The number of children in the U.S. without access to health care could double over the next 15 months as states begin a massive effort to determine who remains eligible for Medicaid and CHIP and who isn’t. 

That’s the finding of a groundbreaking report issued this week by the Georgetown University Center for Children and Families. The report includes one statistic that may surprise some: as a result of the pandemic – and the increased Medicaid support Congress passed in response – 54 percent of children are now covered by Medicaid or CHIP. That’s a 17.5 percent increase from pre-pandemic days and the first time ever that a majority of children received coverage through these programs. 

When Congress in 2020 approved additional Medicaid funds for states, these dollars came with a condition: during the pandemic emergency, states were not allowed to kick anyone off the Medicaid rolls, even if a family’s income level had increased beyond eligibility or if a child had turned 19 and thus would have normally “aged out” of the program. 

Now, as part of the appropriations bill Congress passed in December, states are required to examine their Medicaid rolls and determine who remains eligible – a gargantuan task, given that more than 83 million Americans receive Medicaid. Some states began conducting this evaluation on February 1; all are required to begin it by April 1, which is also the date that states who began their work early may begin removing people from the Medicaid rolls. All states are required to complete their eligibility determinations – also called “Medicaid unwinding” — by May 2024. 

But advocates are deeply concerned that as many as 6.7 million children will lose Medicaid or CHIP coverage. Their concerns are primarily twofold. First, many families will no longer be eligible because their incomes increased by a certain amount during the pandemic. Second, and even more concerning, many families will lose coverage even though they remain eligible. This will be due to bureaucratic snafus – for instance, they changed addresses during the pandemic and did not receive correspondence from the state asking them to update their financial information. 

Overall, 15 million people could be dropped from Medicaid, according to a Department of Health and Human Services analysis released last year. About 8.2 million recipients could be dropped because they are no longer eligible, but 6.8 million people would be removed even though they are still eligible – and this includes a disproportionate number of children, people of color, and people with disabilities. 

According to the Center for Children and Families report, nearly three-quarters of the children projected to be dropped from Medicaid or CHIP will still be eligible for assistance, but will lose coverage because of administrative issues, such as parents not submitting the necessary paperwork or procedural issues. 

Because of this, the report emphasizes that states need to take different approaches when it comes to determining children’s eligibility and adults’ eligibility. The report said states should work with pediatricians, schools, child care centers and others to explain eligibility guidelines to parents and to make sure children retain coverage if they continue to qualify. The situation is exacerbated by the fact that some parents will automatically assume that if they no longer qualify for Medicaid, their children won’t qualify either – this assumption is often false, as eligibility guidelines for children are more generous than for parents. 

“If they’re getting the message that they’re losing their own coverage, a lot of times a parent understandably thinks that their child is also losing coverage,“ said Joan Alker, the Center’s Executive Director and co-author of the report. “My concern is that a large number of children could become uninsured in states that do not take their time and pay particular attention to the unique needs of children.” 

Also making the situation worse: some states, particularly states led by Republican governors and legislators, are rushing to pass legislation that requires state officials to complete the Medicaid eligibility evaluations within a certain time period, such as six months. Arkansas and Ohio have passed such legislation. 

“That’s not good news for children and families because states have longer” to be able to complete the evaluations under federal guidelines, Alker said. “They have 12 months and really 14 months when you count in the time that it takes to do a renewal. So states that rush are going to see more errors, particularly if they are short-staffed, which virtually all states are and I believe Arkansas is.” 

Dr. Lisa Costello, a pediatrician and immediate past President of the West Virginia chapter of the American Academy of Pediatrics, joined Alker in releasing the report on a webinar this week. She said 63 percent of the children in West Virginia are covered by Medicaid. 

“When the Medicaid continuous coverage protection expires, we need to ensure children do not slip through the cracks and can maintain their health care coverage,” Dr. Costello said. “Their health depends on it. Young people have faced crisis after crisis, from the years-long pandemic to this fall’s surge in pediatric respiratory illnesses, to the ongoing youth mental health emergency. The last thing families should have to worry about is whether they have reliable health care coverage and can get their children the care they need.” 

Dr. Costello said she has seen first-hand what happens when gaps appear in health care coverage. 

“I have personally cared for families who were unable to get their insulin prescription filled due to lapse in coverage or no coverage at all, which led to high blood sugars and the need for their child to be hospitalized,” she said. “Another example was a child with asthma who experienced a gap in coverage. They were unable to get their medication that helped control their asthma or get a checkup to monitor their symptoms. Without medicine or monitoring, their asthma worsened and their breathing challenges landed them in the hospital. With health care coverage, these stories likely would have been prevented.” 

Dr. Costello concluded that Medicaid is a “lifeline” for the 34 million children across the U.S. who rely on it and said it is critical that state officials do everything in their power to ensure eligible children and families do not lose their health care coverage. 

“If a child or family is no longer eligible, we must make sure they are seamlessly transitioned into another source of health care coverage,” she said. “Families should not face additional layers of burden like unnecessary paperwork or administrative barriers that will keep them from getting the care they need…There’s too much at stake for children, and we can’t afford to lose the gains we’ve made to keep kids insured. Protecting their Medicaid coverage means supporting their life-long health.”