The 2023 State of Children’s Health in Pennsylvania Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
Table of Contents Introduction.................................................................................................................................................................... 3 Uninsured Rate Trends.................................................................................................................................................4 Regional Comparison............................................................................................................................................4 County Comparison...............................................................................................................................................5 Children Without Health Insurance by Age................................................................................................................6 Children Without Health Insurance by Race/Ethnicity..............................................................................................7 Children Without Health Insurance by Poverty Level.............................................................................................10 Publicly Funded or Supported Health Insurance....................................................................................................11 Enrollment by Race and Ethnicity........................................................................................................................11 How Medicaid Unwinding is Impacting Children.................................................................................................12 Continuous Eligibility Policy.................................................................................................................................15 CHIP Eligibility Systems Transition......................................................................................................................16 Health Insurance Plans Available Through Medicaid, CHIP, & Pennie™...........................................................17 Conclusion................................................................................................................................................................... 18 Acknowledgements..................................................................................................................................................... 19 End Notes.....................................................................................................................................................................19
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November 2023
The 2023 State of Children’s Health report analyzes the latest Census data around children’s health insurance during the last full year of the COVID-19 public health emergency, and the results are surprising. In what was expected to be another year of improvement thanks in large part to pandemic- era flexibilities in Medicaid and the Children’s Health Insurance Program (CHIP), the 2022 data instead shows children in Pennsylvania are less connected to health insurance than the prior year. More PA Children Without Health Insurance 4.4% 5.2% 2023 has been a big year for changes in the landscape of children’s public health insurance. On the Medicaid side, the continuous coverage provision that was put into place at the start of the pandemic, which allowed children and others to stay continuously enrolled, expired on April 1, 2023. For the first time in three years, Medicaid renewals are required to stay enrolled. Another major change that began in April 2023 is the transition of the eligibility systems for CHIP. This change shifts eligibility and enrollment responsibilities from CHIP managed care organizations to the county assistance offices run by the Department of Human Services (DHS). These changes have been disruptive to children’s coverage and are likely to impact next year’s uninsured data reporting. For now, it is troubling to see the unexpected dip in the
uninsured rate ahead of what’s likely to be another declining year. Advocates, policymakers, and other stakeholders have an opportunity to use the latest demographic findings laid out in the report to target outreach efforts more strategically to families of the 145,000 children who need health coverage. The report follows the progress on the Medicaid unwinding and the CHIP eligibility systems transition, and urges DHS to take specific actions to: keep children connected to health insurance by immediately restoring Medicaid coverage for those who lost it during the automated “ex parte” renewals error; and support multi-year continuous eligibility for children during a critically important developmental period from birth to kindergarten. Together, these vital action steps can help offset the loss of children’s coverage and put Pennsylvania on a better path for keeping children enrolled for longer periods, yielding better outcomes.
3
Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
More Pennsylvania children lost health insurance last year, signaling a turn in the wrong direction after a brief reprieve during an earlier period of the pandemic. Between 2021 and 2022, the rate of children in Pennsylvania without health insurance increased significantly from 4.4% to 5.2%. i Pennsylvania now has the 5th highest number of uninsured children in the nation. Lack of coverage or even short gaps in coverage can result in missed appointments and delayed care for chronic conditions such as asthma, resulting in emergency department visits and missed school days. Uninsured Rate Trends The Census data showing a larger number of children going without health insurance than the prior year is surprising for several reasons. First, the Medicaid disenrollment freeze, in place during the COVID-19 public health emergency, continued throughout 2022. Therefore, the 2022 Census data does not reflect the unwinding of the Medicaid continuous coverage process (and the first time that renewals have been required in three years), which didn’t begin until April 2023. It was expected that the last full year of the COVID-19 public health emergency would reflect at least stable coverage or even gains in connecting kids to health insurance. In fact, Pennsylvania is one of only three states, alongside Connecticut and Wisconsin, that saw The more than 145,000 Pennsylvania children without health insurance could fill every seat in Penn State’s Beaver Stadium plus an additional 39,000 kids out in the parking lot.
declines in 2022 regarding its insured child population. All other states had improvements in their uninsured data or relatively stable coverage with no significant changes. ii Notably, private coverage rates significantly decreased for children in Pennsylvania and only five other states, which may provide a partial explanation for the overall worse uninsured rate. It’s also noteworthy that the opposite trend occurred for Pennsylvania adults whose uninsured rate significantly dropped, following the national trend. Another difference not seen in the child population is that the public coverage rate for adults significantly improved in 2022. Regional Comparison Pennsylvania’s uninsured rate for children has risen above the national average for the first time since 2017, with the state at 5.2% and the country at 5.1%. Pennsylvania also has the highest uninsured rate for children when compared to all neighboring states. New York, with a much higher child population, has half the uninsured rate as the commonwealth. Meanwhile, Ohio’s uninsured rate improved since the prior year, resulting in a switch of the rankings with Pennsylvania.
