Every child deserves to be able to access high-quality health care, regardless of where they live or their parents’ income. Unfortunately, in the United States, this is not the reality—even though there are programs like the federal Children’s Health Insurance Program (CHIP). Fortunately, policy solutions to the gap in child health care coverage are well within reach.

CHIP is an insurance program that provides low-cost coverage to children and, in some states, pregnant women.1 This inclusion of pregnant people is important—perinatal and postpartum health have a significant impact on children’s health, not only for the mother but also for the children, including after pregnancy.2 A longitudinal study of children in Australia, for example, found that poor general health of the mother in the year after childbirth was associated with worse general health for the child during both infancy and adolescence, as well as higher likelihood of a chronic condition.3 The same study found that stress, anxiety, and depression during pregnancy increased the likelihood of chronic illness during infancy for the child. Improving coverage rates and increasing access to care for pregnant people is a necessary step toward ending the maternal health crisis—a crisis that is driven by structural racism, with Black and Native American or Alaska Native women being disproportionately more likely to die of preventable, pregnancy-related causes.4

Like Medicaid, CHIP is administered by states and jointly funded by states and the federal government.5 CHIP serves families whose incomes are too high for Medicaid coverage but too low to afford marketplace or other coverage; as a result of this narrower band of eligibility, Medicaid covers significantly more people than CHIP programs do.6 States are able to operate their CHIP programs separately or as an expansion of Medicaid, and most operate the program separately.7 While there are many requirements for the program, states are given far more flexibility in how they operate their CHIP programs, yet CHIP is not an entitlement program in the way that Medicaid is, which limits states’ ability to make coverage more generous.8

This report describes how states can improve their CHIP programs to ensure that more children and new moms are given access to high quality, affordable health care. First, it outlines the state of health coverage, including children’s health coverage, before and during the COVID-19 pandemic. After this, it describes several barriers to children’s access to health care, as well as barriers to pregnant people accessing care in the CHIP program. Finally, it provides several recommendations on how to reduce these barriers, ensuring children, pregnant people, and newly postpartum people are best supported by their states’ program design.

Before we begin, a note about terminology: This report at times uses the term “pregnant women,” as this is the term used in Medicaid and CHIP statute and regulations. It is important to note, however, that not all pregnant people are women, and transgender men and nonbinary people will often face additional barriers in accessing care due to systemic bigotry. Similarly, this report uses the term “unborn child” to refer to a coverage option for pregnant women, as CHIP statute allows for the coverage of children “from conception to birth.” This statute does not reflect the medically accurate language—embryo or fetus—recommended by the American College of Obstetricians and Gynecologists.9

Rising Uninsurance before the Pandemic

In 2017, the coverage gains made under the Affordable Care Act (ACA)—in particular, Medicaid expansion—began to decline. This loss of coverage was largely attributable to the Trump administration’s efforts to undermine the ACA, and the chilling effect associated with the anti-immigrant regulations the administration enacted.10 As a result, the children’s uninsured rate climbed from its historic low of 4.7 percent, or 3.6 million children, back up to 5.7 percent, or 4.4 million children, by 2019.11 A recent report by the U.S. Department of Health and Human Services highlighted the boost that the ACA had provided for women: around 10 million women gained health coverage between 2010 and 2019, and around 70 percent of those women were of reproductive age.12

Unfortunately, marginalized communities continue to bear the brunt of uninsurance. Hispanic or Latino children saw the highest increase in the uninsured rate, increasing by more than 8 percent.13 This only exacerbated the existing inequities in health insurance, as Hispanic or Latino children were among the most likely to be uninsured before this increase began.14 Poorer children were also more likely to become uninsured during this period: the uninsured rate for children with family incomes below 138 percent of the federal poverty level—barely $26,000 for a family of four in 2019 dollars15—increased by nearly a whole percentage point from 2017 to 2019.16 States that expanded Medicaid under the ACA severely mitigated this increase; expansion states increased from 3.5 percent to 4.1 percent from 2016 to 2019, while non-expansion states increased from 6.5 percent to 8.1 percent over the same period.17

Adults experienced similar trends. An analysis of Census Bureau data by the Department of Health and Human Services found that women of color were disproportionately more likely to be uninsured.18 For example, despite representing less than 20 percent of the female population, Hispanic women represented 40 percent of the uninsured population in 2019. Poorer women were also more likely to be uninsured than higher-income women in 2019.19 Women living in poverty and women with household incomes between 139 and 249 percent of the poverty line were the most likely to be uninsured, representing 36 percent and 27 percent of uninsured women, respectively.20

This lack of coverage has real effects on the children involved. Lacking health coverage makes a child significantly less likely to access the care they need and makes the care they do access less effective.21 For example, a 2017 study found that 40 percent of children without health insurance did not have a primary care provider, while only 7 percent of insured children did not.22

Families with uninsured children were also much more likely to report their child’s health needs causing financial problems than families with insured children, according to the same study.23 Children being uninsured also results in less efficient health care spending, with the total cost of care for uninsured children being nearly $2,900 more per year.24 Being uninsured also has significant negative effects for women, as previous TCF research has demonstrated.25

Eligibility Restrictions Undermine Efficacy

While the goal of CHIP is to provide high-quality coverage to lower income children and pregnant people, the reality is that many families who would benefit from the program are not eligible. Eligibility restrictions represent some of the most significant barriers to accessing health care through CHIP. This section describes three forms of eligibility restrictions: income limits, immigration status, and the lack of continuous coverage.

