Increasing Access to Care for Children

The expert testimony, research, scholarship, and lived experience collected by the Commission revealed the following:

• Families and children with low incomes depend on a patchwork of systems to access coverage that makes healthcare affordable and not all of those who qualify for assistance are accessing the assistance. While public program expansions have increased the number of insured children, more than 107,000, or roughly 7.7 percent, of children in Missouri remain uninsured (SHADAC, 2014). In 2012, roughly 85% of these children were eligible for Medicaid or the Children’s Health Insurance Program (CHIP), both public insurance programs (Kenney, Lynch, Huntress, Haley, & Anderson, 2012).
• Medicaid and CHIP are federally authorized health insurance programs that are administered at the state level. Both programs are funded by state and federal contributions. While the federal Department of Health and Human Services sets broad regulations, states have a great deal of authority to establish coverage levels and eligibility terms.  As a result, these terms vary from state to state. In Missouri, Medicaid, called MO HealthNet, covers children living in households that make less than 150-196 percent of the federal poverty limit (depending on the age of the child), or roughly 436,300 children (Missouri Foundation for Health, 2014). CHIP insures an additional 70,000 children who live in families with incomes too high to qualify for Medicaid but too low to afford private coverage (Missouri Foundation for Health, 2014).
• The Affordable Care Act (ACA) also improved access to health insurance by, among other things, instituting Marketplaces where people could purchase private health insurance and receive premium subsidies to help pay for those plans. Individuals earning between 100 percent and 400 percent of the poverty level qualify for the premium subsidies (Kaiser Family Foundation, 2014a). The amount of the subsidy depends on the person’s annual income. As of April 2014, 166,440 people had bought Missouri health insurance plans on the federal Marketplace—about 62 percent of those eligible  (Kaiser Family Foundation, 2014b).
• The ACA also authorized additional funding for states to expand Medicaid programs to cover adults under the age of 65 with incomes up to 133 percent of the federal poverty limit (National Council on State Legislatures, 2011). States are allowed to decide whether to accept these funds and expand Medicaid. Missouri is one of 19 states (currently) that has not yet expanded Medicaid (Families USA, 2015). As a result, for an adult living in poverty in Missouri, he or she must have a dependent child and earn no more than approximately 18 percent of the poverty level, or roughly $2,900/year for a single mother with two children to qualify for Medicaid (Missouri Foundation for Health, 2014). Childless individuals are not eligible for Medicaid under any income circumstances unless they are disabled or pregnant (Missouri Foundation for Health, 2014).
• This has created a coverage gap. Under the design of the ACA, Medicaid expansion was intended to cover the many individuals making too little to qualify for subsidies on the exchange (those earning between 100 percent and 400 percent of the poverty level) (Missouri Foundation for Health, 2014). In Missouri, though, these individuals qualify for neither Medicaid nor federal subsidies to help with the purchase of  private insurance. That means a family of four earning up to $95,000 a year qualifies for assistance (through the Marketplace). A similar family earning $23,000 does not.
• Studies have shown that children who are eligible for coverage are three times more likely to be enrolled and much more likely to stay enrolled if their parents also have insurance (Schwartz, 2007). Children whose parents are covered are also more likely to receive recommended care (Schwartz, 2007).
• Children with insurance are more likely to have a usual source of care as well as access to preventive care. This means they are more likely to be up-to-date with their immunizations, more likely to receive cost-effective care, and more likely to stay well (Smith, Santoli, Chu, Ochoa, & Rodewald, 2005; Starfield & Shi, 2004).
• One study found that 14 percent of children with insurance and 9 percent of children with public insurance had an unmet health care need, compared to 35 percent of uninsured children (Cohen & Bloom 2004). Among uninsured Black children, 37% have an unmet needs compared to 27% of uninsured White children (Shone, Dick, Klein, Zwanziger, & Szilagyi, 2005).  
• Children with undiagnosed or poorly treated health conditions are more likely to miss school and to struggle when they are there. This was exhibited by Missouri’s Managed Care Plus (MC+) initiatives, which showed that Missouri’s Children’s Health Coverage Program decreased student absences by 39 percent (MU-CFPR, 2003).
• By virtue of being a mainstay in most communities, schools are well-positioned to help expand access to healthcare by bringing “critical, developmentally appropriate services to children and adolescents where they spend most of their waking hours” (Keeton, Soleimanpour, & Brindis, 2012). The school-based health center model is one way of doing so that involves “providing a range of comprehensive services that… vary based on community need and resources. SBHCs possess several common characteristics including location inside or on school grounds, provision of comprehensive services by a multidisciplinary team, and integration with the school community.” (Keeton, et al., 2012). Researchers have found school-based health centers to be effective at meeting the health care needs of disadvantaged children and adolescents—who are more likely to have an unmet mental or physical health need and that are at the greatest risk of not receiving regular check ups (Keeton, et al., 2012; Allison, Crane, Beaty, Davidson, Melinkovich, & Kempe, 2007; Irwin, Adams, Park, & Newacheck, 2009; & Nordin, Solberg, & Parker, 2010).

These findings prompted the Commission to draft several recommendations that call for expanded access to care for children.

To that end, the Commission issues the calls to action below.