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Jan.-Mar. 2012

VOL. XXXI NO. 1

Health Care Reform's Impact on Low-Income Youth

toddler in pajamas

By Bryn Martyna

In March 2010, President Obama signed into law comprehensive health care reform legislation.  The two federal laws at the heart of this reform, which address virtually every aspect of health care provision in the US, are commonly referred to collectively as the “Affordable Care Act.”[2]  While many aspects of Obama’s reform package have been discussed and debated, its wide-ranging impact on the health and welfare of low-income infants and youth deserves special attention.

In a significant step, the Affordable Care Act mandates an expansion of Medicaid, the government health insurance program for low-income people.  Medicaid will be expanded, effective January 1, 2014, to cover individuals earning up to 133 percent of the federal poverty level.

Medicaid’s expansion will mean more and improved health care coverage for both low-income children and their parents.  The need is great.  As of 2010, there were an estimated 8 million uninsured children in the US; 5 million youth were in families living below 200 percent of the poverty level.[3]  In February 2011, more than 42 million children who otherwise would not have had access to regular medical care were served by Medicaid or by the Children’s Health Insurance Program (CHIP), which targets low-income youth.[4]  An estimated 5 million additional children thought to be eligible for Medicaid or CHIP were in fact uninsured.[5] 

"The Affordable Care Act’s wide-ranging impact on the health and welfare of low-income youth deserves special attention."

 

The Affordable Care Act will help many of these uninsured, but eligible, children gain coverage under Medicaid and CHIP.  This is said to be the single most important way uninsured children will gain coverage under the Act.[6]  Additionally, children in many low-income families who do not qualify for Medicaid or CHIP will be able to access health care coverage through either their parents’ employers or the health insurance exchanges to be established under the Affordable Care Act .[7]  An insurance exchange is a set of health plans that are state-regulated and standardized, and from which individuals may purchase health insurance eligible for federal subsidies. According to one estimate, the Act will help 95 percent of children in the US access health coverage.[8]

Extension and Expansion of the Children’s Health Insurance Program

The Children’s Health Insurance Program (CHIP) was created by the Balanced Budget Act of 1997 to help states insure low-income children who are ineligible for Medicaid but cannot afford private insurance.[9]  In 2009, President Obama signed the CHIP Reauthorization Act, which funds the CHIP program through September 30, 2013, and sent a memorandum to the Centers for Medicare & Medicaid Services requesting immediate withdrawal of a 2007 directive that limited states’ ability to extend coverage to uninsured children.[10]

The Affordable Care Act extended the CHIP program for two years, with funding through September 30, 2015.  It also increases federal CHIP matching funds by 23 percent, up to a cap of 100 percent.  This matching begins October 1, 2015, and continues through September 30, 2019.[11]  The Act mandates that states cannot change their eligibility criteria under Medicaid or CHIP for children in effect as of the date of enactment (March 23, 2010), and must maintain the criteria through September 30, 2019.  That Act also specifically prohibits states from imposing requirements, methodologies, or enrollment procedures that would make it more difficult for beneficiaries to enroll in CHIP.[12]  Today, nearly all states provide Medicaid or CHIP coverage to children up to 200 percent of the federal poverty level; half of them cover children at or above 250 percent of the poverty level.

"States will be required to provide Medicaid to all individuals earning up to 133 percent of the poverty level."

