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A total of 4.16 million fewer children were enrolled in Medicaid or the Children's Health Insurance Program (CHIP) at the end of last year compared with the month before each state began its Medicaid and CHIP "unwinding" process, from Georgetown University's Center for Children and Families found.

Although some children have undoubtedly moved to other types of insurance -- such as the Affordable Care Act marketplaces or employer-sponsored coverage -- dependent coverage is hard to come by for low-wage workers, Joan Alker, MPhil, the center's executive director, said Thursday on a call with reporters. Data that are available show new enrollment of children in the Affordable Care Act's subsidized health insurance marketplaces or other types of coverage appears to be offsetting only a "modest share" of the net decline in Medicaid/CHIP enrollment, she said.

"These are reasons to worry that children in states with high numbers or rates of Medicaid decline are going uninsured for some period of time," she said. "These states should make efforts to reach out to families with trusted community partners and resources to re-enroll eligible children, and consider systems reforms to make the process go more smoothly."

During the COVID-19 public health emergency, states were barred from disenrolling Medicaid and CHIP beneficiaries. But when the public health emergency began winding down last year, states were allowed to begin the disenrollment process -- also known as "unwinding" -- on April 1, 2023.

The center used data from CMS to analyze child enrollment in Medicaid and CHIP by state; all states and the District of Columbia are required to report monthly enrollment data to the agency. The data show changes in net Medicaid and CHIP child enrollment, taking into account any enrollment declines, such as from Medicaid unwinding, offset by any enrollment increases.

In addition to the overall number, the report also found that:

• Texas, Florida, Georgia, and California saw the largest numeric declines in Medicaid/CHIP child enrollment, accounting for half of the total national decline, the researchers said. Texas alone accounted for more than 1 million of the total decline in children enrolled in Medicaid/CHIP, followed by Florida with nearly 600,000, Georgia with more than 300,000, and California with nearly 200,000.
• South Dakota, Montana, and Utah saw the largest percentage declines in their child Medicaid/CHIP population, with 25% fewer children enrolled in Medicaid/CHIP than prior to the initiation of the unwinding process in each state in 2023.
• Eight states -- Montana, Idaho, South Dakota, Arkansas, New Hampshire, Utah, Alaska, and Colorado -- disenrolled so many children in 2023 that they had fewer children enrolled at the end of the year than prior to the pandemic in early 2020. "This is a troubling finding, given that all but one of these states had relatively low participation rates of eligible children covered by Medicaid/CHIP prior to the pandemic -- suggesting that red tape barriers are likely resulting in high rates of children becoming uninsured," the authors wrote. "Montana's child enrollment is already 15% lower than pre-pandemic -- a very troubling distinction."

Why have children been disenrolled? "Either because they've become ineligible for Medicaid ... or because they lost Medicaid for procedural reasons," said Alker. "It's estimated by federal researchers that three-quarters of children who will or have lost Medicaid during the unwinding will remain eligible for Medicaid but are losing coverage for procedural or 'red tape' reasons. Nationwide, a shockingly high 70% of people losing Medicaid are doing so for procedural reasons."

"This means the renewal process has broken down in some way," she said. "Perhaps the renewal letter got lost in the mail, or the family has trouble completing the paperwork, or the state's computer system is not [functioning] correctly, or the notices the state sends are too complicated to understand."

Pediatricians are seeing the "painfully visible" effects of these disenrollments firsthand, Kimberly Avila Edwards, MD, a pediatrician from Austin, Texas and a member of the American Academy of Pediatrics Committee on Federal Government Affairs, said on the call. "Babies are missing well visits and children are losing vital home health services and are unable to seek needed [care from] specialists."

"Parents are checking in for their child's appointment, only to learn that their child is no longer covered" due to a paperwork issue, she said. "These situations are all avoidable but they are now the daily reality in pediatric offices across the country. Patients who experience gaps in coverage are more likely to have delayed medical care, unmet medical and mental health needs, and unfilled prescriptions ... Too often this exacerbates medical issues and can force families into situations where they must decide whether to pay for out-of-pocket emergency care at the expense of groceries, rent, and other necessities."

"We cannot allow millions of our children to fall through the cracks. We must do better," she said.

In the meantime, Edwards said, she is advising parents whose children have been disenrolled to "Please be proactive -- if you receive a notice, act quickly and respond in the timeframe provided ... Secondly, [we're] asking them to seek assistance from community health centers or patient advocates, and contact their local Medicaid agency."

The Georgetown report was released on the same day as a from the Urban Institute -- one that also included adult disenrollments -- which found that children were disenrolled at higher rates than adults. Nationally, disenrollments for children reached 84.2% of projections, and disenrollments exceeded total projections in 12 states. In addition, seven states exceeded their expected disenrollment of adults.

"Certain states disenrolled more people from Medicaid in 8 months than we projected would be disenrolled over the full course of the unwinding," said Matthew Buettgens, PhD, senior fellow at the Urban Institute, said in a statement. "This suggests that many eligible people may be among those losing Medicaid and CHIP in some states and raises the possibility that this problem may increase as the unwinding continues."

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