The ABCs of Rolling Back Children's Eligibility for Public Coverage: Access, Burdens, and Coverage

A key goal of the Affordable Care Act (ACA) is to provide affordable coverage for health insurance for all Americans.  For children in low- to moderate-income families the ACA relies on a patchwork of Medicaid, CHIP, and subsidized private insurance through employers or the Marketplace to provide coverage.  While these pathways provide insurance options for most children, families may face very different experiences depending on which options are available.  There is, as a result, the potential for wide variation in costs, benefit plans, and access to care.  Furthermore, the future of Medicaid and CHIP for children in families above 138% of poverty is uncertain; maintenance-of-effort requirements expire in 2019, and CHIP funding is only assured through 2017.  Loss of eligibility for public coverage and transitions to less affordable coverage options are likely to have significant effect on access, coverage and financial burden. One way to examine the potential fallout from a roll-back is to identify different groups of children based on their post-ACA eligibility and their likelihood of being rolled back, and observe their current level of access, burden and coverage.

This paper focuses on children in low-to moderate-income families and examines their coverage, access to care, and financial burdenof health care expenditure (ABCs) in the pre-ACA period based on their eligibility for different types of coverage, if any, in the post-ACA period. In particular, we study children in families with incomes below 400% of poverty and identify them as one of the following: Medicaid-eligible below 138% of poverty, Medicaid-eligible above 138% poverty, Separate CHIP-eligible, Marketplace-subsidy-eligible, and eligible for employer sponsored coverage (has a parent with an ESI offer).  A sixth category contains any remaining children; these children currently have no pathways to coverage under the ACA. 

Coverage, access, and burden are measured for each of the six categories above.  In addition, access and burden are also measured by insurance status within those categories.  For example, we measure average burden for CHIP-eligible children, but also for CHIP-eligible children with public vs. private coverage.  For Medicaid- and CHIP-eligible children, these coverage-based estimates may provide insight into the potential burdens faced by publicly eligible children if CHIP funding is not extended on 2017 or maintenance-of-effort requirements for Medicaid and CHIP are allowed to expire in 2019.   

We use pooled data from the Medical Expenditure Panel Survey for 2005-2010 for non-disabled children ages 0-18.  2014 eligibility is simulated for each child using individual- and family-level characteristics (age, income, family size) along with federal and state rules.  Coverage is measured by whether a child is publicly or privately insured.  Access is measured by usual source of care, any well-child visit during the year, any well-dental visit during the year, and any visit to the emergency room during the year.  Finally, burden is measured as percent of family income spent on out-of-pocket medical expenditures and premiums.