Apr 2, 2024 - Health

Surge in ACA enrollment brings tradeoffs for kids

Illustration of a child wearing a cast that reads "ACA" and including doodles of crosses and hearts

Illustration: Sarah Grillo/Axios

More kids than ever are covered through the Affordable Care Act as the law's insurance markets help catch those affected by the nationwide Medicaid enrollment purge that began a year ago this week.

Why it matters: The transition to the ACA marketplaces from Medicaid or a sister program just for kids comes with tradeoffs that hundreds of thousands of families may be discovering about their child's new coverage.

  • Generally speaking, the coverage may not be as generous and families may have to switch doctors, but they'll have a wider choice of providers.

Context: The ACA marketplace plans historically haven't covered a large proportion of kids because they're eligible for Medicaid at higher income levels than adults.

  • As ACA enrollment surged during this year's sign-up season, the number of kids with marketplace coverage increased to 2.2 million — up by nearly 40% over last year's period, according to a recent Georgetown University analysis.
  • Some are likely among the nearly 3.4 million kids who have lost Medicaid coverage in the year since states were allowed to pare their rolls for the first time since the pandemic, per a KFF tracker.
  • More generous premium subsidies and a 2023 policy that made it less expensive for families with pricey employer insurance to buy ACA coverage have also helped boost marketplace enrollment among kids, said Georgetown research professor Edwin Park.

Between the lines: There are some key differences between Medicaid and marketplace health coverage.

  • For starters, the costs. Medicaid can't charge premiums or impose cost-sharing on kids' coverage, unlike ACA coverage.
  • States have to provide periodic comprehensive screening services to all Medicaid enrollees under age 21, including health education and vision, dental and hearing exams.
  • Marketplace plans also have to cover essential services, but coverage may not be as comprehensive.
  • Kids with complex or chronic conditions in marketplace coverage may face more hurdles to get care paid for than kids in Medicaid because the scope of essential health services isn't as well-defined, the Children's Hospital Association told Axios.

West Virginia pediatrician Lisa Costello said it can be hard for families to figure out the best private insurance plan for their kids.

  • "I always tell parents to think about, 'What am I going to need for my child?' [But] it's hard to predict the future," said Costello, who is the incoming chair of state government affairs for the American Academy of Pediatrics.
  • "That's why Medicaid is really such a great program for kids, because it has a lot of those needed" services, she added.

Yes, but: Private insurance, including ACA plans, usually pays providers better than Medicaid, and ACA plans tend to have larger provider networks. That could mean better access to care.

  • On the other hand, there's very little overlap between providers who take Medicaid and providers who accept ACA plans, meaning families may need to switch doctors if they're moving between the two options, the Robert Wood Johnson Foundation determined last year.

Meanwhile, many of the kids who have lost Medicaid coverage in the past year may still be eligible for the program, since most people were disenrolled for procedural reasons, like not filing the proper paperwork.

  • That means their families won't qualify for ACA subsidies, Park said.
  • "It's obviously welcome that marketplace enrollment among kids is up," Park said. "But it's not solving the problem of a lot of kids losing coverage during unwinding."

Go deeper: States rethink Medicaid enrollment efforts as millions lose coverage

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