 

The Affordable Care Act also requires states to establish procedures to screen for Medicaid eligibility.  If children are ineligible for Medicaid, and cannot be covered under CHIP due to insufficient federal allotments, states must ensure that they are provided coverage through state-based health insurance exchanges.[13]  Finally, the Act creates a state option for expanding CHIP coverage to children of state employees who are eligible for state health benefits, but would not previously have been eligible for CHIP.[14]

Expansion of Medicaid Coverage for Low-Income Children

Currently, states must provide Medicaid to children under 6 in families earning up to 133 percent of the federal poverty level, and to youth 6 through 18 in families with income up to 100 percent of the federal poverty level.  Notably, all states have chosen to provide coverage that exceeds these mandates.  Under the Affordable Care Act, states will be required to provide Medicaid to all individuals, including children, in families earning up to 133 percent of the federal poverty level.[15]  This expansion of Medicaid takes effect January 1, 2014; states will receive 100 percent federal funding for the first three years.[16]

Medicaid currently covers an estimated four to five times as many children as CHIP does.[17]  When Medicaid gets expanded in 2014, children 7 and older who are currently in non-Medicaid CHIP plans will be shifted into Medicaid.  Having the higher, uniform Medicaid standard should provide more continuity of coverage within families, as under the current system, some children end up having to transition from Medicaid to CHIP due to different eligibility criteria[18]

The Affordable Care Act also streamlines the process of applying for and determining health coverage eligibility.  Individuals seeking coverage through Medicaid, CHIP, or a state-based exchange will be able to file a single application form.  Under this “no wrong door” approach, eligibility for each program is determined and the applicant is referred along to the appropriate program.  States will be required to establish a Medicaid and CHIP enrollment website that is connected to a state-based health insurance exchange.[19]

"President Obama’s health care reform established a $1.5 billion grant program for home visitation programs."

 

Grants for Early Childhood Home Visitation Programs

Another element of Obama’s health care reform that improves the lives of low-income children is the federally funded expansion of early childhood home visitation programs.  These programs provide voluntary in-home services to at-risk families with children up to kindergarten-entry age.  Trained home visitors – nurses, social workers, early childhood education specialists, and other trained paraprofessionals – meet with families at home to advise them on their children’s health and development and to teach child-rearing skills.  The programs also help connect families to other community services and supports.[20]

Research has demonstrated that home visits improve the social and emotional development of very young children and increase the chances that mental health problems in infants and toddlers are identified.[21]  Early childhood home visitation programs have been shown to reduce the effects of maternal depression and child maltreatment, improve mother-infant relationships, and increase infant scores on cognitive tests and measures of social functioning.[22]  They have also been linked to better health, greater school readiness, higher levels of academic achievement and parental involvement, greater economic self-sufficiency, a reduction in child injuries and maltreatment, and lower levels of juvenile delinquency.[23]

The Affordable Care Act took the important step of establishing a $1.5 billion five-year federal grant program for evidence-based home visitation programs.  This is the first time funding specifically for home visitation has been mandated on the federal level.[24]  The grant program allocated $100 million for fiscal year 2010; that figure rises to $400 million in 2014.  The amount allocated to a particular state is determined by the proportion of children in that state in families at or below 100 percent of the federal poverty level as compared to the national rate.

"If health care reform proceeds as scheduled, the boost provided to low-income youth will be nothing short of historic."

 

Under the federal program, caretakers of all kinds are potential beneficiaries of home visitations.  The category encompasses anyone playing the role of primary caregiver; it could be a parent, a foster parent, a grandparent, or another relative.  The federal grant program also targets certain “high-risk” populations, including low-income families; pregnant women under the age of 21; families with histories of child abuse, neglect, or involvement with the child welfare system; and children with developmental delays or disabilities.[25]

The grant program places heavy emphasis on home visitation models that are supported by rigorous research and evaluation.  At least 75 percent of grant funds must be used to support evidence-based models that have been evaluated via well-designed and rigorous randomized control trials or quasi-experimental research designs.  The remaining 25 percent of funds must go to promising or new approaches that have been developed or identified by a national organization or institution of higher education and that will be evaluated through a well-designed and rigorous process.[26]

