With contributions from Elisabeth Burak & Joan Alker

Medicaid and CHIP are joint federal-state programs that serve more than one in three kids annually. Medicaid is by far the more important program of the two. States administer Medicaid with the federal government setting parameters and paying a majority of the cost. States enjoy a great deal of flexibility with respect to how programs operate, from eligibility and enrollment policies to payment rates and service types. However, all children in Medicaid have a guarantee of coverage if they meet income rules (which is not true in CHIP) and Medicaid’s pediatric benefit (EPDST) is recommended by the Academy of Pediatrics as the gold standard for kids. There are three main ways that Medicaid’s potential can be further realized:

  1. Unfortunately the number of uninsured children is on the rise for the first time in recent memory. The majority of uninsured children are eligible for Medicaid/CHIP but not enrolled so, with a renewed national commitment from federal and state leaders, we can get back on track to reduce the number of uninsured children in an incremental way. That is key – without coverage, children have less access to the health services they need and worse educational and economic outcomes and their families are protected from large medical bills, debt, and even bankruptcy.
  2. We have other ideas about how bolder steps can be taken to cover ALL children which you can read about here – like no newborn should leave the hospital without health insurance. It is time for a renewed national dialogue which pushes the boundaries to make sure that no child is left behind.
  3. Once children are connected with Medicaid/CHIP coverage, we need to make sure they have access to the right care, at the right place, at the right time. As the nation’s largest health insurer, it’s easy to forget that children make up the largest group of Medicaid beneficiaries. Yet, the developmental needs of children often don’t receive the attention they deserve when federal and state policymakers set their priorities. Why? In part because children are the least expensive to cover— which is the good news and the bad news. Payors- including Medicaid—seek to save money on the costliest and sickest patients, so children don’t rise to the top of the agenda for policymakers. Yet, by overlooking children, Medicaid is squandering an opportunity to prevent disease and illness before they get worse.

Paying for prevention isn’t just a good idea—it’s a federal requirement. Medicaid requires states to embed prevention into the pediatric benefit. This requirement, Early Periodic Screening Diagnostic and Treatment (EPSDT), applies to all Medicaid beneficiaries under age 21. EPSDT’s promise is not always met in practice though, and we need to do a lot of work to make sure that Medicaid managed care is providing high quality services to children that address the serious challenges and disparities that lower income children face.

The good news is that research is very clear that having Medicaid as a child ensures better short- and long-term health outcomes as well as higher high school graduation rates and economic outcomes. However, there are gaps in our knowledge, and one of those gaps is that the data itself can be lacking. Some children aren’t getting recommended preventive screenings or regular check-ups. Mental health, in particular, is an area where we are failing to meet growing demand for children and families, especially for very young children. The idea of mental health for infants and toddlers is so new that many states and healthcare plans don’t allow or promote evidence-based practices for young children alongside their parents and caregivers.

At the Medicaid or health insurance payor level, it’s difficult to glean whether children and families are getting the services they need. Much of Medicaid managed care is operating behind a curtain and that needs to change. Effectively looking at service gaps and the ways children move between screenings, referrals, and treatment is important—for all children, but especially those who touch multiple systems, like special education, child welfare, or social services. We need to demand more accountability from states and managed care plans. Some specific questions need to be asked such as:

  • How can we ensure children—especially young children—receive early intervention or mental health services as soon as needed?
  • Where and how might children fall through the cracks and not get the recommended services?
  • If a child’s parent is uninsured or underinsured, how does this affect the whole family? Thinking about children in isolation from their parents is a mistake.

Above federal minimums, states determine the “who, what, when, where, and how” in Medicaid: Who is eligible for the programs? What benefits and services are allowable? Where and how may services be delivered? What qualifications are required for providers of specific services? What data should be reported to the state and what should be reported publicly? Unfortunately, with respect to holding states and Medicaid managed care plans accountable, this Administration is moving in the wrong direction – weakening consumer protections and transparency. More regulatory barriers to children enrolling in and maintaining their Medicaid coverage are being proposed and implemented.

Some states like New York and Oregon have moved to ensure that children are a top priority in their state Medicaid programs. The “First 1000 Days” initiative in New York has made a number of Medicaid policy and payment changes for children, such as requiring all Medicaid managed care plans to detail a child health quality agenda and allowing dyadic treatment for a child and parent based on a parent’s diagnosis of substance abuse or mood disorder. Oregon uses payment incentives to improve screening rates and is moving to do the same for referrals and follow-up care. With maternal depression as a known impediment to healthy child development, more states are allowing or even requiring maternal depression screenings during well child visits, paid for under the child’s Medicaid account. While these are promising examples of what’s possible, so far we’ve only scratched the surface of unrealized opportunities.

This audience needs no convincing of the need to focus on children and families. With Medicaid serving more than one third of kids in the US and paying for close to half of all births, its importance cannot be overstated – especially for communities of color, children in the foster care system, children with chronic illness, and low-income families in general.

What can be intimidating is the complexity of Medicaid and the politics around it – which can get pretty hot! But kids and families need a seat at the table. That requires strategic policy analysis at both the federal and state level, constant education of policymakers for whom these issues are understandably complex, and a strong network of child advocacy groups around the country.

Funders have a key role as a trusted voice in the community. In focus group research, those advocating for children are often seen as trusted messengers – especially because they don’t have a dog in the fight. We believe it is critical for funders to support child and family advocates around the country. In addition, funders can support work to:

Educate, educate, educate. Medicaid/CHIP are complex and basic education about their importance to families and their role in state budgets is needed. This work must take into account political context. Because Medicaid is one of the few surviving entitlement programs, it is frequently the target of political attacks, efforts to break the guaranteed funding stream, and spending cuts. It is critical to keep an eye on emerging threats to the program and not shy away from discussions.

Don’t forget about local, state and national efforts to make sure children and families are getting enrolled in public coverage. For example, we are seeing a “chilling effect” in immigrant communities who are currently experiencing a great deal of fear about using public benefits – even though children’s use of Medicaid/CHIP should not penalize a family in any way. This is one of the reasons the child uninsured rate is on the rise again.

Support efforts to ensure that states make good policy choices in Medicaid and efforts to ensure greater transparency and accountability in Medicaid managed care. States have many choices – check out how your state compares to others on our children’s health report card. Change doesn’t happen overnight, so take the long view on engaging with these questions.

Support best practices in Medicaid. Many well-researched models and practices may be supported by Medicaid. Healthy Steps, Centering Pregnancy, and other best practices, such as early childhood mental health services or team-based care, should be supported at least in part by Medicaid. This can help move funders’ initial investments toward broader application and sustainability. This is by no means simple work and varies by state, but it is well worth the effort as it can provide tangible long-term results.