Income Limit Variations between States

The most significant eligibility barrier is household income limits. As with the Medicaid program, eligibility for CHIP is restricted to low-income families, and the exact income threshold varies by state. Maps 1 and 2 show the variation in upper income limit for children and pregnant women, respectively.

Map 1

Map 2

These varying eligibility levels result in a patchwork of coverage for low-income children and mothers—the same household could be eligible for CHIP coverage in one state and ineligible in another, resulting in inequitable outcomes for families based in large part on where in the country they live. Southern states are more likely to have the lowest income threshold for children.

Immigration Status

In addition to income-based eligibility varying by state, immigration status is another barrier to eligibility. Undocumented immigrants are generally excluded from the program, though the “unborn child” option allows undocumented pregnant women to enroll in CHIP (as discussed in the opening of this report, this term is not medically accurate).26 Twenty states currently cover undocumented pregnant women through this approach.27

Map 3


Even “lawfully present” immigrants (essentially, all immigrants except undocumented immigrants), however, face barriers to coverage that citizens do not.28 Under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act, lawfully present immigrants must have resided in the United States for five years or more, though asylees and refugees do not have this waiting period.29 The 2009 CHIP Reauthorization Act allows states to waive the five-year waiting period for lawfully present immigrants. Twenty-four states and the District of Columbia have waived this waiting period for both children and pregnant women, and ten states have waived this period for children only.30 Wyoming has only waived the waiting period for pregnant women.31

Map 4


In part because of these exclusions, immigrants of any status are less likely to be insured than their citizen counterparts. In 2020, almost 21 percent of noncitizen children were uninsured, compared to only 5 percent of native-born citizen children.32 Similarly, the Guttmacher Institute estimated in 2021 that some 33 percent of noncitizen women of reproductive age were uninsured in 2018, compared to around 10 percent of U.S.-born women in the same year.33

Income Volatility

Another barrier to accessing health care is the reality that income volatility—inconsistent changes in income over time—often results in people being disenrolled from CHIP. Unlike marketplace subsidies, which are based on annual income, Medicaid and CHIP eligibility is based on monthly income.34 While enrollees typically have a year before their eligibility must be renewed, they are required to regularly report any changes in income, and states review wage reports and other data sets.35 As a result of these changes, enrollees may be disenrolled due to temporary changes in income, such as working additional shifts or overtime or another member of the household taking a seasonal job. While states were barred from disenrolling people for most of the COVID-19 pandemic, this policy recently ended, and states are redetermining eligibility for all enrollees, reintroducing the risk of disenrollment due to income volatility.

Disenrollment due to income volatility contributes to health insurance “churn”—when a patient transitions between sources of coverage or between having coverage and being uninsured.36 Previous TCF research has highlighted the effects of churn during the postpartum period: disruptions in coverage reduce new moms’ ability to seek care if they cannot pay for it out of pocket, limiting their continuity of care and increasing risk of complications from diabetes or high blood pressure.37 These disruptions in coverage are more common in states that have not expanded Medicaid, exacerbating their impacts on women of color, who disproportionately live in non-expansion states.38

Children are not immune from the effect of churn: prior to the pandemic bans on disenrollment, children in states without continuous coverage policies in place were 4.7 percentage points less likely to have received any medical care over the past year, 6.2 percentage points less likely to have had one or more preventive visits over the past year, and 5.3 percentage points less likely to have received any specialty care over the past year.39

In addition to making people’s health care access worse, churn also increases health system costs. First, the process of repeatedly enrolling and disenrolling patients increases administrative costs to states. A study published in Health Affairs in 2015 estimated that the cost of one person disenrolling and reenrolling in Medicaid was around $400–$600 per instance,40 or around 8–12 percent of the average Medicaid spending on a non-disabled, non-elderly adult that same year.41

Churn also increases actual medical spending by worsening health outcomes. Because patients often delay care during the periods they are uninsured, their health conditions often go unaddressed until they are reenrolled in an insurance program. A recent issue brief by the Medicaid and CHIP Payment Advisory Commission highlights this: in the first month after an episode of Medicaid churn, hospitalization rates and emergency department visits for four conditions examined more than doubled.42 The same study found that even three months after the episode of churn, hospitalization and emergency department visits were higher than the six months before losing coverage.

These effects are especially concerning from a health and racial equity perspective. Black and Hispanic people are significantly more likely to be enrolled in Medicaid than their white peers,43 and people of color—especially Black and Hispanic women—are much more likely to experience high income volatility, putting them at higher risk of churn and losing needed health benefits due to short-term income fluctuation.44

CHIP Program Design Flaws

Even for children and adults who are eligible for CHIP, states’ program design creates additional barriers to accessing care. This section describes several of these factors: waiting periods, reduced benefit generosity, and out-of-pocket costs for enrollees.

Waiting Periods

One way that state program design can undermine access to coverage is through waiting periods. Under federal law, states are required to ensure that CHIP does not serve as a substitute for private health coverage.45 To satisfy this requirement, many states require waiting periods—some length of time that a person must be uninsured—to become eligible for coverage through CHIP. Federal law limits these periods to no more than ninety days, but this can still serve as a significant barrier to care.

