Near-Universal Children's Coverage: New York's Threatened Legacy

New York has a proud history of ensuring that children have comprehensive and continuous health insurance coverage, increasing access to routine health care that not only treats immediate needs but also lays the groundwork for improved long-term physical, emotional, and cognitive health and well-being. In 1997, 12% of children in New York State and 17% of children in New York City were uninsured. Since then, the uninsured rate for New York children has plummeted to 2.5%.

While dramatic coverage gains have been made across the country, achieving nearly universal health coverage for children is a distinctly New York story of hard work, perseverance, and innovation. Only Vermont, Massachusetts, the District of Columbia, and Hawaii have lower rates of uninsured children than New York, and arguably no state has made better use of its strong coverage platform to catalyze improvements in care for children.

Yet that impressive accomplishment is now at risk, as the federal government deliberates restructuring Medicaid—including through provisions in the American Health Care Act, which the Congressional Budget Office estimates will reduce federal spending for Medicaid by $880 billion—and whether to extend funding for the Children's Health Insurance Program. With the future of those programs in question, it is important to reflect on the underpinnings of New York's coverage gains and the benefits they provide, to remind ourselves of what we stand to lose and how hard it was to get here, and to preview the additional achievements the State is poised to attain if that strong coverage platform can be sustained.

Brick by Brick: Building Success
Historic achievements are rarely the result of “magic bullets,” and health coverage is no exception. New York's child coverage rate has edged remarkably close to 100% through a combination of legislative, executive, judicial, and programmatic decisions implemented over decades:

Strengthening public insurance programs. New York's public insurance programs, Medicaid and Child Health Plus, have been essential to ensure that financial burdens and low household incomes do not prevent families from accessing health insurance for their children. New York's Medicaid program provides coverage to children living in families with incomes up to 154% of the Federal Poverty Level (up to 233% for families with infants under age 1), making it a critical source of coverage for children living in or near poverty. Recognizing that, in a state with a relatively high cost of living, low- to middle-income families with incomes above those levels may also face financial hardship, in 1990 New York established its groundbreaking Child Health Plus program. Through it, families can purchase children's health insurance with modest premium and cost-sharing provisions. Child Health Plus became the model for what is today known nationally as the Children's Health Insurance Program, or CHIP. Subsequent bipartisan efforts expanded Child Health Plus eligibility through the 1990s.

Investing in community education and marketing. Since the 1990s, particularly after the enactment of Child Health Plus, New York has engaged in intensive public-private efforts to raise awareness of health insurance options for children. Community outreach coordinators broadly promoted enrollment across the state. Booths were set up at local fairs, faith communities were visited by insurance educators, and even McDonald's pitched in by placing Child Health Plus enrollment information on food trays. Traditional marketing efforts—radio, TV, and billboard advertisements—were also deployed.

Increasing coverage for parents. Helping parents enroll in their own health insurance was particularly useful in identifying and assisting the remaining children considered to be “eligible but unenrolled” in public programs. In 2001, New York established Family Health Plus as a mechanism to expand Medicaid eligibility for working low-income adults—particularly parents. New York's passage in 2015 of the Basic Health Plan—an option enabled by the Affordable Care Act—also made it easier for low-income parents to access health insurance by offering lower premiums and cost-sharing than would be available on the individual marketplace.

Simplifying enrollment and maintenance processes. Beginning in the early 2000s, dedicated advocates and nonprofits throughout New York developed and championed the novel approach of “facilitated enrollment,” in which the State permitted and paid for health plans and community-based organizations to help enroll uninsured families at sites in the communities in which they lived and worked. This proved to be a critical strategy for making enrollment more accessible and reducing stigma around Medicaid and Child Health Plus. The State also led the way in adopting 12-month continuous eligibility for children (allowing children to remain insured for the year regardless of changes to income or family size), a single common application for public insurance programs, streamlined renewal processes, and elimination of face-to-face interviews. These steps were all taken prior to federal legislation mandating such updates in enrollment processes; numerous others were taken post-ACA implementation.

Critical Investment
Perfection has not been reached. Approximately 104,000 New York children remain without health coverage today. But achieving what was once considered unimaginable, a 97.5% coverage rate among children, is a result New York should proudly claim.

That nearly universal health coverage has led to very real and significant benefits for New York's children and families. Coverage provides families with greater financial security, and—while more work is needed to prevent medical debt and bankruptcy—the value of health insurance in providing peace of mind for parents when their child is sick cannot be underestimated. In 2009, 32% of New York City parents of uninsured children stated they had to delay or skip health care for their child due to cost, whereas only 2% of parents of insured children did.

There is strong evidence that children in New York's public programs are accessing high-quality medical care. And it is increasingly clear from national research that children insured under Medicaid are more likely than uninsured children to graduate from high school and college, grow up to be healthier adults, and attain economic success—long-term benefits that suggest public health insurance is a smart investment rather than an entitlement or privilege.

A Broader Agenda

The story does not, and should not, end there. Building on that foundation, New York is positioning itself to use payment and delivery system reform to ensure that children's health care is optimally designed to not only treat kids as medical needs arise but also to strategically engage with their health and developmental needs to build a healthier, more successful future generation of New Yorkers.

Here at United Hospital Fund, we are engaged with the State's policymakers and health care community in three specific efforts to improve the health of children in New York:

Value-Based Care for Children. Across the country there is widespread agreement on the need to transition from paying for the volume of health care services to paying for value. Payment reform typically focuses on achieving better outcomes and more efficient care for chronically ill adults, but New York's Medicaid program is leading the way in figuring out how to create more value in children's health care. One dimension of this focuses on the outcomes that most matter to children and their families. Through the All Albany Kids Ready pilot, New York Medicaid is testing whether investments in pediatric primary care can affect one such outcome: kindergarten readiness.

Mental Health Reform. As part of New York's Medicaid Redesign Team efforts, the State is investing in developing a higher-performing behavioral health care system for children. This includes reducing fragmentation in care, ensuring that children receive the right mix of services for their needs, and making the system more accountable for outcomes and quality services.

Primary Care Innovation. High coverage rates and access to care for children in New York have unleashed incredible innovation in a surprising place: the primary care office. Now a nearly universal touchpoint for very young children and their families, child health providers across the state are adopting new programs—screening for maternal depression, promoting cognitive growth and literacy, addressing social needs through linkages with social services, and more—that maximize a child's chances for long-term healthy development.

New York is poised to achieve the thoughtful, innovative health care reforms children deserve. That possibility, though, depends entirely on the State's ability to maintain health insurance coverage for its children. It is the foundation that cannot be allowed to crumble.