To be eligible for the first grants under this program, states had to follow three arduous steps.  The initial step was submission of an application that included a detailed plan for completing an initial needs assessment to determine which communities are most at risk for poor maternal and child health and have few high quality home visitation programs. [27]  That plan also had to establish quantifiable, measurable benchmarks in a number of areas, from maternal and newborn health to school readiness and achievement.[28]  The initial submission was due in July 2010; all fifty states were awarded grants as a result.  The second step was submission of the needs assessment itself.  The third and final step was submission of a detailed plan for addressing the needs identified in the assessment, including a plan for collecting benchmark data.  Plans were due in 2011 and will be reviewed and updated on a rolling basis.[29]

Additional Health Care Reform Elements Affecting Youth on Private Insurancei


Elimination of Pre-Existing Condition Exclusions for Children – bars health insurance companies from imposing pre-existing condition exclusions on children’s coverage.  (This provision will also apply to adults in 2014.)

Extension of Coverage for Young Adults – requires any group health plan or plan in the individual market that provides dependent coverage for children to continue to make that coverage available until the child turns 26.

Specialized Coverage for Children – requires that new health plans provide free preventive care and screenings identified in Bright Futures, the American Academy of Pediatrics’ “gold standard” for preventive care.


i. Summary of Medicaid, CHIP, and Low-Income Provisions in Health Care Reform, Health Care Reform Publications (Georgetown University Health Policy Institute, Center for Children and Families, Washington, D.C.) April 2010, available at ccf.georgetown.edu/index/key-provisions-in-health-care-reform-package.


Medicaid Coverage for Former Foster Youth and Financial Support for Adoption

Children currently or formerly in foster care, although a small proportion of the total youth population, have more health and mental health problems than the general population, or even the population of poor children.[30]  In an encouraging development, the Foster Care Independence Act of 1999 gave states the option of extending Medicaid coverage to former foster youth between the ages of 18 and 21.  However, few states have chosen to do so.[31]

Obama’s health care reform requires states to provide Medicaid coverage to former foster youth under the age of 26 who were in foster care when they turned 18, were enrolled in Medicaid while in foster care, and do not fall into any other eligibility category for Medicaid or some other form of public health care.  Such youth are entitled to all Medicaid benefits, including Early Periodic Screening, Diagnosis and Treatment services.[32]

The Affordable Care Act also increased the adoption tax credit and the adoption assistance exclusion by $1,000 in 2010.  The tax credit, which has been extended through 2011, is also now refundable.[33]

Looking Forward

The Affordable Care Act represents a landmark effort to improve the health and welfare of low-income children in the US.  Many of those gains lie in the future, when key elements of the Act are scheduled to take effect.  If implementation proceeds as scheduled, and the promise of President Obama’s reform plan is realized, the boost provided to low-income youth will be nothing short of historic.


Bryn Martyna is a former NCYL staff attorney.  She graduated from Stanford Law School in 2005, and worked at NCYL from 2005 to 2011, focusing on foster care reform litigation.  She recently moved to Madison, Wisconsin and plans to continue her youth advocacy career in the Midwest. 