Percent Under Age 19 Without Health Insurance New York
2.6% 2.8% 3.4% 3.9% 4.2% 4.5%
West Virginia
Delaware
New Jersey
Maryland
Ohio
Pennsylvania 5.2% Source: PPC analysis, U.S. Census Bureau, American Community Survey (1-year estimates), 2022
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November 2023
Difference in Uninsured Rates for Children, 2021-2022
Uninsured rates increased, and more children are without health insurance Uninsured rates decreased, and less children are without health insurance
Erie -0.03%
Susquehanna -0.09%
Bradford -0.12%
Warren 2.00%
Tioga -0.12%
McKean -2.89%
Potter -2.89%
Crawford 5.43%
Wayne -3.09%
Forest 1.45%
Wyoming 0.06%
Elk -2.89%
Sullivan -0.12%
Cameron
Venango 1.45%
Lackawanna -1.38%
-2.89%
Pike -3.09%
Lycoming 1.16%
Mercer 2.84%
Clinton -1.05%
Clarion 1.45%
Jefferson 1.45%
Luzerne -0.97%
Columbia 1.61%
Monroe 1.99%
Lawrence -3.31%
Union 4.39% Snyder 4.39%
Clear eld -2.72%
Butler 0.28%
Centre -1.87%
Carbon 5.04%
Armstrong 1.09%
Beaver 0.40%
Schuylkill -0.60%
Mif in 4.39%
Indiana 1.67%
Juniata
Lehigh 0.77%
4.39%
Dauphin 4.79%
Allegheny 0.46%
Blair -4.57%
Cambria -1.83%
Bucks 0.21%
Perry -1.05%
Berks 0.84%
Lebanon 11.13%
Westmoreland 1.90%
Huntingdon -4.20%
Washington 3.52%
Montgomery -0.50%
Cumberland -0.27%
Lancaster 2.21%
Bedford -0.35%
Somerset -3.10%
Chester 2.01%
Philadelphia 1.00%
York 0.35%
Fulton -0.35%
Fayette -1.39%
Franklin -8.39%
Adams 2.68%
Greene 3.67%
Delaware 2.04%
Source: PPC analysis, U.S. Census Bureau, American Community Survey (1-year estimates), 2021 and 2022 Note: Small area regional rates were used for the 28 smallest counties not included in the 1-year ACS—Bedford, Bradford, Cameron, Clarion, Clinton, Columbia, Elk, Forest, Fulton, Greene, Huntingdon, Jefferson, Juniata, McKean, Mifflin, Montour, Perry, Pike, Potter, Snyder, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, and Wyoming.
Focusing outreach about public health insurance options through Medicaid, CHIP, and Pennie™ to families in these seven counties would reach nearly half of the uninsured population.
County Comparison Comparing the 2022 rates to the prior year, seven counties had notably better rates (Blair, Franklin, Huntingdon, Lawrence, Pike, Somerset, and Wayne) and 11 counties had notably worse rates (Carbon, Crawford, Dauphin, Greene, Juniata, Lebanon, Mifflin, Northumberland, Snyder, Union, and Washington). The vast majority, or three-quarters, of counties had no substantial change to their rates, meaning they had less than a 3% difference from the prior year. Because rates only tell part of the story in locating the uninsured population, it’s important to also look at the number of children without health insurance in each county. Seven counties have at least 5,000 or more uninsured children and, together, account for nearly half of all the uninsured children in the commonwealth. The remaining 74,000 uninsured children are spread across the other 60 counties.
Number of Uninsured Children
County
Lancaster* Philadelphia
22,100 16,700
Chester Lebanon Allegheny
8,400 7,200 5,800 5,600
Berks
Dauphin 5,000 *Lancaster County is home to the largest Amish settlement in the United States and is likely to be a leading factor affecting the uninsured population. iii The Amish and Anabaptists do not participate in traditional health insurance but rather rely on their church support and community structure to pool funds and self-pay their medical expenses.
5
Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
Children Without Health Insurance by Age
about their free or low-cost health coverage options, such as child care centers, community family centers, other family-serving programs, legislative offices, school districts, and after-school programs. Pennsylvania’s five counties with the highest child uninsured rates during 2022 also have the highest rates within both age groups, children under age 6 and school-age children: Juniata, Lebanon, Mifflin, Snyder, and Union.
