WASHINGTON — All U.S. infants at birth should be automatically enrolled in public Health coverage, and “universal eligibility” should be given up to age 26 years, according to a new American Academy of Pediatrics (AAP) recommendation.

The proposed overhaul of the Medicaid and the Children’s Health Insurance Program (CHIP) was presented at the AAP annual meeting, and aims to promote equity and improve child health.

“We have this huge vision,” said Jean L. Raphael, MD, MPH a member of the AAP Committee on Child Health Financing (COCHF).

“There’s always the potential to go small, to go incremental, and this is not that time. This is the time to think big, to think about foundational changes and that’s what we aspire to do as an organization,” added Raphael, who is at the Baylor College of Medicine in Houston.

Approximately 42 million children, or about half of all kids in the U.S., are currently enrolled in Medicaid and/or CHIP, with Black and Latino children tending to be disproportionally represented. In March 2023, a COVID-era policy that helped Medicaid enrollees maintain coverage ended. This led states to resume the redetermination process whereby eligibility of each enrollee is reviewed. As of October 2023, approximately 1.78 million children lost their Medicaid coverage.

The AAP “envisions a child and adolescent healthcare system that provides individualized, family-centered, equitable and comprehensive care that integrates with community resources to help each child and family achieve optimal growth development, and well-being,” according to the recommendation in Pediatrics.

Raphael acknowledged that questions remain on how to achieve and implement this goal, but emphasized that “we can get to this space where kids have equitable care … and lifelong positive outcomes.”

Eligibility for the two programs does differ — Medicaid is an entitlement program and CHIP is funded through a block grant — but both have clear benefits over being uninsured, he added, noting that broad access to healthcare reduces neonate and child mortality; lowers avoidable hospitalizations; and, in the long-term, children with access to public insurance have fewer chronic illnesses, lower rates of teen pregnancy, higher rates of high school graduation, increased college enrollment, and higher future wages.

The AAP put forward three core goals in the recommendation:

• Ensure that all children, ages 0 to 26 years, living in the U.S. have access to health insurance. Such universal eligibility would be guaranteed until age 6 years, with no “re-verification of eligibility” up to that age, and then no follow-up verifications more than every 2 years going forward. Those with other sources of insurance coverage would have the option to opt out.
• Ensure the coverage is “meaningful,” including mental, dental, and preventive health services; a “uniform Medicaid or CHIP program;” and a set of federal Medicaid/CHIP core drug benefits.
• Attract a “robust high-quality network of providers, services and supports” with more federal funding for the payment structure.

COCHF member Jennifer Kusma, MD, gave some details on the second goal: “Rather than having a Medicaid program with one set of eligibility criteria, and a CHIP program with another that’s different than your neighboring state, all of these programs will be Medicaid and CHIP together.”

“And all have the same set of eligibility criteria,” said Kusma, who is at Northwestern University Feinberg School of Medicine in Chicago.

The implementation of a Medicaid/CHIP set of core drug benefits would entail setting a minimum requirement for state formularies, she noted.

As for the third goal, she explained that “we know that there are limitations in access due to low payments, and that in order for all children to have high quality access to care, we really need to raise the payment structure.”

In the recommendation, Kusma, Raphael, and colleagues called for the establishment of a “federal minimum rate schedule,” to help mitigate the kinds of variations in payment that lead to inequities in care. The proposal also suggested, at a minimum, aligning Medicaid payments with rates comparable to Medicare.

Medicaid is jointly financed by the federal government and by states, which leads to states creating different rules around eligibility criteria, payments, benefits, and quality standards. “So what that means for patients and providers is that it’s hard to get care, and it’s hard to maintain care,” and there tends to be a lot of “fragmentation” and “churning” in and out of programs, Raphael said.

Other concepts floated are:

• “Cross-state coverage” that helps mitigate gaps in care when a child moves to another state.
• Establish a “standard medical necessity definition” so a child relocating from one state to another doesn’t lose access to certain services if the definition of what services count as medically necessary changes.
• Full implementation and monitoring of the Medicaid Early and Periodic Screening, Diagnostic, and Treatment benefit (EPSDT) in which states are “required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines,” according to the EPSDT website.
• A “racial and health equity analysis” into the process of developing all Medicaid and CHIP policies.
• Expand federal oversight of Medicaid and restructure CHIP as an entitlement program.