Map 5


A requirement to be uninsured for ninety days is a significant burden on pregnant people, who need access to prenatal care. A recent study by researchers at the University of Michigan found that women who were not consistently insured throughout their pregnancy were around 16 percent less likely to receive prenatal care in the first trimester than women who were continuously insured throughout their pregnancy.46 The same study found that women of color, especially Hispanic women, were the majority of those who were uninsured for some or all of their pregnancies, highlighting the impact these waiting periods have on health equity.

Skimpy Benefits

Comprehensive health coverage that meets all the needs of a beneficiary is essential to achieving health equity, and CHIP often does not cover the complete needs of children and new moms.47 One of the most striking gaps in CHIP benefits is the lack of requirement to provide one of Medicaid’s most important benefits: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). EPSDT requires Medicaid programs to cover all medically necessary services for children under age twenty-one, regardless of whether a state’s Medicaid program covers that service for adults.48 Separate CHIP programs are not required to provide an EPSDT-like benefit for enrollees, and most states that separate CHIP from Medicaid do not provide such a benefit.49

Skimpy CHIP benefits also affect pregnant and postpartum people. Twenty of the twenty-five states that cover pregnant women with CHIP funding do so through the “unborn child” option.50 While this approach does enable undocumented women to access health coverage they otherwise would be ineligible for, states are not obligated to provide the full set of services required for Medicaid or CHIP programs.51 Under the unborn child option, states are only required to cover prenatal care and labor and delivery services for enrollees, regardless of immigration status.52

Accessing prenatal care is an important part of improving health outcomes for pregnant women, as well as ending the maternal mortality crisis, but it is not sufficient.53 Particularly as CHIP programs typically fail to cover the services that promote better maternal outcomes—such as doulas, midwifery care, or lactation support—the scope of coverage for pregnant women is even less meaningful to patients.54 While all pregnant people are at risk of being underinsured due to this limitation, undocumented pregnant people are especially vulnerable due to their systemic barriers to coverage otherwise as described above.

Another service that CHIP programs often do not cover for children or pregnant adults is abortion. This lack of coverage is partially due to the Hyde Amendment—an appropriations provision that prohibits federal funds from being spent on abortions outside of limited exceptions for rape, incest, and endangerment of the life of the pregnant person.55 The Hyde Amendment disproportionately impacts low-income women and women of color because they are more likely to be enrolled in Medicaid or CHIP.56

Failing to cover abortion care is even more dire in the wake of last year’s Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, which overturned the precedents of Roe v. Wade and Planned Parenthood v. Casey.57 About half of all states have banned or are expected to ban abortion, and many of those bans have no exceptions for abortions for which Hyde requires coverage.58 These bans and coverage restrictions could result in health care expenses a pregnant person cannot afford, if the needed services are even available to them in the first place.

Out-of-Pocket Spending

In addition to the impact of limited coverage in CHIP, many states require premiums and cost-sharing for health services. Maps 6 and 7 show the states that require premiums and cost-sharing, respectively. Thirty states charge premiums or enrollment fees for Medicaid and CHIP enrollees, including seven states that charge premiums to families making below 150 percent of the poverty line.59 Twenty states charge cost-sharing to children enrolled in CHIP, and Tennessee charges cost-sharing to children enrolled in its Medicaid program beginning at 100 percent of the federal poverty line.60

Map 6

Map 7


Federal law generally limits premiums and cost-sharing for low-income CHIP enrollees: For households at or below 150 percent of the federal poverty level, cost-sharing is limited to what enrollees in Medicaid are charged. And for households above 150 percent of the federal poverty level, cumulative premiums and cost-sharing cannot exceed 5 percent of the family’s income.61 While these amounts can seem low, for families with such limited funds, they can represent a significant burden.62

These premiums can also contribute to churn among enrollees: if a family does not pay its premium within a certain period from its due date—typically sixty days—the state is allowed to impose a “lock-out” period of up to ninety days, during which the enrollee is not permitted to enroll in CHIP.63 Just four states have grace periods for premium repayment that are only thirty days—the federally required minimum. But half of states that charge premiums and can impose lock-out periods impose the maximum ninety days.64 Similarly, imposing cost-sharing on services can significantly reduce access, especially among the lower-income families enrolled in CHIP. While cost-sharing may not result in a full loss of coverage like premium requirements do, it still significantly reduces access to needed services. For example, a 2014 study found that cost-sharing was associated with reduced treatment for children with asthma.65

Policies for Improving Access to Health Care

The barriers presented in this report so far have clear solutions. This section outlines several approaches that states, as well as the federal government, can take to respond to the barriers that prevent children and new mothers from accessing the care they need:

  • Eliminate eligibility restrictions
  • Carefully adopt the “unborn child” option
  • Cover needed services without financial burdens
  • Promote continuous coverage throughout pregnancy and childhood

Eliminate Eligibility Restrictions

There are several ways states can address the eligibility barriers described above. First, states can simply raise the eligibility threshold for their programs. Unlike Medicaid, which generally has an upper eligibility limit of 138 percent of the federal poverty level, CHIP has no such limit.66 New York state is an example of having greatly expanded its CHIP program: since 2009, households that earn up to 400 percent of the federal poverty level are eligible for subsidized coverage through Child Health Plus, New York’s CHIP, and households that earn less than 220 percent are eligible for free coverage.67

States that do expand their CHIP programs can receive additional federal funding to make up for their increased spending. Federal law allows states to apply for increased funding associated with expanded eligibility or benefits by describing the addition in expenditures that are associated with the expansion, as well as the extent to which this increase in spending would exceed their current CHIP spending allotment.68 Applying for increased funding in this way would allow states to better serve children and new mothers without spending more from state coffers.