4.6% 5.6% 4.4% 5.0% More young children (under age 6) in PA without health insurance More school-age children (6-18 years) in PA without health insurance
Counties with Highest Percent of Uninsured Children by Age Group
Source: PPC analysis, U.S. Census Bureau, American Community Survey (1-year estimates), 2021-2022
The latest Census data shows that the statewide rates for children under age 6 and for children over age 6 without health insurance have significantly worsened since the prior year. Additionally, the gap between those statewide rates has grown larger, indicating younger children are increasingly more likely to go without coverage than older children. Looking at the county-level data, gaps exist between the age cohorts but are less distinct. While two-thirds of Pennsylvania counties have higher uninsured rates for younger children than school- age children, many are not significantly higher. This provides opportunities for a variety of partnerships to reach families with uninsured children of all ages
Uninsured Under Age 6
Uninsured School-Age
County
Lebanon
19% 21% 21% 21% 21%
23% 19% 19% 19% 19%
Juniata
Mifflin
Snyder
Union
Juniata, Mifflin, Snyder, and Union counties in the central part of the state continue to have the highest uninsured rates for the youngest children at 21%, although it represents a slight improvement from the prior year. Conversely, the uninsured rates for school-age children in those same counties have worsened, rising from 12% to 19%. Lebanon County has the highest uninsured rate for children of all 67 counties, with 21% uninsured. It also has the highest uninsured rate for school-age children at 23%, which has nearly doubled since the prior year. Its uninsured rate for younger children has also significantly worsened, tripling from the previous 6% to currently 19% without coverage. One contributing factor may be the increase in children who are eligible for Medicaid but are uninsured, noted later in this report.
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The 2023 State of Children’s Health in Pennsylvania
Children More Likely to Be Uninsured by Race/Ethnicity
Percent of PA Children by Race and Ethnicity Without Health Insurance (Chart A)
11.9 %
10 12 10 12
American Indian and Alaska Native Asian Black or African American Native Hawaiian and Other Pacific Islander
White Some Other Race Two or More Races Hispanic or Latino
0 2 4 6 8 0 2 4 6 8
6.2 %
6.1 %
5.8 %
5.6 %
5.1 %
5.0 %
4.9 %
4.7 %
4.7 %
4.7 %
4.8 %
4.4 %
4.3 %
4.2 %
4.1 %
3.8 %
3.8 %
3.2 %
2.7 %
1.8 %
0.0 %
0.0 %
0.0 %
2019 (pre-pandemic) 2019 (pre-pandemic)
2021 2021
2022 2022
Source: U.S. Census, 2019, 2021 and 2022 American Community Survey (1-year estimates) *2020 ACS 1-year was not released due to the impact of the COVID-19 pandemic on data reporting. Race categories are reported on the ACS and can be any ethnicity. Hispanic or Latino can be of any race.
Pennsylvania children do not experience equal access to health care insurance. It’s important to look at the uninsured rates by children’s race and ethnicity to determine where structural barriers and inequities play a part in preventing access and to use that information to improve outreach within certain populations. This section reflects an analysis of data on uninsured children by race and ethnicity compared to current population numbers to determine where imbalances may be (Chart B), as well as, comparing the percentages of children by race and ethnicity with no health insurance to that
group’s prior uninsured rates (Chart A) to determine whether any progress has been made or lost. The good news, at least at the statewide level, is that limited disproportionality is present in the latest Census data, as reflected in Chart B. To determine whether disproportionality exists, we compared the proportion of uninsured children by race and ethnicity to their rates in the general population. Disproportionality occurs when the uninsured rates for a group are higher than expected—meaning higher than the group’s population size—and with a proportion scoring at least 1.1 or greater on the racial disproportionality index.
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Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
Percent of Uninsured PA Children by Race and Ethnicity Compared to Population (Chart B)
Racial Disproportionality Index 1.12 *AIAN 0.74 Asian 0.82 Black 1.08 White 1.19 *Other 0.79 Two+ 0.94 Hispanic *1.1 or greater = overrepresentation or disproportionality
80.0%
Population under 19 Uninsured 2021 Uninsured 2022
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
AIAN
Asian
Black
NHOPI
White
Some Other Race
Two+ Races
Hispanic or Latino
Source: PPC analysis, U.S. Census Bureau, American Community Survey (1-year estimates), 2021 and 2022 Race categories are reported on the ACS and can be any ethnicity. Hispanic or Latino can be of any race. Population Under 19 Uninsured 2021 Uninsured 2022
Racial Disproportionality Index = calculate scores using the rate of the uninsured population by race/ethnicity divided by the rate of that group’s population under 19 years. Scores less than 1.0 are indicative of underrepresentation, scores of 1.0 indicate no disproportionality and scores of 1.1 and greater indicate overrepresentation.
