At least two million low-income children have lost health insurance since the end of a federal policy that guaranteed coverage through Medicaid earlier in the Covid-19 pandemic, according to new analyses by researchers at the Georgetown Center for Children and Families and KFF, a health policy research organization.
The figures, which are likely a significant undercount, represent one of the fastest and most dramatic ruptures in the American safety net since Medicaid went into law in 1965, experts say. Many of the children were qualified for federal assistance but lost it because of bureaucratic mistakes, such as missing paperwork or errors by state officials.
It is not clear how many of these children have found new coverage in the more than seven months since the Medicaid rolls began shrinking, but at least one million are likely to still be uninsured, said Joan Alker, the executive director of the Georgetown center and a research professor at the university’s McCourt School of Public Policy.
The trend is accelerating: In the coming weeks, she said, new state numbers will probably show that three million children have lost coverage.
“This is an unprecedented situation,” Ms. Alker said. The unraveling, she added, “has the potential to increase the uninsured rate for children by the largest amount that we’ve seen in decades.”
Federal researchers forecast the crisis, estimating last year that more than five million children would eventually lose their health insurance through Medicaid or the federal Children’s Health Insurance Program as states tried to redetermine eligibility, a process health experts have called “unwinding.”
But the scale and speed of coverage losses among children has surprised even those who anticipated an upheaval. “This is not happening in a vacuum — states have the power to make choices,” said Senator Ron Wyden, Democrat of Oregon. “And they can either stand up for kids or they can basically walk away from them.”
In Lady Lake, Fla., about 50 miles northwest of Orlando, Christina Ragsdale’s children twice lost Medicaid insurance because of what she said were state enrollment errors. Her 13-year-old son, Aaron, went without his A.D.H.D. medication at school until a family member covered the out-of-pocket costs, which ran over $1,000 for a monthlong supply, she said.
“The anxiety, the panic, being overwhelmed, the frustrations in class — there are just so many moving variables when that happens and you don’t have notice,” said Ms. Ragsdale, 38, who has just finished cosmetology school.
She added: “When you can’t help your kids, you feel like you’re failing.”
The number of people with Medicaid coverage rose dramatically earlier in the pandemic. By 2022, researchers estimate, more than half of children in the United States were covered by Medicaid or CHIP, programs that are jointly financed by states and the federal government.
More than 90 million Americans, or more than one-quarter of citizens nationwide, were enrolled in the programs. Medicaid enrollment has already declined by nearly six million people during the unwinding, according to the Georgetown center.
A significant number of children who no longer qualified for Medicaid were expected to be absorbed into CHIP, which is intended to cover young Americans in families with incomes too high for Medicaid eligibility but too low for private plans.
But the program has not functioned as the refuge that lawmakers and health officials had hoped it would be. Ms. Alker and her colleagues estimate that 21 states with separate CHIP programs had picked up only 87,355 children — after 1.5 million were removed from Medicaid in those states.
Since respiratory illnesses circulate widely in the fall and winter, the insurance coverage losses are happening at a particularly risky time. Even small medical expenses can be prohibitively costly for families of uninsured children, while larger bills can eat up savings.
Parents “are being asked to make a decision between their children’s health care and something else that is a necessity,” said Dr. Valerie Borum Smith, a pediatrician in Tyler, Texas, who treats a large number of patients on Medicaid.
One child she saw went a month without therapy before his Medicaid was reinstated, she said. A mother of two children who had lost Medicaid because of a paperwork error was forced to pay out-of-pocket costs for multiple rounds of antibiotics.
Some Republican governors have defended the unwinding, arguing that Medicaid programs are reverting to their intended shape and scope after enrollments soared earlier in the pandemic.
Over 70 percent of Americans who have lost Medicaid since April did so for procedural reasons, according to KFF. Through official letters and public and private coaxing, the Biden administration has implored state officials to follow federal guidelines and help Medicaid recipients through the process of establishing their eligibility.
Still, some experts say that the federal government, which can halt a state’s unwinding process, has not been aggressive enough with officials in states such as Texas, which has disenrolled more than 700,000 children from Medicaid.
Some children cut off from government-sponsored insurance may have parents with incomes that are too high, or their families may have obtained coverage through plans offered by an employer. Some may have moved to other states, while others are now over 18, the age cutoff.
Still, the rising rate of low-income children without insurance is alarming, especially since many of the newly uninsured likely should not be, experts and officials said in interviews.
“I go to sleep at night thinking about this,” Daniel Tsai, a senior official at the Centers for Medicare and Medicaid Services, said in an interview.
He added: “We should not have kids being uninsured without health care, with families worried about how to pay for medication or what to do if your kid needs to go to the emergency department.”
There is some imminent relief for parents. A law passed in December will require that states preserve Medicaid and CHIP coverage for a year for all children starting in January 2024. But children first will need to establish eligibility as part of the current unwinding, Ms. Alker noted.
A week or even a day without health insurance can be precarious for young children. Medicaid and CHIP allow families to visit primary care practices, pay for inhalers or to receive specialty care for developmental needs, for example.
Dr. Eliza Varadi, a pediatrician in Charleston, S.C., said that without Medicaid medications her patients need for asthma and diabetes can cost hundreds of dollars. Families regularly canceled appointments at her practice after realizing their children no longer had health coverage.
In Carlisle, Pa., Rhiannon Hall’s 17-year-old daughter, Kayden, went two months this year without Medicaid, leaving Ms. Hall frightened of potential medical expenses that could have suddenly swallowed her savings.
Before Kayden secured a free CHIP plan, Ms. Hall, a medical records employee at a community health clinic, canceled Kayden’s urgent orthodontist appointments and a regular dental cleaning.
She nearly stopped picking up her daughter’s supply of Depo-Provera shots, used to control an internal bleeding problem. “When it’s gone, you worry every day that something is going to happen,” Ms. Hall said of her daughter’s health insurance.
Kerstin Foor, one of Ms. Hall’s co-workers at the clinic, has a 2-year-old daughter who went without health insurance for several weeks in July before receiving a free CHIP plan. Her daughter suffers from ear infections and allergies, and medication was unaffordable while she was uninsured.
“It makes you feel like you’re not doing your part, because your child should never go without health insurance,” Ms. Foor said. “It made me feel like the worst person in the world.”