Before the onset of the coronavirus pandemic in February 2020, there were 71 million people enrolled in Medicaid and Children’s Health Insurance Program (CHIP). Now, with the expiration of the national Covid-19 Public Health Emergency (PHE) in May 2023, millions have faced the loss of their Medicaid and CHIP coverage during the eligibility renewal process known as Medicaid redetermination that reevaluated household incomes and healthcare benefits. This transition has significantly altered the healthcare landscape at both the federal and state level.
For a closer look at the numbers and how we got here, we must review enrollment at its height. National Medicaid and CHIP enrollment peaked at 94.5 million people in April 2023, the month prior to the end of continuous enrollment, which was an increase of 23.1 million enrollees or 32.4% from February 2020. From February 2020 to April 2023, enrollment among adults grew by 45% while child enrollment increased by a more modest 20%.
As of June 2024, 79.9 million people nationwide are enrolled in Medicaid and CHIP plans, with children making up nearly half (47%) of the total enrollment. Between May and June of 2024, Medicaid and CHIP enrollment decreased by 17%. One contributing factor may be the new federal rule that went into effect in June, which requires states to seamlessly transition enrollees between Medicaid and CHIP when their eligibility changes. Although a portion of the children who lost coverage are likely eligible for CHIP, they may have slipped through the cracks due to paperwork issues or some states’ failure to automatically transfer enrollees between the programs.
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From a state perspective, most concluded the redetermination process with higher total Medicaid and CHIP enrollment than they began with in February 2020, including seven states where enrollment levels were at least 30% higher. In stark contrast, Texas, Florida, Georgia, and California saw the largest number of decreases in Medicaid and CHIP child enrollment, accounting for half of the total national decline. Texas alone accounted for more than one million of the total decrease in children enrolled in Medicaid/CHIP followed by Florida (nearly 600,000), Georgia (more than 300,000) and California (nearly 200,000).
With the redetermination process largely completed, Centers for Medicare & Medicaid Services (CMS) has raised concerns about significant disenrollment during the unwinding, especially critical for children.
Consequences for oral health
In the U.S., 38% of children ages zero-18 have dental benefits through Medicaid or CHIP. Unlike adult coverage, states are mandated to provide dental benefits to children covered by Medicaid and CHIP. At a minimum, Medicaid requires the benefits to include dental services for the relief of pain and infections, restoration of teeth, and maintenance of dental health.
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For those families with income just above Medicaid requirements, children rely on CHIP coverage to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions. Medicaid and CHIP facilitate necessary access to oral health services, which helps to bridge the gap in dental care for children from low- and moderate-income families. By providing coverage, it ensures that socioeconomic status does not hinder a child’s ability to receive necessary dental services.
The federal government has taken note of the importance of oral health and its influence on physical health and has set new mandates. Starting in 2024, states are required to report the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP. Measures include those related to oral exams, fluoride application, and dental sealants.
In September 2024, CMS also released comprehensive guidance to support states in ensuring the 38 million children with Medicaid and CHIP coverage – nearly half of the children in this country – receive the full range of healthcare services they need. This guidance, Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), requires “eligible children and youth are entitled to a comprehensive array of prevention, diagnostic, and treatment services – including well-child visits, mental health services, dental, vision, and hearing services. These requirements are designed to ensure that children receive medically necessary healthcare services early, so that health problems are averted or diagnosed and treated as early as possible. Because of the EPSDT requirements, Medicaid provides some of the most comprehensive health coverage in the country for children and youth.”
This is the most comprehensive EPSDT guidance that CMS has released in a decade, and I applaud the agency’s action.
What’s at stake for children
Healthcare coverage in America is an evolving landscape, specifically during an election year. Nevertheless, we must remember what is at the heart of this issue- children’s health.
CMS has acknowledged that poor oral health can have a detrimental effect on children’s quality of life, their performance at school, and their success later in life. Yet, shockingly, it has been found that about half of all American children do not receive regular dental care. Even worse, only 18% of dentists treat 100 plus children with Medicaid coverage annually, while 67% treat none.
Over the past two decades, social determinants of health (SDOH) such as socioeconomic status and race have been recognized as significant contributors to oral diseases in children. About half of all American children do not receive regular dental care due to certain SDOH. Children from vulnerable populations have less access to oral health care and generally experience more dental caries. And for children with special needs, the progress in access to dental care has lagged, in part due to the challenges faced by dental professionals without the in-depth training required to treat patients with complex conditions.
Children’s health is a bipartisan issue, and we must make a call to action for all states to further Medicaid and CHIP resources for children, especially dental care. By expanding access to dental services, promoting continuity of care, reducing disparities, and enabling cost-effective prevention, we can contribute to the well-being and overall development of these vulnerable children.
To foster a nation of happy, healthy smiles, it is essential to treat and fund oral health on par with physical health. Ensuring access to proper oral care is crucial in dismantling the barriers to coverage that persist nationwide, particularly in marginalized communities where the need is greatest.
Photo: Tom Werner, Getty Images
Bryan Carey is the CEO of Benevis, a leading dental healthcare delivery organization for practices focused on delivering life-changing oral care and orthodontics to underserved communities. He has spent over 20 years improving and streamlining healthcare services for both providers and patients, ultimately making healthcare more equitable and accessible to those who need it most. Carey has an Applied Baccalaureate Degree in Economics from Georgetown University and an MBA from The Wharton School.
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