last year’s rate of 2.7% but also is now larger than the 2019 pre-pandemic rate of 3.2% (Chart A). • Similarly, the uninsured rate for White children at 5.6% is also above both last year’s rate of 4.7% and the 2019 pre-pandemic rate of 5.0%, showing movement in the wrong direction (Chart A). Data for White children in Pennsylvania shows that no disproportionality exists at the statewide level because the uninsured rate is close enough to the population rate for this group staying just under the 1.1 racial disproportionality index score (Chart B). • Children who identify as Two or More Races are the only group to have continued seeing worse uninsured rates from 2019 pre-pandemic to present: 1.8% in 2019 up to 3.8% in 2021 and 4.1% in 2022 (Chart A). Despite the rising uninsured rates, no statewide disproportionality exists for this group since the uninsured rate remains lower than the population rate (Chart B).
Lost Ground • While American Indian and Alaska Native (AIAN) children in Pennsylvania had significant improvement in their uninsured rates between 2019 and 2021, dropping from 11.9% to 4.7%, the latest Census numbers show an uptick in their uninsured rate to 5.8% (Chart A). This movement in the wrong direction shows some disproportionality with a slight overrepresentation of uninsured AIAN children (.5%) compared to the AIAN child population (.4%) in Chart B. • Data for Black children in Pennsylvania continues to show that no disproportionality exists at the statewide level because there is a lower uninsured rate than population rate for this group (Chart B). However, there is cause for concern that the uninsured rate for Black children is moving in the wrong direction. The current uninsured rate of 4.3% for Black children increased not only from
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November 2023
Progress Made • Asian children are the only group to have continued seeing improved uninsured rates from 2019 pre-pandemic to present: 4.4% in 2019 down to 4.2% in 2021 and 3.8% in 2022 (Chart A). No disproportionality exists for Asian children at the state level with uninsured rates well below the population rate (Chart B). • Hispanic or Latino children have also made progress since the prior year, with a drop in the uninsured rate from 5.1% to 4.9%, although it remains slightly above the 2019 pre-pandemic rate of 4.7% (Chart A). The uninsured rate for Hispanic or Latino children has improved enough to erase the disproportionality that existed during the last report and is now nearly proportional with the population rate (Chart B). • The uninsured rate for children who identify as Some Other Race remained relatively stable compared to the prior year, shifting from 6.2% to 6.1%, yet well above the 2019 pre- pandemic rate of 4.8% (Chart A). This group of children also represents the biggest difference between their uninsured rate and population rate, representing some disproportionality, albeit on the lower end of the index and to a lesser degree than the prior year (Chart B). And while we don’t see great differences and disproportionality at the statewide level, the Counties by the Numbers fact sheets include data that paints a more localized picture of racial disparities in obtaining health insurance. For example, counties with scores on the higher end of the racial disproportionality index with the biggest differences between their uninsured rates and population rates represent the greatest disproportionality. The following counties have uninsured rates for children at least 3x higher than the group’s population size in their county:
• The uninsured rates for Asian children are 6.2x higher than its population in Beaver County and 9.9x higher than its population in Columbia County. • The uninsured rates for Black children are 11.5x higher than its population in Carbon County and 4.2x higher than its population in Wayne County. • The uninsured rates for children who identify as Some Other Race are 5.8x higher than its population in Erie County; 7.5x higher than its population in Lackawanna County; and 7.2x higher than its population in Washington County. • The uninsured rates for children who identify as Two or More Races are 3.5x higher than its population in Susquehanna and Westmoreland counties and 3.7x higher than its population in Union County. • The uninsured rates for Hispanic or Latino childre n are 3.5x higher than its population in Montgomery County; 5.2x higher than its population in Washington County; and 4x higher than its population in Wyoming County.
9
Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
Children Without Health Insurance by Poverty Level
Percent of PA Children by Poverty Level Without Health Insurance
< 100% of poverty (<$27,750/year)
< 138% of poverty (<$38,295/year)
< 200% of poverty (<$55,500/year)
< 400% of poverty (<$111,000)
400%+ of poverty ($111,000+)
Source: PPC analysis, U.S. Census Bureau, ACS (1-year estimates), 2022. Income levels using the 2022 federal poverty guidelines based on a family of 4. 6.7% 7.3% 6.9%
6.2%
3.4%
Children in families of all income levels had increases in their uninsured rates since the prior year. The biggest statistical increase was in families with incomes above 400% of the federal poverty level, with an uninsured rate rising from 2.5% in 2021 to 3.4% in 2022. However, children living in families with lower incomes are still more likely to go without insurance despite the free and subsidized options available through Medicaid, CHIP, and Pennie™.
