Access to Care

Transition Plan for Healthy Children

Access to Care

In 2019, an estimated 4.4 million children did not have health coverage, an increase of 726,000 since 2016, when the nation reached historic lows of children lacking coverage. Without coverage, children are likely to delay or skip needed care. Children without access to care suffer long-term harm, ending up in poorer health, with less educational attainment, and less financial security in adulthood. It should be our national goal to cover all children. 

Facilitate children’s enrollment in health insurance. Millions of children are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) but are simply not yet enrolled. This administration must act to further streamline Medicaid/CHIP enrollment and retention rules and work with states to simplify their eligibility procedures and boost outreach to ensure that every child is enrolled in quality, affordable health insurance. Appropriate support for presumptive Medicaid eligibility and increased periods of continuous Medicaid eligibility for children would also increase access to insurance, including presumptive eligibility for newborns at birth if they do not have other coverage. The administration should reinstate and prioritize funding for outreach and enrollment for Medicaid, CHIP, and exchange plans to promote enrollment in affordable, comprehensive coverage for children and their families, including restoring navigator funding to 2016 levels to provide culturally competent consumer assistance for Medicaid, CHIP, and exchange coverage.

Rescind Medicaid waivers that reduce coverage. Medicaid 1115 waivers should be used to expand coverage and promote the objectives of the Medicaid program, not create barriers to access. The administration should rescind current guidance that allows states to implement work reporting requirements and block grants/per capita caps. Provisions of previously approved waivers should be void if they impede coverage and access, such as elimination of benefits like Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and retroactive coverage.

Eliminate the Family Glitch. Under the current regulatory structure, a family that has access to employee-only coverage that is deemed “affordable” cannot qualify for a subsidy to purchase coverage on the individual market even if dependent coverage is unaffordable. The administration should redefine the affordability test to account for the cost of family coverage rather than individual coverage.

Suspend operation of promulgated rules that would impede access in Medicaid. Proposed revisions to the Medicaid Access Rule and Medicaid Managed Care Rule have yet to be finalized. The administration should pause these rulemaking processes and evaluate, with stakeholder input, better ways to improve access and network adequacy in Medicaid. A moratorium should be placed on other harmful pending rules being reviewed by OMB, including Medicaid premiums and cost sharing (CMS-2411-P), eligibility determinations (CMS-2421-P), and payment for eligibility workers (CMS-2433-P). Each of these policy areas places a burden of increased reporting, diminished resources, or both on state Medicaid programs – burdens that act at cross-purposes in light of the ongoing public health emergency.

Cover all children regardless of immigration status. Remove eligibility restrictions based on citizenship status so that all children who meet the income eligibility requirements for Medicaid and CHIP are able to enroll.  Although most children living in immigrant families are U.S. citizens, undocumented children and Deferred Action for Childhood Arrivals (DACA) youth are excluded from federal health insurance programs in most cases. Additionally, the administration should withdraw the Oct. 2019 proclamation suspending entry of immigrants to the U.S. without approved health insurance as it would force immigrant families seeking a visa towards less comprehensive coverage options, higher costs, and fewer consumer protections. The government should also stop defending this policy in court.

Increase access to care. On average, Medicaid pays providers about two-thirds of what a Medicare provider receives for the same service. Inappropriately low Medicaid payments impede the ability of providers to accept more patients covered through this program. That leaves children enrolled in Medicaid facing barriers to access like long wait times to see a specialist and needing to travel far to find a practice that will accept their coverage. The administration should apply the equal access rule to both Medicaid fee-for-service and Medicaid managed care to ensure that Medicaid programs can provide children timely access to needed services.

Ensure that insurance offers children appropriate benefits.  All children must have access to the full range of age-appropriate health care providers, subspecialists, and facilities. Affordable Care Act (ACA) marketplace plans and other health plans should not be allowed to create narrow networks that exclude pediatric appropriate providers or essential health benefits. The administration should rescind guidance related to State Relief and Empowerment waivers and return to the original guardrails for the approval of Section 1332 Innovation Waivers. Regulatory changes that allow for the proliferation of short-term plans and Association Health Plans should be rolled back.

Support the Affordable Care Act through regulatory actions. The administration should clarify its support for the structure of the Affordable Care Act by rescinding Executive Order 13765, “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal,” and direct agencies to support and strengthen the protections of the Affordable Care Act to the fullest extent available under statutory authority.

Intervene in the California v. Texas case to support the Affordable Care Act. The Supreme Court will hear oral arguments in this case surrounding the constitutionality of the Affordable Care Act’s individual mandate, and the degree to which the remainder of the law can stand if that provision falls. The DOJ should issue a brief in support of the constitutionality of the individual mandate, and of the severability of the remaining provisions of the Affordable Care Act.