It is important to note, however, that unlike Medicaid expansion under the ACA, expanding eligibility for CHIP and increasing a state’s federal allotment would require the use of a so-called 1115 waiver.69 The 1115 waiver process is more complicated than the state plan amendment option that existed prior to the enactment of the ACA—states must seek approval from the federal government to change their program outside of preapproved ways under the waiver process. But states should pursue the 1115 waiver process anyway, to increase the number of people who are eligible for their programs. The federal government should also pass legislation restoring the ability of states to make such a change via state plan amendment, ensuring that states can more easily expand their program eligibility.

In addition to reducing restrictions on eligibility based on income, states also have opportunities to reduce the impact of immigration status on access to care. While federal law generally prohibits federal funds from being spent on undocumented immigrants, states are able to enroll these immigrants in federally funded programs if exclusively state funds are used to cover costs associated with them. For example, the California state legislature passed a law in 2015 allowing low-income undocumented children to enroll in Medi-Cal, the state’s Medicaid program.70 Around 110,000 children enrolled in May 2016 when enrollment began, and enrollment peaked at just over 134,000 in April 2017.71 In 2019, just under 130,000 undocumented children were enrolled in Medi-Cal, and the state had to appropriate only around $365 million in state funds—less than $3,000 per child—to pay for their health needs.72

California’s program allows children with household incomes up to 266 percent of the federal poverty level to enroll in the program,73 and the state has the highest population of undocumented immigrants in the nation, representing nearly 20 percent of the total undocumented population in 2016.74 This means that other states looking to expand their CHIP or Medicaid programs to cover undocumented families will likely need to spend much less than California to cover their undocumented populations, even if they combine this reform with increasing the eligibility threshold.

The “Unborn Child” Option

Another way states can improve access to care through their CHIP programs is by carefully adopting the so-called unborn child option. In particular, this approach has the potential to promote access to care for undocumented immigrants while requiring lower amounts of state-level spending. As discussed above, the unborn child option allows states to enroll undocumented immigrants in their CHIP, ensuring that their immigration status is not a barrier to enrollment. The states that have not yet adopted this approach should consider doing so to improve the health of both undocumented pregnant people and their children.

This approach should be taken carefully, however, as a blanket adoption of this option runs the risk of lowering the scope of benefits to which enrollees have access. While most states that have adopted the unborn child option provide full benefits to pregnant enrollees, around 30 percent of the states that currently use this approach do not, limiting the coverage to a restricted set of services directly related to pregnancy. Such limitations ignore the reality that other forms of care also promote better pregnancy outcomes. States that adopt the unborn child option should ensure they do so in a way that provides full coverage of all the health services a pregnant person may need, and the states that do not currently do so should reform their programs to make this change.

In addition to adopting this option, states should maximize the use of health services initiatives (HSIs). HSIs are “activities that protect the public health, protect the health of individuals, improve or promote a state’s capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children, including targeted low-income children and other low-income children.”75 States can use HSIs to address a variety of needs: current state uses range from support for poison control centers to preventing lead poisoning.76

While not statutorily tied to the unborn child option, HSIs are especially useful for ensuring postpartum coverage for undocumented immigrants. One common HSI program is implementing a twelve-month postpartum coverage extension in CHIP programs to mirror Medicaid’s SPA option. The Consolidated Appropriations Act requires states to extend postpartum coverage to pregnant people enrolled in CHIP if the states extend postpartum coverage under Medicaid, but this provision would not apply to undocumented immigrants covered under the unborn child option.77 Extending this coverage through a CHIP HSI would ensure that the immigration status of a pregnant person does not determine their access to postpartum care. California and Illinois have both taken this approach in recent years to promote access to care.78

Importantly, HSIs are achieved through state plan amendments, rather than waivers.79 This allows states to much more easily implement an HSI than other reforms mentioned in this report. HSIs also make use of existing federal funds—CHIP programs are permitted to spend up to 10 percent of their total funding on administrative purposes, which includes HSI operations. By maximizing the use of federal funds, states can promote coverage without requiring an increase in state funding or applying for additional federal funding.

Needed Services without Financial Burdens

States should also examine their programs to ensure that full-scope coverage meaningfully promotes access to all the services a patient might need. As noted above, many services that promote better pregnancy outcomes are not currently covered by CHIP programs, such as doulas, midwifery care, and lactation support.80 Covering these services for all CHIP beneficiaries will help improve access to those services and, in turn, maternal and child health outcomes.

In addition, states should take the necessary steps to cover abortion for CHIP enrollees. While insurance coverage is not the only barrier to abortion access, it represents an important way for states to ensure cost is not a barrier. Providing this coverage will require state investment, but the women and other pregnant people enrolled in CHIP—including children—need and deserve this coverage to be as healthy as possible.81 Despite claims to the contrary from abortion opponents, children can and do become pregnant, and many of them may need abortion care and should have that care covered as well.