Using the 138% Federal Poverty Level threshold for Medicaid eligibility, the Census data shows that 7.3% of children living in Pennsylvania who are financially eligible for Medicaid are not insured . iv All of those children should have Medicaid coverage. While it may be that some families are not aware of their public health insurance options, there are other reasons that are more likely driving disparities in coverage, including difficulty in navigating the enrollment processes, confusion about eligibility policies, and language and literacy barriers. v, vi Counties with children who are eligible for Medicaid but are not enrolled are more likely to have a spike in their uninsured rates. There are 25 counties with at least 1 in 10 Medicaid-eligible children who do not have health insurance. These counties have an average 11% child uninsured rate. For example, Lebanon County, which has the highest uninsured rate in Pennsylvania, had a large jump from 4% to 21% over one year of children who are Medicaid-eligible but don’t have health insurance. The remaining approximately two-thirds of counties with smaller percentages of Medicaid- eligible but uninsured children only have an average 4% child uninsured rate.
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November 2023
Publicly Funded or Supported Health Insurance
Pennsylvania families have excellent options when it comes to no-cost or low-cost comprehensive health insurance for their children between Medicaid, the Children’s Health Insurance Program (CHIP), and the state-based marketplace Pennie™. It’s no wonder that about half of all children who live in the commonwealth have health insurance through one of those options. 49% of Pennsylvania children rely on Medicaid, CHIP, or Pennie™ health plans to meet their health care needs. vii The largest of the three options is Medicaid, with more than 1.3 million children enrolled for health insurance—more than half (56%) of whom are children of color. viii CHIP provides health insurance for approximately 150,000 Pennsylvania kids, or about 5% of the child population. ix That number is expected to climb as children shift from Medicaid to CHIP during the unwinding of the continuous coverage available during the COVID-19 public health emergency described in more detail on page 13. Finally, Pennie™ rounds out the options as the state-based marketplace that allows families to purchase health insurance. As expected, only a small number of children—1% or nearly 34,000—have health insurance through the marketplace. That is because Pennsylvania has a buy-in program for CHIP, meaning families with higher incomes who don’t qualify for financial assistance can opt to purchase CHIP coverage. Despite its fewer numbers, child enrollment in
Pennie™ plans did increase over the past year by approximately 5,800 children. x Enrollment by Race and Ethnicity Looking at enrollment data by race and ethnicity shows how children access programs and resources differently and provides an opportunity to evaluate and address health disparities for children of color. While most children enrolled in Medicaid are white, Medicaid is a primary source of coverage for children of color, particularly Black children, because, due to historical and continued institutionalized discrimination, they are more likely to be economically disadvantaged. Since last year, Medicaid enrollment declined for both Non-Hispanic Black children and Non- Hispanic White children, while children of other/ unknown race and ethnicity had the largest increase, now representing nearly 1 in 10 children in Medicaid. Pennie™ enrollment has become more diverse over the past year. The proportion for Non-
11
Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
Hispanic White children decreased, while children in every other category increased, most notably for Hispanic children and Non-Hispanic Black children. It represents movement in the right direction, but enrollment for Hispanic
children and Non-Hispanic Black children remain far below population rates. Note: CHIP data disaggregated by race and ethnicity was not available for September 2023.
Medicaid Enrollment by Race/Ethnicity (Comparison 2022-2023)
0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80
80.0%
Population under 19 Sept 2022 Enrollment Sept 2023 Enrollment
70.0%
Source: PPC analysis, Pennsylvania Department of Human Services, (2022 and 2023) Office of Income Maintenance [Data sets] *Includes population counts for American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander, and Some Other Race.
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Non-Hispanic Asian
Non-Hispanic Black
Non-Hispanic White
Non-Hispanic Two or More Races
Hispanic
Other or Unknown Race/Ethnicity*
CHIP Enrollment by Race/Ethnicity (2022 only)
80.0%
Population under 19 Sept 2022 Enrollment
70.0%
Source: PPC analysis, Pennsylvania Department of Human Services, (2022) Office of CHIP [Data set]. *Includes population counts for American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander, and Some Other Race.
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Non-Hispanic Asian
Non-Hispanic Black
Non-Hispanic White
Non-Hispanic Two or More Races
Hispanic
Other or Unknown Race/Ethnicity*
12
November 2023
Pennie TM Enrollment by Race/Ethnicity (Comparison 2022-2023)
0 10 20 30 40 50 60 70 80
80.0%
Population under 19 Sept 2022 Enrollment Sept 2023 Enrollment
70.0%
Source: PPC analysis, Pennsylvania Health Insurance Exchange Authority, (2022-2023) Pennie TM [Data sets]. *Includes population counts for American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander, and Some Other Race.
