Kids' Use of Medicaid, CHIP Fell During Pandemic, CMS Says

Ken Terry

September 28, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Utilization of children's health services in Medicaid and the Children's Health Insurance Program (CHIP) has declined steeply during the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) revealed in a September 23 news release.

"Because preventative and routine healthcare is crucial to ensuring that children stay healthy, CMS is releasing this preliminary data to raise awareness of the vital services Medicaid and CHIP provides, and is calling on stakeholders to take action to make services more readily available so that we can begin closing the gap in care for children," CMS said.

Between March and May of this year, there were 22% fewer (1.7 million) vaccinations of children up to age 2 years covered by these programs than there were during the same period in 2019, the agency noted.

There were 44% fewer (3.2 million) child screening services provided and 69% fewer (7.6 million) dental services provided. According to a CMS report on the underlying data, 44% fewer (6.9 million) mental health services were provided to the children in Medicaid and CHIP.

Together, the two programs cover about 40 million children, including 75% of those in poverty and 4 in 10 children with special needs, CMS said.

Many primary care offices have been offering telehealth services since the beginning of the pandemic. However, CMS said, "Preliminary data shows that while service delivery via telehealth for children has increased dramatically, it is still not enough to offset this decline in care for vulnerable children."

In addition, many vital health services, including vaccinations, cannot be provided via telehealth, CMS added.

"As a mother, I have witnessed first-hand how important early and regular access to screening and medical care is for children's development," said CMS Administrator Seema Verma in the news release.

"The absence of these vital healthcare services may have lifelong consequences for these vulnerable children, and I call on states, pediatric providers, families, and schools to ensure children catch up on overdue medical, behavioral health, and dental appointments as well as childhood immunizations."

Pediatricians Doing All They Can

Responding to CMS' data release, Sally Goza, MD, president of the American Academy of Pediatrics, told Medscape Medical News that pediatricians are doing all they can to ensure children receive appropriate care.

Goza and colleagues have been concerned about the potential impact of the decline in services since March. "We knew that children were missing out on their well visits and their vaccines, because our volumes — I'm a primary care pediatrician — dropped like 80% overnight.

"We weren't seeing patients in the office; we were doing telehealth visits and talking to them on the phone, but we had a hard time getting them to come in, because everyone was told to stay home."

Although patients started to return in April, she said, "We know that children are missing out on vital care. They're missing vaccines. But they're also missing social, developmental, and emotional guidance and monitoring. I've had parents tell me their children are regressing socially because they aren't around other people.

"And we're seeing horrible mental health outcomes — children have so much anxiety and depression because of isolation. It's making what was already a crisis a bigger crisis."

Vaccination rates are rising but are still substantially down compared with last year, Goza said. "When children miss their vaccinations, they're at risk for those preventable diseases. We could have another measles or whooping cough outbreak. We could have a resurgence of meningitis in our young babies.

"Polio is not eradicated around the world — it's unlikely, but it could come back. Any of these could rear their ugly heads, and we don't need a second outbreak of disease along with COVID."

Vaccine Hesitancy

Part of the problem is that some parents are hesitant to get their children vaccinated. This was already a growing problem before the pandemic, Goza said, but it has gotten worse in recent months.

Pediatricians are doing everything possible to make sure children are vaccinated, she explained. They're reaching out to parents of children who are overdue for shots, and they always ask about vaccines when a child comes in for an acute problem.

Few pediatric offices closed at the peak of the COVID-19 crisis, and most offices are now open and ready to see more patients, she noted.

Pediatric practices have also done many things to assure parents of safety, from separating sick and well patients to cleaning surfaces, eliminating waits in waiting rooms, and even seeing patients in parking lots.

Besides COVID-19 concerns, she said, one reason why some parents aren't bringing children in with regularity is they've been laid off and no longer have health insurance.

In many cases, their children are eligible for Medicaid or CHIP, she pointed out. "We need for those children to be enrolled in those programs so parents feel they can come in and get the care they need."

According to a report by the Kaiser Family Foundation (KFF), around 20 million children live in households where someone has lost a job. Although most of these children are eligible for Medicaid or CHIP, the report said, "some parents may not enroll children in coverage due to challenges completing the application, lack of knowledge or understanding of eligibility, or other reasons."

Medicaid Enrollment Up

In an interview with Medscape Medical News, Rachel Garfield, PhD, vice president at KFF and codirector of its Program on Medicaid and the Uninsured, said that Medicaid and CHIP enrollment has increased slightly in recent months.

"So these declines in utilization [reported by CMS] are happening at a time when enrollment is actually up," she said

The CMS data shows large variations across states in the provision of children's health services in the two programs. Garfield said this probably reflects several factors, including when the pandemic hit a particular state, what actions the state took in response, and the economic impact of the crisis on the state.

"While Medicaid and CHIP are very low-cost coverage, and cost shouldn't be a barrier to coverage, it's possible that parents are facing other economic challenges in their lives that led them to put off, say, dental care for their children. They're more concerned about getting food and housing for their kids."

Garfield attributed the decline in behavioral health care — despite the availability of telehealth — to the lack of therapists in many areas and the relatively low percentage of pediatric offices ready to use telehealth when the pandemic struck.

The federal government has given state Medicaid programs new flexibilities in a number of areas since the public health emergency began, Garfield said. But states are primarily responsible for the direction of their Medicaid programs, she added.

Although all states provided some type of telehealth coverage before the pandemic, many have expanded the services that can be provided through telehealth, as well as who can supply those services, she said. Moreover, some states have authorized Medicaid managed care plans to cover additional services.

To induce more parents to bring their children into doctors' offices for necessary services, Garfield observed, "states could do public information campaigns. But they have a lot on their plates right now."

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