Beyond simply ensuring these services are covered, however, states should work to reform the financial contributions that families are expected to make to remain eligible for the program. States are permitted to charge premiums for CHIP enrollment, with some states charging premiums as soon as a child is no longer eligible for Medicaid.82 Premiums and cost-sharing both deter patients from being able to access the services their coverage should provide, and these burdens are especially with regard to CHIP, which by definition covers lower-income families.

Many states temporarily waived or lowered premiums and cost-sharing requirements during the COVID-19 public health emergency,83 and six states (California, Colorado, Illinois, Maine, New Jersey, and North Carolina) do not intend to reinstate them.84 The unwinding of the Medicaid and CHIP continuous coverage provisions presents an ideal opportunity to make these changes permanent, helping reduce the potential for a loss of coverage during this period.

Continuous Coverage through Pregnancy and Childhood

States also have many options to promote continuous coverage throughout a pregnancy and throughout childhood, both critical periods for ensuring a healthy start to life. Building on the continuous eligibility requirement of the Consolidated Appropriations Act is a great way for states to do so. Under the law, states are now required to provide twelve months of continuous eligibility for children in both Medicaid and CHIP. The law also made permanent the option to provide twelve months of postpartum coverage in the programs.85 States should take up this extension option to promote better maternal and childhood health.

Adopting the postpartum extension and connecting pregnant people to coverage can help avoid negative outcomes for the children and improve outcomes for pregnant people.86 This would have a significant impact, as pregnant women are often only eligible for sixty days postpartum coverage in many states.87

States should also apply to the Centers for Medicare and Medicaid Services (CMS) for demonstration waivers to go beyond the lengths required for children. Oregon is a leader in this approach: on September 28, 2022, the state received approval from CMS to provide continuous eligibility for children from birth until age six, and for twenty-four months of coverage for children age six and older and adults.88 As TCF researchers have previously written, expanding continuous eligibility is an evidence-supported way to promote better health outcomes. Income fluctuation is very common, and households of color are even more likely to experience significant income fluctuations.89 Smoothing coverage through continuous eligibility would help address these changes in income and avoid disenrolling beneficiaries because of temporary changes in income. Three other states—Washington, New Mexico, and California—have taken steps to join Oregon in providing this continuous eligibility.90

Other policies that states can effect to reduce churn are eliminating lock-out and waiting periods. Lock-out periods only serve to punish children for their parents being unable to pay a premium, and they are especially concerning in the context of income volatility among low-income households. In addition to lock-out periods, states should eliminate waiting periods for CHIP; including the five-year waiting period for lawfully present immigrants, and uninsured waiting periods for both citizen and immigrant beneficiaries. Because these beneficiaries would be eligible for federal funding, the financial impact of including these patients would be far lower than covering undocumented immigrants.

Every Family Deserves a Healthy Start

While CHIP has helped ensure that many low-income children have access to the health care they need, more is needed to further improve the program. States have an opportunity and an obligation to make their CHIP programs as effective as possible for the children and families served by them. Healthy parents are essential to ensuring healthy kids; improvements to CHIP must include maternal health as well. States should examine their CHIP programs and implement the solutions provided in this report in order to better promote maternal and childhood health.

