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Children’s Health Care Coverage

Adequate health insurance coverage for children is vital. Kids who have health insurance have better health throughout their childhood and into adolescence and adulthood. They are more likely to receive preventative care to keep them from getting sick and can more easily get the treatment they need when they do. Conversely, uninsured kids are more likely to have unmet medical care needs, and much less likely to receive important preventative services. Fortunately, the majority of kids in our country are covered by at least one form of insurance, and as many as half of those who don’t have insurance, are eligible for Medicaid or CHIP. 

Medicaid Coverage for Kids

Medicaid provides health coverage to more than 30 million children. It also covers families, pregnant women, the elderly and people with disabilities.

Medicaid is available in every state. While there are variations in each state’s program, all states provide Medicaid to infants and children under the age of 6 with family incomes of up to 133 percent of the federal poverty level ($29,725 for a family of four as of 2011). Medicaid is also available for children under age 19 with family incomes at the poverty level ($22,350 for a family of four). 

Medicaid covers a full set of comprehensive services for children (up to age 21), including preventive care, immunizations, screening and treatment of health conditions, doctor and hospital visits, and vision and dental care. In most cases, these services are free of charge.

More than two million children in Medicaid are considered “medically complex,” with expensive, highly specialized needs. Although these medically complex children comprise only six percent of all children enrolled in Medicaid, they represent more than 40 percent of all Medicaid spending on children.

Medicaid costs are shared by federal and state governments. As state budget shortfalls and the number of Medicaid recipients both increase, state lawmakers from across the country continue to push budget measures that include cuts to Medicaid. This year alone, 41 states have attempted to freeze or cut Medicaid payments to providers (physicians, inpatient hospitals, dentists, etc.)

Click here to learn more about the Medicaid program in your state.

The Children’s Health Insurance Program (CHIP)

CHIP provides free or low-cost health coverage to more than eight million children in families that earn too much money to qualify for Medicaid (generally children in families with incomes up to $44,100 for a family of four, though in many states, families can have higher incomes and their children can still qualify). In some states, CHIP also covers parents and pregnant women.

Every state offers CHIP coverage, which works closely with its state Medicaid program; CHIP provides federal matching funds for states that put up funds of their own to expand Medicaid to uninsured children, create alternative insurance programs for them, or both. Each state designs its own CHIP program (within Federal guidelines), including eligibility, benefits, premiums and cost-sharing, and application and renewal procedures. States can decide on the benefits provided under CHIP, but all states cover routine check-ups, immunizations, hospital care, dental care, and lab and x-ray services. Children get free preventive care, but low premiums and other cost-sharing may be required for other services.

Unless Congress intervenes, CHIP is set to expire in 2015.

Learn more about CHIP programs in your state. 

TRICARE

TRICARE is the Department of Defense (DOD) health care program for military families and retirees, serving more than 9.6 million beneficiaries including almost two million children. TRICARE is the only health plan insuring children that is consistent in policy and payment across all 50 states. 

Uninsured

While the number is decreasing, ten percent of children in the United States remain uninsured. Nearly half of those uninsured kids are eligible for Medicaid or CHIP, but their families may not know it. If you or someone you know needs health coverage, you should apply. To find information about Medicaid and CHIP health coverage programs in your state, visit insurekidsnow.gov, or call the Department of Health and Human Services’ hotline at 1-877-Kids-Now (1-877-543-7669). They will connect you with someone from your state who can help you apply for coverage.

Private Insurance

More than fifty percent of kids are covered by employer-sponsored or other private insurance. The Affordable Care Act ensures that these kids cannot be denied coverage because of pre-existing conditions, and that individual and group plans must provide coverage until age 26.

Access to Pediatricians

Even though 90 percent of children in the United States have insurance, access to care continues to be an issue as the population of children grows while the number of pediatric providers holds steady, or in the case of some pediatric specialties, decreases.

Fewer physicians and more kids means longer wait times. The prevailing benchmark in children’s hospitals for clinic wait times to schedule appointments is two weeks. But for certain specialties experiencing these physician shortages, the wait time is much longer. For pediatric neurology, for example, the average wait time to see a specialist is almost nine weeks.

The Affordable Care Act helps address this issue by strengthening the pediatric workforce through a number of different provisions, including a new loan repayment program (up to $35,000 a year for three years) for individuals who pursue full‐time employment in pediatric medical subspecialties, pediatric surgical specialties, or child and adolescent mental and behavioral health care fields.

Another solution to this problem is to encourage and supplement pediatric training programs. One such program, the Children's Hospital Graduate Medical Education (CHGME) program, supports children’s health care by providing freestanding children's hospitals with federal funding to train pediatricians and pediatric specialists.

This program is vital to the future of pediatric care in this country as CHGME recipient hospitals, just one percent of all hospitals, train nearly half of all pediatricians, as many as 6,000 each year.

Unfortunately, funding for CHGME has been significantly reduced in recent years, from $317.5 million in 2010 to $251 million this year.

ACA Impact on Kids

While it has been the subject of intense debate since its passage, the Affordable Care Act (ACA) of 2010 provides many benefits to children and their families, which are being implemented over a number of years. Among many others, the ACA:

  • Includes private health insurance reforms such as a prohibition on pre-existing condition exclusions; a requirement that private plans provide dependent coverage until a child turns 26; prohibitions on lifetime limits on the dollar value of coverage and many annual limits on coverage; and required coverage of a range of preventive services without cost-sharing.
  • Requires private health insurance plans to cover basic benefits in each of 10 categories and establishes state or national insurance exchanges to facilitate the purchase of qualified (certified) private insurance. (These exchanges or “marketplaces” are currently a subject of great debate in many states.)
  • Authorizes and funds CHIP through September 30, 2015. Beginning on October 1, 2015, states will receive a 23 percentage point increase in their CHIP federal matching rate.
  • Strengthens the pediatric workforce through a number of different provisions, including a new loan repayment program (up to $35,000 a year for three years) for individuals who pursue full‐time employment in pediatric medical subspecialties, pediatric surgical specialties, or child and adolescent mental and behavioral health care fields.

Drug Shortages

Ensuring access to necessary and lifesaving medicines and vaccines is critical to the health and well-being of our nation’s children. In recent years, drug shortages have become all too common in the United States, reaching unprecedented levels. The causes of these shortages are numerous and complex and lawmakers are working to understand market factors that may play a role in causing the currently unstable supply chain.

Perhaps the most troubling aspect of the increasing drug supply problem is the frequency of shortages in medications for infant development. Infant care (and pediatric care in general) frequently requires the use of injectable (as opposed to oral) medications, and according to some reports, more than 80 percent of the drugs in short supply are injectables.

While Congress passed a law in 2012 to alleviate the impact of shortages on patient care, that alone won’t end drug shortages. It is critical for private industry stakeholders and lawmakers to work together to find a more comprehensive solution. 

Pediatric Research

The National Institutes of Health (NIH) budget devotes just five percent of funds to pediatric research. This underinvestment threatens to hinder efforts to develop novel treatments and therapies for pediatric patients.

Bipartisan legislation passed by the House, “The National Pediatric Research Network Act of 2013” (H.R. 225) would authorize NIH to support research and training at up to 20  national pediatric research consortia for five years, helping to address critical resource and capacity issues in pediatric research and to give pediatric research parity with research into adult conditions.