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Non-Hispanic Black
Non-Hispanic White
Non-Hispanic Two or More Races
Hispanic
Other or Unknown Race/Ethnicity*
Non-Hispanic Asian
How Medicaid Unwinding is Impacting PA Children
What is Medicaid “unwinding?” Pennsylvania families who rely on Medicaid for health insurance for themselves and their children began seeing a big change to the rules this past spring. Renewing Medicaid coverage restarted on April 1, 2023, for the first time in three years after Congress ended the continuous coverage requirement that had been in place since the COVID-19 pandemic began. Like most states, Pennsylvania is using a year-long process to unwind the disenrollment freeze and resume regular pre-pandemic eligibility and enrollment operations. What does it mean for kids enrolled in Medicaid? As would be expected, pausing disenrollments for three years had a significant impact on the total number of enrollees. Child enrollment in Medicaid increased by 22% during that time, peaking at well over 1.4 million children.
Because of the significant task for DHS, along with a high risk for loss of eligible coverage, PPC has two key objectives during the unwinding process: • Make sure children who remain eligible for Medicaid stay enrolled without gaps in coverage. Inappropriate terminations or temporary loss in coverage and then re- enrolling, called “churn,” often impact children more than the adult population. xi • Make sure children who no longer qualify for Medicaid are quickly connected to CHIP to avoid gaps in coverage. DHS’ timing to transition the duties of CHIP enrollment from CHIP managed care organizations to DHS county assistance offices (more details in the CHIP section on page 16) has complicated this process.
13
Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
With Pennsylvania’s historically low use of conducting renewals on an ex parte basis, the CMS requirement is welcome news in supporting much needed, long-term system corrections. However, a solution is needed now to correct the error and get children reconnected to coverage. What is the status and how is the process affecting children’s coverage? DHS created an online data tracker to share the results of the unwinding process on a month-by-month basis. xii With about a third of the total children in the unwinding group reviewed as of September 2023, more than half (57%) of children have maintained their Medicaid coverage. However, that number should be higher because children are losing coverage despite remaining eligible. Over half the children who lost Medicaid coverage during the unwinding process are due to procedural or paperwork reasons, not eligibility. It is alarming that a large portion of children (51%) who lost Medicaid coverage during the unwinding process is because of administrative or paperwork reasons rather than ineligibility. These children very likely remain qualified and otherwise would still have health insurance if not for procedural problems. The automated renewals error, as noted above, is a likely reason for this high percentage. One way to counter churn, i.e., these unnecessary gaps in children’s coverage, is through continuous eligibility (more on page 15). The DHS data tracker just began to report the number of children who returned to Medicaid within four months of losing their coverage. Unfortunately, it is remarkably low with only 2% of children returning to Medicaid within four months of closure.
Does the recent CMS warning to states to fix automated renewals during unwinding impact PA? Yes. In response to the August 30th letter from the Centers for Medicare & Medicaid Services (CMS) warning all states to assess and fix their eligibility systems so eligible children and their families can remain enrolled in Medicaid, Pennsylvania is identified as one of the 30 states with an error. The issue is how some states have been conducting automated renewals, also known as “ex parte” renewals, that are causing improper disenrollments for those still eligible, especially children. CMS believes the problem lies in how states conduct automated renewals at the household level instead of at the individual level, most likely because parents have different eligibility requirements than their children. If parents’ eligibility couldn’t be completed automatically at the household level, then states’ systems weren’t completing it for children, resulting in loss of coverage. CMS is requiring all states with the error to take immediate action. However, the remedy is being determined by each state and Pennsylvania is all too slowly figuring out how many have been impacted and the timing for reinstating coverage. Given the preliminary estimates that this error disproportionately impacted children, we urge DHS to immediately reinstate all children who incorrectly lost coverage.
14
November 2023
There are also lower-than-expected results for CHIP referrals. As noted, one of the data points PPC has been eagerly waiting for months is how many children who have lost Medicaid coverage successfully transitioned to CHIP (or to the state- based marketplace Pennie™). The DHS data tracker shows that 2% of children who lost Medicaid coverage have enrolled in plans through Pennie™ (and we would expect that number to be small), and 34% of children who lost Medicaid coverage have enrolled in CHIP. While we don’t know whether a child’s family has instead enrolled in private coverage, perhaps through an employer, CHIP remains available to all Pennsylvania families not eligible for Medicaid—regardless of income—who don’t Referrals to CHIP during the unwinding process are lower than expected, with only 1 out of 3 children shifting from Medicaid to CHIP, despite CHIP’s broader eligibility guidelines. otherwise have health insurance. That makes it likely that more than 34% of children who have lost their Medicaid coverage should have a free or low-cost option through CHIP. Although the unwinding process is over halfway completed, the data shows an early picture of what’s happening. With two-thirds of children in the unwinding group still pending, there’s still a long way to go. For more detailed data, refer to the Counties by the Numbers fact sheets, which include these unwinding metrics at the county level.