Notes

  1. “Children’s Health Insurance Program (CHIP),” Centers for Medicare and Medicaid Services (CMS), https://www.healthcare.gov/glossary/childrens-health-insurance-program-chip/.
  2. Dana Garbarski, “The Interplay between Child and Maternal Health: Reciprocal Relationships and Cumulative Disadvantage During Childhood and Adolescence,” Journal of Health and Social Behavior 55, no. 1 (March 2014): 91–106, https://doi.org/10.1177/0022146513513225.
  3. Kabir Ahmad et al., “Maternal Health and Health-Related Behaviours and Their Associations with Child Health: Evidence from an Australian Birth Cohort,” Public Library of Science One, September 13, 2021, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257188.
  4. Jamila Taylor, “Promoting Better Maternal Health Outcomes by Closing the Medicaid Postpartum Coverage Gap,” The Century Foundation, November 16, 2020, https://tcf.org/content/report/promoting-better-maternal-health-outcomes-closing-medicaid-postpartum-coverage-gap/; Anna Bernstein, Jamila Taylor, and Vina Smith-Ramakrishnan, “Almost All Pregnancy-Related Deaths Are Preventable, So What Is Congress Waiting For?,” The Century Foundation, September 23, 2022, https://tcf.org/content/commentary/almost-all-pregnancy-related-deaths-are-preventable-so-what-is-congress-waiting-for/.
  5. CMS, “Children’s Health Insurance Program (CHIP).”
  6. “CHIP,” Georgetown University Center for Children and Families, https://ccf.georgetown.edu/topic/childrens-health-insurance-program/; “January 2023 Medicaid & Chip Enrollment Data Highlights,” CMS, https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html.
  7. “Key CHIP Design Features,” Medicaid and CHIP Payment and Access Commission, https://www.macpac.gov/subtopic/key-design-features/.
  8. Ibid.
  9. ACOG Guide to Language and Abortion,” American College of Obstetricians and Gynecologists, https://www.acog.org/contact/media-center/abortion-language-guide.
  10. Joan Alker and Alexandra Corcoran, “Children’s Uninsured Rate Rises by Largest Annual Jump in More than a Decade,” Georgetown University Center for Children and Families, October 8, 2020, https://ccf.georgetown.edu/2020/10/08/childrens-uninsured-rate-rises-by-largest-annual-jump-in-more-than-a-decade-2/.
  11. Ibid.
  12. Sarah Sugar et al., “Health Coverage for Women under the Affordable Care Act,” Assistant Secretary for Planning and Evaluation, March 21, 2022, https://aspe.hhs.gov/sites/default/files/documents/9082fc42757552c429d8b1c3c8949595/aspe-womens-coverage-ib.pdf.
  13. Alker and Corcoran, “Children’s Uninsured Rate.” (“Hispanic or Latino” is the term used by the U.S. Census.)
  14. Ibid.
  15. “HHS Poverty Guidelines for 2023,” Office of the Assistant Secretary for Planning and Evaluation, https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines.
  16. Alker and Corcoran, “Children’s Uninsured Rate.”
  17. Adam Searing, Allie Corcoran, and Joan Alker, “Report Finds Medicaid Expansion Associated with Lower Child Uninsured Rates,” Georgetown University Center for Children and Families, February 17, 2021, https://ccf.georgetown.edu/2021/02/17/report-finds-medicaid-expansion-associated-with-lower-child-uninsured-rates/.
  18. Sugar et al., “Health Coverage for Women under the Affordable Care Act.”
  19. “The Hispanic Population in the United States: 2019,” United States Census Bureau, October 28, 2021, https://www.census.gov/data/tables/2019/demo/hispanic-origin/2019-cps.html, Table 1; Sugar et al., “Health Coverage for Women under the Affordable Care Act.”
  20. Sugar et al., “Health Coverage for Women under the Affordable Care Act.”
  21. Yvonne W. Fry-Johnson et al., “Being Uninsured: Impact on Children’s Healthcare and Health,” Current Opinion in Pediatrics 17, no. 6 (2005): 753–58, https://doi.org/10.1097/01.mop.0000187455.17077.94.
  22. Glenn Flores et al., “The Health and Healthcare Impact of Providing Insurance Coverage to Uninsured Children: A Prospective Observational Study,” BMC Public Health 17, no. 1 (May 23, 2017), https://doi.org/10.1186/s12889-017-4363-z.
  23. Ibid.
  24. Ibid.
  25. Jamila Taylor and Anna Bernstein, “The Medicaid Coverage Gap and Maternal and Reproductive Health Equity,” The Century Foundation, August 10, 2022, https://tcf.org/content/commentary/medicaid-coverage-gap-maternal-reproductive-health-equity/.
  26. “Can Immigrants Enroll in Medicaid or Children’s Health Insurance Program (CHIP) Coverage?,” Kaiser Family Foundation, https://www.kff.org/faqs/faqs-health-insurance-marketplace-and-the-aca/can-immigrants-enroll-in-medicaid-or-childrens-health-insurance-program-chip-coverage/.
  27. Tricia Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision,” Kaiser Family Foundation, April 4, 2023, https://www.kff.org/report-section/medicaid-and-chip-eligibility-enrollment-and-renewal-policies-as-states-prepare-for-the-unwinding-of-the-pandemic-era-continuous-enrollment-provision-report/.
  28. “Health Coverage of Immigrants,” Kaiser Family Foundation, April 6, 2022, https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-of-immigrants/.
  29. Hansa Chowdhury, “Immigration Healthcare and the Five Year Bar,” Alliance for Citizen Engagement, August 23, 2022, https://ace-usa.org/blog/research/research-immigration/immigration-healthcare-and-the-five-year-bar/.
  30. Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision.”
  31. Ibid.
  32. Katherine Keisler-Starkey and Lisa N. Bunch, “Health Insurance Coverage in the United States: 2020,” Census.gov, September 2021, https://www.census.gov/content/dam/Census/library/publications/2021/demo/p60-274.pdf.
