to reduce the number of uninsured children and the effort have borne fruit. Unfortunately, today we do not feel confident that this national commitment still exists.”
Typically, a drop in enrollment for government health programs is tied to an improving economy; more Americans are presumably getting health insurance through their employers. The study's authors say they see little evidence that’s what’s happening here.
So far, the authors wrote, “there is no clear evidence that there was a sizable increase in employer-sponsored insurance among children in low- and moderate-income families” during the months they reviewed.
“It’s far more likely eligible children are falling through the cracks,” said Tricia Brooks, a senior fellow at the Georgetown University Center for Children and Families and lead author of the report.
Census data expected to be released this fall ultimately should provide a clearer picture of whether these losses were offset in any way by private insurance gains.
The study pointed to a series of factors that might help explain the enrollment drop.
Among those factors are ongoing cuts to marketing, outreach and grants aimed at letting families know they are eligible for the programs and how to sign up. Another factor is a lapse in CHIP funding caused by gridlock in Congress in 2017 that led to some declines in enrollment for the program.
Researchers also found a “chilling effect” caused by anti-immigrant rhetoric and proposed policies.
In particular, there’s evidence some immigrant families are not enrolling their citizen children in government programs because of a potential change to who can get a legal status, or a green card, in the U.S. In 2018, there were reports the Trump administration began the process of changing “the public charge” rule, making it more difficult for people who rely on government services to get green cards.
“Reports of a decline in participation in Medicaid began after draft proposals were leaked to the press and intensified after the proposed rule was released in October 2018,” the study said.
Advocates have said, anecdotally, families are not enrolling in services for fear it could hurt their chances of getting a green card.
The report flagged a letter from a Medicaid health plan in Texas that found evidence that leaked versions of changes to the green card rules actually contributed to declining enrollment in the state.
“It is thought,” the letter said, “that nearly 150,000 fewer individuals currently access Medicaid in Texas in part due to the leaked rule.”
Last, researchers found red tape and bureaucracy has led to a significant slowdown in enrollment of children in Medicaid and CHIP. For example, they say, changes to eligibility systems and verification procedures have made a big impact in certain states, particularly Texas.
“One of the more stark examples of the move to conduct more frequent and stricter reviews of eligibility is occurring in Texas,” the authors wrote. “The state contracts with a third-party vendor to review children’s Medicaid eligibility in months 5, 6, 7, and 8 of enrollment, while more moderate-income children enrolled in CHIP get 12-month continuous eligibility.”
According to the report, Texas is disenrolling more than 4,000 children from Medicaid a month. During those monthly check-ins, families are given only 10 days after they are flagged by the state to send in paperwork to prove they meet the income requirements for the program.
“That’s causing significant confusion for families and throughout our health care system,” said Laura Guerra-Cardus, deputy director of the Children’s Defense Fund of Texas.
Guerra-Cardus said in some cases, children are being kicked out of the program before the letter to send paperwork is even sent to families. Nine out of every 10 children dropped from coverage are dropped because of red tape, she said.
“So when this month-to-month coverage policy began, the entire child health care community started seeing a significant increase in churn of Medicaid-eligible children,” she said. “And the families had no idea.”
There was an effort to get Texas lawmakers to reverse the policy during this year’s legislative session, but those efforts failed. House Bill 342 would have allowed children to remain covered by Medicaid for a year at a time once they are deemed eligible. The bill moved slowly through the Legislature, however, and failed to pass.
“Our lawmakers failed to prioritize this issue and actually left this flawed policy in place,” Guerra-Cardus said, “which means we are going to continue knocking thousands of eligible children off of their health care coverage every month.”