Continuous Eligibility Policy Late last year, Congress passed a federal requirement for states to implement at least 12 months continuous eligibility for children in both Medicaid and CHIP beginning in January 2024 (previously only available in Pennsylvania for children up to age 4 in Medicaid, but all children in CHIP). Even before this new requirement takes effect, states, having learned from the benefit of keeping children continuously enrolled during the COVID-19 pandemic, are beginning to build upon 12-month continuous enrollment policies to provide multi-year continuous coverage for children. To date, eight states have expanded or are actively seeking approval from CMS for multi- year continuous coverage. They are doing so based on a body of research showing that fewer disruptions in insurance coverage allow young children to maintain access to critical preventative services and necessary treatments to support their healthy development. Individuals with inconsistent Medicaid access receive less and more delayed preventive care, refill prescriptions less often, and have more emergency department visits. Many partners, including child advocates, providers, and childrens’ hospitals are urging DHS to join this momentum in providing continuous eligibility for children
from the time of initial eligibility
determination until they reach age six. We are encouraged by DHS’ initial response and interest in this policy change for young children.
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Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
That means that current CHIP families and all new enrollees must go through DHS instead of their CHIP health insurance plan to determine eligibility. DHS now determines who qualifies for CHIP and processes all new applications and renewals. The transition of eligibility processing and determinations from the CHIP MCOs to caseworkers in local DHS County Assistance Offices (CAOs) came on the heels of the unwinding process of Medicaid continuous coverage—and unsurprisingly, complications arose. First, problems are likely to occur with any significant IT transition. However, many unanticipated system errors arose, which DHS had to fix or is still attempting to resolve. Some of the system problems have caused enrollment challenges. It is unclear how many children lost coverage—or experienced even temporary gaps in coverage—during the months after the transition because DHS stopped releasing its typical monthly data reports. It also took until October for the DHS unwinding data tracker to populate the number of CHIP referrals. As noted in a prior section, the number is much lower than expected. Second, and a hurdle predicted well ahead of time, is that the CAO caseworkers, who already have full workloads with the unprecedented task of Medicaid unwinding along with other benefit programs, added more work onto their plates by processing CHIP applications and renewals amid staffing shortages. This results in long wait times on phones to try and solve problems. It is clear that the complexity of the CHIP eligibility systems transition overlapping with the Medicaid unwinding has caused an unnecessary burden, mainly falling on CHIP families who have experienced added barriers to gaining or restoring coverage for their children.
The first years of a child’s life are ones of rapid development and need for regular access to health care. Continuous eligibility in early childhood provides consistent coverage and continuity of care by keeping children enrolled, regardless of their family’s fluctuations in monthly income, disruptions due to difficulty navigating the renewal process, or other changes that cause a loss of eligibility. States also aim, with multi-year coverage, to reduce the administrative burdens of processing terminations and subsequent reenrollment. Medicaid enrollment churn and administrative burden is an issue of growing concern in Pennsylvania and nationally, as the unwinding of the pandemic-era provision illustrates reenrollment takes a toll on eligible individuals, particularly children. Children’s Health Insurance Program (CHIP) Eligibility Systems Transition This spring, a significant operational change that had been in the works long before the pandemic occurred in the Children’s Health Insurance Program. Disappointingly, it happened during the same month as the Medicaid unwinding got underway. Despite advocates’ concerns about the timing and urging the state to exercise its flexibility to delay, DHS moved forward in April with an IT eligibility systems transition. DHS should demonstrate its commitment to the health of Pennsylvania’s youngest children by providing continuous Medicaid coverage from birth through kindergarten.