  33. Adam Sonfield, “Uninsured Rate for People of Reproductive Age Ticked Up between 2016 and 2019,” Guttmacher Institute, April 1, 2021, https://www.guttmacher.org/article/2021/04/uninsured-rate-people-reproductive-age-ticked-between-2016-and-2019.
  34. “Income Definitions for Marketplace and Medicaid Coverage,” Beyond the Basics, Center on Budget and Policy Priorities, August 2022, https://www.healthreformbeyondthebasics.org/key-facts-income-definitions-for-marketplace-and-medicaid-coverage/.
  35. Jennifer Wagner and Judith Solomon, “Continuous Eligibility Keeps People Insured and Reduces Costs,” Center on Budget and Policy Priorities, May 4, 2021, https://www.cbpp.org/research/health/continuous-eligibility-keeps-people-insured-and-reduces-costs.
  36. Quynh Chi Nguyen, “Health Insurance Churn: The Basics,” Community Catalyst, November 2016, https://www.communitycatalyst.org/resources/publications/document/Health-Insurance-Churn-November-2016_FINAL.pdf.
  37. Taylor, “Promoting Better Maternal Health Outcomes by Closing the Medicaid Postpartum Coverage Gap.”
  38. Ibid; Robin Rudowitz et al., “How Many Uninsured Are in the Coverage Gap and How Many Could Be Eligible If All States Adopted the Medicaid Expansion?,” Kaiser Family Foundation, March 31, 2023, https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/.
  39. Leighton Ku and Erin Brantley, “Continuous Medicaid Eligibility for Children and Their Health,” Working Paper, George Washington University Center for Health Policy Research, May 2020, https://www.communityplans.net/wp-content/uploads/2020/06/GW-continuous-eligibility-paper.pdf.
  40. Katherine Swartz et al., “Reducing Medicaid Churning: Extending Eligibility For Twelve Months Or To End Of Calendar Year Is Most Effective,” Health Affairs, July 2015, https://www.healthaffairs.org/doi/10.1377/hlthaff.2014.1204.
  41. “2016 Actuarial Report on the Financial Outlook for Medicaid,” CMS, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2016.pdf.
  42. “Effects of Churn on Potentially Preventable Hospital Use,” Medicaid and CHIP Payment and Access Commission, July 2022, https://www.macpac.gov/wp-content/uploads/2022/07/Effects-of-churn-on-hospital-use_issue-brief.pdf.
  43. “Distribution of the Nonelderly with Medicaid by Race/Ethnicity,” Kaiser Family Foundation, https://www.kff.org/medicaid/state-indicator/medicaid-distribution-nonelderly-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
  44. Michael Carr and Bradley L. Hardy, “Racial Inequality Across Income Volatility and Employment,” February 24, 2022, http://www.bradleyhardy.com/wp-content/uploads/2022/03/Carr-Hardy-2022.pdf.
  45. “Waiting Periods in Chip,” CMS, April 2021, https://www.medicaid.gov/chip/eligibility-standards/waiting-periods-chip/index.html.
  46. Lindsay K. Admon et al., “Insurance Coverage and Perinatal Health Care Use among Low-Income Women in the US, 2015-2017,” JAMA Network Open 4, no. 1 (2021), https://doi.org/10.1001/jamanetworkopen.2020.34549.
  47. Jamila Taylor and Thomas Waldrop, “Health Equity in Practice: A Framework to Assess Meaningful Implementation in Health Insurance Reforms,” The Century Foundation, September 21, 2022, https://tcf.org/content/report/health-equity-in-practice-a-framework-to-assess-meaningful-implementation-in-health-insurance-reforms/.
  48. “Early and Periodic Screening, Diagnostic, and Treatment,” CMS, https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-treatment/index.html.
  49. Tricia Brooks, Lauren Roygardner, and Samantha Artiga, “Medicaid and Chip Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey,” Kaiser Family Foundation, March 27, 2019, https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2019-findings-from-a-50-state-survey/.
  50. Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision.”
  51. Ibid.
  52. Ibid.
  53. Taylor, “Promoting Better Maternal Health Outcomes by Closing the Medicaid Postpartum Coverage Gap.”
  54. On doulas, see Tomás Guarnizo, “Doula Services in Medicaid: State Progress in 2022,” Georgetown University Center for Children and Families, June 2, 2022, https://ccf.georgetown.edu/2022/06/02/doula-services-in-medicaid-state-progress-in-2022/. On midwifery care, see Anna Bernstein, “This Black Maternal Health Week, Let’s Expand Access to Midwifery Care,” The Century Foundation, April 5, 2022, https://tcf.org/content/commentary/this-black-maternal-health-week-lets-expand-access-to-midwifery-care/. On lactation support, see Denys Symonette Mitchell, “Investing in Breastfeeding Will Advance Health Equity,” The Century Foundation, August 30, 2022, https://tcf.org/content/commentary/investing-in-breastfeeding-will-advance-health-equity/.
  55. Jamila Taylor, “Let’s Get Rid of Abortion Coverage Restrictions Once and for All,” The Century Foundation, September 26, 2019, https://tcf.org/content/commentary/lets-get-rid-abortion-coverage-restrictions/.
  56. Jessica Arons and Lindsay Rosenthal, “How the Hyde Amendment Discriminates Against Poor Women and Women of Color,” Center for American Progress, May 10, 2013, https://www.americanprogress.org/article/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color/.
  57. Dobbs v. Jackson Women’s Health Organization, 597 U.S. _ (2022).
  58. “Tracking the States Where Abortion Is Now Banned,” New York Times, October 13, 2022, https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html.
  59. “Premiums, Enrollment Fees, and Cost-Sharing Requirements for Children,” Kaiser Family Foundation, 2020, https://www.kff.org/medicaid/state-indicator/premiums-enrollment-fees-and-cost-sharing-requirements-for-children/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D.
  60. “Premiums, Enrollment Fees, and Cost-Sharing Requirements for Children,” Kaiser Family Foundation.
