By Kelly Pate Dwyer
Just 2.5 percent of Colorado’s children lacked health insurance in 2015—an all-time low and a huge win for families across the state. That’s down from 7 percent in 2013, according to the Colorado Health Institute (CHI).
Children’s health advocates celebrate this progress, and expect more kids to gain coverage following recent policy changes that filled gaps in public insurance coverage, in part by making it easier for some kids to qualify for and stay enrolled in Medicaid.
But for several reasons, researchers and advocates say it will be a steep climb to reach all of the 33,000 remaining uninsured kids.
Complexity, confusion, cost
In some pockets of the state, including parts of the southwest, northwest and resort regions, kids are uninsured at rates as high as 14 percent to 17 percent. However, the largest raw numbers of uninsured kids live in Arapahoe, Denver and El Paso counties.
The reasons some kids lack coverage are many and multi-faceted, explains Emily Johnson, a policy analyst at CHI, a grantee of The Colorado Trust that conducts in-depth surveys and analysis of health access.
In some cases, coverage has lapsed. In others, parents erroneously believe their kids won’t qualify for government-sponsored plans.
“Two out of three uninsured kids in Colorado are eligible for Medicaid or CHP+, but are not enrolled,” Johnson says. (CHP+, or Child Health Plan Plus, is a public insurance program for low-income kids and pregnant women who earn too much to qualify for Medicaid.) She notes that an additional 10 percent of the state’s uninsured kids are eligible for subsidized coverage, through Connect for Health Colorado, the state health insurance exchange.
Still, there are kids lacking insurance for unknown reasons. “When you get down to 2.5 percent, the kids who aren’t insured are harder to find,” Johnson says.
CHI’s 2015 Colorado Health Access Survey (CHAS) reached more than 10,000 adults, who were asked about insurance coverage for them and their families. Among those who said they were uninsured, cost was the most common reason. Others said their employer didn’t offer insurance; they lost their job or changed jobs; they did not know how to get insurance; they did not know which plan to choose; or they did not need insurance. Some also reported they didn’t qualify for insurance based on a pre-existing condition; in fact, the Affordable Care Act bars insurance companies from refusing coverage for this reason.
In Denver Health clinics across the city, community health workers hear many of these reasons from patients, explains Steven Federico, MD, director of general pediatrics at Denver Health. Some parents are confused about their children’s eligibility for certain plans and how to sign up.
“With employer-sponsored insurance, your open enrollment time comes around and you get five emails reminding you. If you don’t sign up, you default to your current plan,” Federico says.
“If you are poor, you may move on a frequent basis and you don’t receive the right paperwork. Communication through cell phones is difficult if you don’t have minutes on your phone. There are language barriers, transportation barriers,” he adds.
It gets more complex: Families of mixed immigration status have different insurance eligibility requirements for different family members. Some undocumented adults don’t realize how and where to sign up their kids who are legal residents, Federico says.
What’s more, some Coloradans go on and off Medicaid as their income fluctuates.
“If you have seasonal income and you come in for [public] health insurance, you may not qualify even though your income the rest of the year is really low,” Federico says.
In October, Colorado started offering Medicaid eligibility to children for 12-month periods, meaning they won’t lose benefits if their families’ income fluctuates within that time span.
“Before that, families would get completely booted off and have to re-enroll, so you were basically chasing your tail,” Federico says.
According to CHI, 3.1 percent of Hispanic kids in Colorado are uninsured, down from 11.3 percent in 2013. However, while Hispanic children comprise 29 percent of the population, they make up 37 percent of the total uninsured.
“In the last decade, we’ve made so much progress based on policy changes, but we are still struggling with these disparities,” says Chris Watney, president and CEO of Colorado Children’s Campaign, a Trust grantee that advocates for children’s health and economic security.
Among the uninsured Latino children are undocumented immigrants. This group comprises about 14 percent, or 4,600, of all uninsured kids.
Under current laws, undocumented immigrants cannot receive public insurance or buy subsidized health care plans on the state exchange. While their families can purchase some private health plans, high costs are a common barrier. And while eligible for emergency Medicaid and care in some community health centers, some undocumented residents fear that they will encounter legal difficulties if they seek care.
Using its own research and 2012 data from the Pew Hispanic Center, CHI estimates about 41 percent of undocumented Coloradans had some form of insurance in 2014, most of them covered by employer-based plans, student plans through a college or university, or privately purchased plans.
For those private plans, “paying the full cost, which could easily be more than $100 a month to cover a single child with basic coverage, could be out of reach for some families,” says Erin Miller, vice president of health initiatives for Colorado Children’s Campaign, referring to some inexpensive Kaiser Permanente plans with deductibles of $5,000 or more.
Coverage does not equal access
CHI policy analyst Natalie Triedman points out that the statistics on uninsured kids don’t paint a complete picture of who is or isn’t receiving care. Some insured kids aren’t accessing needed health care services—due to barriers such as transportation and parents’ work schedules—while some uninsured kids are receiving care.
The 2015 CHAS survey showed that 13.8 percent of Colorado kids are “underinsured,” meaning their families spend more than 10 percent of their income on out-of-pocket medical expenses.
These numbers have been increasing with the expansion of Medicaid and CHP+, and the introduction of individual commercial plans with low premiums and high deductibles. Of the latter plans, Federico notes they discourage some people from seeking care, including preventive care for their kids.
Building trust at school
Among uninsured kids, many receive pediatric, dental and mental health services through safety-net clinics, including those in school settings, Triedman says. In 2015, one in five, or 6,900, Colorado kids served by school-based clinics were uninsured.
Federico oversees 17 school-based Denver Health clinics located in Denver Public Schools (DPS), serving 12,000 students across the district.
The clinics only provide care for DPS students, but they’ve become a hub for reaching students’ siblings and parents, many of whom are referred to one of Denver Health’s eight community health clinics. Community health workers in the school clinics coach families about what insurance plans they may qualify for and help them navigate the enrollment process.
“We are not just enrolling the kids but the entire family,” Federico says. “They trust people in the schools with sensitive information.”
Gains expected to continue
While the 2.5 percent uninsured rate for Colorado children may never make it all the way to zero, odds of it coming close are promising. Industry watchers expect further gains in coverage in the coming years, following various policy changes, particularly Medicaid expansion.
“What we find among all populations is that kids are more likely to have coverage when their parents do,” Miller says.
In 2015, Colorado initiated some policy changes expected to further increase coverage among children. A five-year waiting period for some legal immigrants was eliminated, meaning that children or pregnant women who qualify for Medicaid or CHP+ coverage can now access those services immediately. This, along with the new 12-month eligibility rules for Medicaid, are expected to fill some gaps in coverage.
Federico credits All Kids Covered, a local coalition dedicated to expanding health care coverage for kids, with driving much of the recent coverage gains. The group works both at the ground level, streamlining education and enrollment processes, as well as the policy level.
“Face-to-face visits are crucial,” Federico says. “People may enroll through the exchange one year and CHP+ the next, and it’s a completely different ball game. Those changes are confusing.
“We need to make sure we are there for families through that transition.”