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Health Insurance Plans Available Through Medicaid, CHIP, and Pennie™
Availability of health plans varies by geographic region, but lists are available in the Counties by the Numbers fact sheets. • CHIP • o Eight health plans: Aetna, Capital Blue Cross, Geisinger, Highmark, Keystone, KidzPartners, UnitedHealthcare, and UPMC xiii • Pennie™ • o Eight health plans: Ambetter, Capital Blue Cross, Cigna, Geisinger, Highmark, Independence, Oscar, and UPMC. xiv
• DHS has separate networks in Medicaid for physical health (HealthChoices) and behavioral health (Behavioral HealthChoices). • Medicaid • o Seven physical health plans: AmeriHealth Caritas PA, Geisinger, Health Partners, Highmark Wholecare (formerly Gateway), Keystone First, United, and UPMC xv • o Five behavioral health plans: Carelon Health of PA Inc (formerly Beacon Health Options), Community Behavioral Health, Community Care Behavioral Health Organization, Magellan Behavioral Health of Pennsylvania, and PerformCare xvi
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Health Insurance Trends During the Final Year of the COVID-19 Public Health Emergency
Conclusion
It has been a challenging time for children’s health coverage. Pennsylvania is moving in the wrong direction ensuring children have coverage to meet their health care needs. The latest data shows more kids are going without health insurance even before the flexibilities from the COVID-19 public health emergency ended. Additionally, Pennsylvania is in the midst of huge operational changes in Medicaid and CHIP that are in many cases negatively impacting children’s connection to coverage. During a time of rising prices, low-income families are especially struggling to make ends meet for basic necessities like food and housing. Adding to this hardship is that children living in families with lower incomes are likely not to have health insurance.
We must do all we can to reach families about their health insurance options through Medicaid, CHIP, and Pennie™. We must also ensure that children can easily keep their coverage once enrolled by implementing proven strategies like continuous eligibility and automatic “ex parte” renewals. Multi-year continuous eligibility for children is critically important to meet their developmental needs and become healthy adults; further, DHS can ensure children are more connected to their health insurance by immediately restoring Medicaid coverage for those who lost it during the automated “ex parte” renewals error.
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Acknowledgements PPC gratefully acknowledges the support of: • Alliance for Early Success • The Annie E. Casey Foundation • The Georgetown University Center for Children and Families
• The Heinz Endowments • Philadelphia Health Partnership • Pritzker Children’s Initiative
End Notes
i U.S. Census Bureau, American Community Survey (ACS) (1-year estimates), 2021 and 2022. ii State Health Access Data Assistance Center. 2022 ACS: Declining Uninsured Rates for the U.S. and States are Supported by Private and Public Coverage Increases (September 14, 2023). https://www.shadac.org/news/2023-acs-2022- state-estimates iii “Twelve Largest Amish Settlements, 2023.” Young Center for Anabaptist and Pietist Studies, Elizabethtown College. http://groups.etown. edu/amishstudies/statistics/twelve-largest- settlements-2023/ iv ACS 1-year estimates, 2022. Under 138% poverty threshold. v Garrett, B., Abdus, S., Banthin, J., & Selden, T. (2023). Medicaid-Eligible Adults Who Lack Private Coverage and Are Not Enrolled: Are They Uninsured? Urban Institute. https://www. urban.org/sites/default/files/2023-08/Medicaid- Eligible%20Adults%20Who%20Lack%20Private%20 Coverage%20and%20Are%20Not%20Enrolled.pdf vi Kaiser Family Foundation. (2023). Key Facts on Health Coverage of Immigrants. https://www.kff.org/ racial-equity-and-health-policy/fact-sheet/key-facts- on-health-coverage-of-immigrants/ vii PPC analysis, Pennsylvania Department of Human Services, (2023) Office of Income Maintenance and Office of CHIP [Data sets]; Pennsylvania Health Insurance Exchange Authority, (2023) Pennie [Data set].
viii PPC analysis, Pennsylvania Department of Human Services, (2023) Office of Income Maintenance [Data set]. ix PPC analysis, Pennsylvania Department of Human Services, (2023) Office of Income Maintenance [Data set]. x PPC analysis, Pennsylvania Health Insurance Exchange Authority, (2022-2023) Pennie™ [Data set]. xi Assistant Secretary for Planning and Evaluation (ASPE). (2022). Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches.https://aspe.hhs.gov/reports/ unwinding-medicaid-continuous-enrollment-provision xii PA Department of Human Services, Medicaid Continuous Coverage Unwinding Data. https:// www.dhs.pa.gov/PHE/Pages/Unwinding-Progress- Tracker.aspx xiii Find CHIP Coverage. https://www.dhs.pa.gov/CHIP/ CHIP-Coverage/Pages/CHIP-Coverage.aspx xiv Pennie Plan Comparison Tool. https://enroll.pennie. com/hix/preeligibility#/ xv Statewide Managed Care Map. https://www.dhs. pa.gov/providers/Providers/Pages/Statewide- Managed-Care-Map.aspx
xvi Behavioral HealthChoices Managed Care Organizations (BH-MCOs) https://www.dhs. pa.gov/HealthChoices/HC-Services/Pages/ BehavioralHealth-MCOs.aspx
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