  61. “CHIP Cost Sharing,” Medicaid.gov, https://www.medicaid.gov/chip/chip-cost-sharing/index.html.
  62. Samantha Artiga, Petry Ubri, and Julia Zur, “The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings,” Kaiser Family Foundation, June 1, 2017, https://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings/.
  63. Tricia Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Kaiser Family Foundation, March 26, 2020, https://www.kff.org/report-section/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey-premiums-and-cost-sharing/.
  64. Ibid.
  65. Vicky Fung et al., “Financial Barriers to Care Among Low-Income Children With Asthma,” JAMA Pediatrics 168, no. 7 (2014): 649–56, https://jamanetwork.com/journals/jamapediatrics/fullarticle/1872780.
  66. “Medicaid Eligibility,” Medicaid.gov, https://www.medicaid.gov/medicaid/eligibility/index.html.
  67. New York State Legislature, Assembly, A4308, 2007–8 session, 1st sess., https://nyassembly.gov/leg/?default_fld=&leg_video=&bn=A04308&term=2007&Summary=Y&Text=Y; “Eligibility and Cost,” New York State Department of Health, August 2022, https://www.health.ny.gov/health_care/child_health_plus/eligibility_and_cost.htm.
  68. 42 USC 1397dd (m)(7), https://www.ssa.gov/OP_Home/ssact/title21/2104.htm.
  69. Joan Alker and Anne Dwyer, “Future of Children’s Health Coverage: Next Steps for CHIP,” Georgetown University Center for Children and Families, August 4, 2021, https://ccf.georgetown.edu/2021/08/24/future-of-childrens-health-coverage-next-steps-for-chip/.
  70. California State Legislature, Senate, SB 75, 2015-2016 session, 1st sess., https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160SB75.
  71. Ana B. Ibarra, “Medi-Cal Enrollment among Immigrant Kids Stalls, Then Falls. Is Fear to Blame?,” Kaiser Health News, July 9, 2019, https://khn.org/news/medi-cal-enrollment-among-immigrant-kids-stalls-then-falls-is-fear-to-blame/.
  72. Ibid.
  73. “Medicaid and CHIP Income Eligibility Limits for Children as a Percent of the Federal Poverty Level,” Kaiser Family Foundation, https://www.kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-children-as-a-percent-of-the-federal-poverty-level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
  74. “U.S. Unauthorized Immigrant Population Estimates by State, 2016,” Pew Research Center, February 5, 2019, https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state/.
  75. “CHIP Health Services Initiatives: What They Are and How States Use Them,” Medicaid and CHIP Payment and Access Commission, July 2019, https://www.macpac.gov/wp-content/uploads/2019/07/CHIP-Health-Services-Initiatives.pdf.
  76. Ibid.
  77. Edwin Park et al., “Consolidated Appropriations Act, 2023: Medicaid and CHIP Provisions Explained,” Georgetown University Center for Children and Families, January 5, 2023, https://ccf.georgetown.edu/2023/01/05/consolidated-appropriations-act-2023-medicaid-and-chip-provisions-explained/.
  78. Amy Lutzky to Jacey Cooper, “California State Plan Amendment Approval Letter,” CMS, September 14, 2021, https://www.medicaid.gov/CHIP/Downloads/CA/CA-21-0032.pdf; Amy Lutzky to Kelly Cunningham, “Illinois State Plan Amendment Approval Letter,” CMS, September 15, 2021, https://www.medicaid.gov/CHIP/Downloads/IL/IL-21-0014.pdf.
  79. Medicaid and CHIP Payment and Access Commission, “CHIP Health Services Initiatives: What They Are and How States Use Them.”
  80. On doulas, see Guarnizo, “Doula Services in Medicaid;”on midwifery care, see Bernstein, “This Black Maternal Health Week, Let’s Expand Access to Midwifery Care;” on lactation support, see Mitchell, “Investing in Breastfeeding Will Advance Health Equity.”
  81. On children, see Tracey Wilkinson, Julie Maslowsky, and Laura Lindberg, “A Major Problem for Minors: Post-Roe Access to Abortion,” STAT, June 26, 2022, https://www.statnews.com/2022/06/26/a-major-problem-for-minors-post-roe-access-to-abortion/. On the general need for coverage of pregnant people, see Black Maternal Health Federal Policy Collective, “The Intersection of Abortion Access and Black Maternal Health,” The Century Foundation, June 22, 2022, https://tcf.org/content/facts/the-intersection-of-abortion-access-and-black-maternal-health/.
  82. Kaiser Family Foundation, “Premiums, Enrollment Fees, and Cost-Sharing Requirements for Children.”
  83. Alker and Dwyer, “Future of Children’s Health Coverage: Next Steps for CHIP.”
  84. Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision.”
  85. Edwin Park et al., “Consolidated Appropriations Act, 2023: Medicaid and CHIP Provisions Explained.”
  86. Judith Solomon, “Closing the Coverage Gap Would Improve Black Maternal Health,” Center on Budget and Policy Priorities, July 26, 2021, https://www.cbpp.org/research/health/closing-the-coverage-gap-would-improve-black-maternal-health.
  87. Taylor, “Promoting Better Maternal Health Outcomes by Closing the Medicaid Postpartum Coverage Gap.”
  88. Chiquita Brooks-LaSure to Dana Hittle, “2022-2027 1115 Demonstration Approval,” CMS, September 28, 2022, https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/or-health-plan-09282022-ca.pdf.
  89. “How Income Volatility Interacts with American Families’ Financial Security,” Pew Charitable Trusts, March 9, 2017, https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2017/03/how-income-volatility-interacts-with-american-families-financial-security.
  90. Cathay Hope, “Medicaid and CHIP Continuous Coverage for Children,” Georgetown Center for Children and Families, October 7, 2022, https://ccf.georgetown.edu/2022/10/07/medicaid-and-chip-continuous-coverage-for-children/.

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