  1. Summary of Medicaid, CHIP, and Low-Income Provisions in Health Care Reform, Health Care Reform Publications (Georgetown University Health Policy Institute, Center for Children and Families, Washington, D.C.) April 2010, available at ccf.georgetown.edu/index/key-provisions-in-health-care-reform-package.
  2. The two laws are the Patient Protection and Affordable Care Act (H.R. 3590) and the Health Care and Education Reconciliation Act. See Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, at 1 (also explaining that the second law was necessary for procedural reasons, and generally improves on some aspects of the first). 
  3. Who Are the Uninsured Children, 2010 (Children’s Defense Fund, Washington, D.C.), January 2011 at 1.
  4. Press Release, U.S. Department of Health & Human Services, Two Year Anniversary of Children’s Health Insurance Law Sees Millions of Newly Insured Children, Families (Feb. 3, 2011) (available at hhs.gov/news/press/2011pres/02/20110203b.html).
  5. Id.
  6. Genevieve M. Kenney & Jennifer Pelletier, How Will the Patient Protection and Affordable Care Act of 2010 Affect Children?, Timely Analysis of Immediate Health Policy Issues (Urban Institute, Washington D.C.), July 2010, at 1.
  7. Id.  Currently, more than 40 percent of poor parents and 33 percent of near poor parents are uninsured – many of these will gain coverage through health care reform.  Id. at 2.
  8. New Investments to Help Children and Families: The Patient Protection and Affordable Care Act and the Maternal, Infant, and Early Childhood Home Visiting Program (Children’s Defense Fund, Washington, D.C.), Updated February 2011, at 1.
  9. National Conference of State Legislatures, Children’s Health Insurance Program Overview, available at www.ncsl.org/issues-research/health/childrens-health-insurance-program-overview.aspx, last updated May 2010. 
  10. Id.  CMS is the federal agency that administers Medicare, Medicaid, and CHIP.
  11. Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, at 13.
  12. Id.
  13. Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010.
  14. Previously, children of state employees were excluded from CHIP eligibility, regardless of family income or participation in state health insurance coverage.  Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, at 13-14.
  15. Summary of Medicaid, CHIP, and Low-Income Provisions in Health Care Reform, Health Care Reform Publications (Georgetown University Health Policy Institute, Center for Children and Families, Washington, D.C.) April 2010, at 3, available at ccf.georgetown.edu/index/key-provisions-in-health-care-reform-package
  16. Affordable Care Act Implementation Timeline (Democratic Policy Committee), at 8, available at dpc.senate.gov/healthreformbill/healthbill65.pdf
  17. Genevieve M. Kenney & Jennifer Pelletier, How Will the Patient Protection and Affordable Care Act of 2010 Affect Children?, Timely Analysis of Immediate Health Policy Issues (Urban Institute, Washington D.C.), July 2010, at 1.
  18. Genevieve M. Kenney & Jennifer Pelletier, How Will the Patient Protection and Affordable Care Act of 2010 Affect Children?, Timely Analysis of Immediate Health Policy Issues (Urban Institute, Washington D.C.), July 2010, at 1.
  19. Id. at 5.
  20. New Investments to Help Children and Families: The Patient Protection and Affordable Care Act and the Maternal, Infant, and Early Childhood Home Visiting Program (Children’s Defense Fund, Washington, D.C.), Updated February 2011, at 1.
  21. Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, at 14.
  22. Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, at 15.
  23. New Investments to Help Children and Families: The Patient Protection and Affordable Care Act and the Maternal, Infant, and Early Childhood Home Visiting Program (Children’s Defense Fund, Washington, D.C.), Updated February 2011, at 1.
  24. Id. at 1.
  25. Id. at 2.
  26. New Investments to Help Children and Families: The Patient Protection and Affordable Care Act and the Maternal, Infant, and Early Childhood Home Visiting Program (Children’s Defense Fund, Washington, D.C.), Updated February 2011, at 4.
  27. Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, at 14.
  28. New Investments to Help Children and Families: The Patient Protection and Affordable Care Act and the Maternal, Infant, and Early Childhood Home Visiting Program (Children’s Defense Fund, Washington, D.C.), Updated February 2011, at 3.
  29. Id. at 4.
  30. See Medicaid Coverage for Former Foster Care Children, Health Reform Issue Briefs (Office of Health Reform Integration), Vol. 2, Issue 4, November 2010. 
  31. See Medicaid Coverage for Former Foster Care Children, Health Reform Issue Briefs (Office of Health Reform Integration), Vol. 2, Issue 4, November 2010. 
  32. Medicaid Reforms in the Patient Protection & Affordable Care Act and the Health Care & Education Reconciliation Act, (Bazelon Center for Mental Health Law, Washington, D.C.), July 7, 2010, and the Health Care & Education Reconciliation Act, July 7, 2010.
  33. Affordable Care Act Implementation Timeline, from Democratic Policy Committee, available at dpc.senate.gov/healthreformbill/healthbill65.pdf

 

 



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