Over the past year, pediatricians around the country have seen patients’ surgeries postponed, access to crucial medications jeopardized and appointments canceled at the last minute, all due to children losing Medicaid coverage that had been secure during the COVID-19 public health emergency.
The AAP has been working diligently at the state and federal levels to mitigate these impacts and help eligible children stay covered during this “unwinding” period. It has been supporting chapters in their ongoing state-level advocacy, educating pediatricians and patients on steps they need to take, challenging inappropriate terminations, tracking data and lobbying for long-term protections.
“It’s been hard to know some of our most vulnerable children … lost access,” said Kimberly Avila Edwards, M.D., FAAP, a member of the AAP Committee on Federal Government Affairs. “… There are such dedicated and committed associates at federal and state agencies, but there are still gaps in terms of the processing of children who are trying to get reenrolled."
Impact on patients
During the public health emergency, states were required to keep children enrolled in public insurance, and an additional 7 million children gained coverage. However, starting April 1, 2023, states began determining if enrollees were still eligible and were given up to 14 months to return to prior eligibility and enrollment procedures, although many states have extended timelines.
By the end of December, 4 million fewer children were enrolled. Nearly every state has shown a decrease in child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) during the unwinding period, according to an AAP analysis of the data.
While some children who have been disenrolled are no longer eligible, about seven in 10 disenrollments are due to procedural reasons such as outdated mailing addresses and unreturned forms.
Pediatricians say patients often don’t realize they’ve lost coverage until right before or even during a visit, leading to delays and cancellations. In some cases, it’s driving children to emergency departments where they won’t be charged upfront, according to Pamela Shaw, M.D., FAAP, chair of the AAP Committee on State Government Affairs.
Colleagues of Dr. Avila Edwards have reported postponed surgeries and children with medical complexities waiting months for an appointment only to find out they had been disenrolled. Some families are concerned they won’t be able to access medications for chronic conditions.
“It just puts so much strain on families like, oh my gosh how am I going to pick up the EpiPen, how am I going to pick up the albuterol I need?” Dr. Avila Edwards said. “That (makes) it really heartbreaking for us as physicians on the other side. We had so much effort to raise awareness, but it still was not even close to what was needed.”
Deborah M. Greenhouse, M.D., FAAP, vice chairperson for AAP District IV, said her practice in Columbia, S.C., used posters, social media and other means to educate families on the need to reenroll. Some families, however, may have mistaken enrollment forms for junk mail or struggled with the paperwork due to language barriers. Dr. Greenhouse also heard from families who said they had to go to the Medicaid office to reenroll, which is difficult for those without transportation or child care.
“If your child has lost their Medicaid coverage, trying to get reinstated and making sure you have got every i dotted and t crossed on the application, getting it turned in correctly, it’s not an easy process,” Dr. Greenhouse said.
Impact on clinicians
Some practices have hired more staff to help with billing and enrollment issues, while others are diverting staff from other duties. Dr. Shaw said her social worker is spending hours at a time with patients trying to help them reenroll, time that otherwise would be spent counseling adolescents with mental health struggles or connecting families to community resources to address food insecurity.
Some practices are seeing fewer patients due to last-minute cancellations, while others take patients who have lost coverage and hope to get reimbursed later.
“When you have an empty spot, that means you also have no revenue to take care of the people in your practice who work for you,” Dr. Shaw said. “ … It may be that you’re just eating the cost of taking care of that kid, too. Any time you do that it’s going to (impact) your practice and your ability to take care of other children as well as the people you employ. It’s not good business, but in many cases pediatricians do it.”
AAP efforts, advocacy
Months before the unwinding started, the AAP created and communicated resources so pediatricians could assist families keep or reinstate coverage.
Throughout the unwinding, the AAP has held webinars, distributed resources, partnered with organizations like the Georgetown University Center for Children and Families, tracked data and met with state and federal officials. It also has been collecting stories of children who have been disenrolled inappropriately and sharing them with state and federal agencies to highlight issues and help officials track patterns.
The AAP’s “tracking and their reporting and their policy and advocacy efforts make a difference and (are) why I feel so incredibly proud to be part of this organization because we can’t do it alone, our states can’t do it alone,” Dr. Avila Edwards said. “And the AAP just brings us all together.”
Chapters have been key partners, creating and sharing resources, leveraging their relationships with state agencies and forming local partnerships. For instance, many chapters including West Virginia and Kansas created state-specific resources to boost their outreach work.
“In general, advocacy is about relationships, repetition and respect,” said Elizabeth Hudgins, M.P.P., executive director of the North Carolina Pediatric Society. “If you put it in that context, we’ve been building those relationships, we’ve been talking about the importance of continuous eligibility and other strategies to make sure children have strong and continuous access to health care so that care is not disrupted. And we’ve been respectful of all the complications that are going on.”
Despite the challenges, there have been victories like the Centers for Medicare & Medicaid Services (CMS) streamlining enrollment in Medicaid and CHIP and eliminating punitive practices.
Outside unwinding, the AAP has seen progress in related advocacy efforts to ensure children don’t experience disruptions in care. In January, new requirements took effect that guarantee 12 months of continuous eligibility for all children enrolled in Medicaid and CHIP.
Advocacy efforts now are focused on longer-term eligibility. The AAP released a policy last fall calling for bold reforms to Medicaid and CHIP, including continuous eligibility from birth through age 6 years and a minimum of two years of continuous eligibility without renewal requirements for people ages 6 through 26 years.
Those proposals are gaining traction as well. Three states have implemented Medicaid waivers that include continuous eligibility until age 6 years, and several other states are pursuing similar policies. President Joe Biden’s budget proposal released in March would allow states to provide continuous eligibility until age 6 years.
While the proposal still has a long road to gaining congressional approval, experts said it shows the message is reaching the highest levels of government.
Continuous coverage is “exactly what you need for a good start,” Dr. Shaw said. “As we know, if you’re healthy, you can learn and develop and do all the things we want kids to do. And the first step to being healthy is to make sure you have insurance so that you can be seen (by a doctor).”
Next steps
The AAP will continue its advocacy work around unwinding and push for the continuous eligibility provisions in Biden’s budget proposal and state waivers from CMS for continuous eligibility.
In the meantime, pediatricians can work with their chapters and managed care organizations. They can continue helping patients’ families navigate unwinding and re-enroll if they’ve lost coverage.
“Reaching out to your families in every possible way you can is the most important thing and that can be with social media, that can be with flyers in your offices, it can be with text messages, it can be with messages through your portal,” Dr. Greenhouse said. “Any way you can reach families to make sure they all know about this and they are keeping their information up to date is absolutely worthwhile.”
Resources
