The Medicaid Expansion, which was responsible for a large part of the reduction in uninsurance in the United States over the last few years, was mostly aimed at adults. This is because Medicaid has traditionally covered nearly all children in poverty for some time. The CHIP program has bolstered that coverage, so that uninsurance in children fell steadily in the 1990's and well into the 21st century.

The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) assured that CHIP coverage would continue for some time. But even before that, trouble was brewing with respect to the coverage of children. These troubles were not in the Medicaid  program, though. Issues were arising in the employer-sponsored insurance market.

As I've written about in many posts here before, the cost of employer-sponsored insurance has been rising quite steadily for some time. Further, the out-of-pocket costs for such insurance have also been increasing. Deductibles, co-pays, and co-insurance - not to mention premiums - can put the cost of insurance out of reach for many employees even when it is "offered" as a benefit from their job. The costs of insurance have outpaced both income and wages for more than a decade, meaning that more and more must come out of employee's pockets if they want to maintain coverage for themselves and their children.

For many working Americans, though, employer-sponsored insurance has been their only option. They make too much to qualify for Medicaid and had few options outside of the employer-sponsored market for coverage. And that's if Medicaid is even available for working adults in their state; in many, it's not. Their children, however, may qualify. For the kids of lower-income employees, Medicaid or CHIP may become an acceptable alternative to more expensive private insurance options for their children.

In a recent Health Affairs study, researchers from CHOP's Policy Lab used Medical Expenditure Panel Survey data from 2008 through 2013 to look at levels of insurance for children from various sources over that time. They tracked the coverage rates of low and moderate income families where one or more parents were offered employer-sponsored health insurance (ESI).

Over this time period, they found that in families where parents were covered by ESI, the percentage of kids who were not covered by that insurance increased from 22.5% in 2008 to 25.0% in 2013. The percentage of such children who were covered by Medicaid or CHIP also increased from 12.1% to 15.2%. In other words, in families where parents were covered by job-offered private insurance, more and more of their kids were being covered by public insurance.

The poorer working families were, the more likely this was to happen. Among those earning between 100% and 200% of the poverty line, coverage by Medicaid and CHIP rose from 22.8% to 29.9%.

Children in families earning more, though, may be even harder pressed. Many of them can't qualify for public insurance, even CHIP, because their parents "make too much". The study found that among families earning between 200% and 300% of the federal poverty line, uninsurance among their children rose from 6.0% to 9.2%.

There are caveats to this study, as with all studies. Because it used MEPS, there's no way to tell the exact reasons for why coverage for children changed over time. There's also no way to see how the quality of their coverage or their care might have been affected by these changes. It's also important to recognize that these data covered through 2013, which is before the Medicaid expansion and insurance exchanges appeared.

But as policymakers consider changes to health care programs in 2017 and beyond, it's important to recognize that for some time, employer-sponsored health coverage for children has been eroding. Medicaid and CHIP have been picking up the slack, but not enough. They truly are a safety net for working class families. Any proposed cuts to these programs will need to take that into account.

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Author, Board Member, Member, Staff

Aaron E. Carroll, M.D., M.S.

President and CEO - AcademyHealth

Dr. Aaron E. Carroll is President & CEO of AcademyHealth. A nationally recognized thought leader, science comm... Read Bio

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