Newly minted California Sen. Kamala Harris recently tweeted her warning about the doom to befall her state’s children if the GOP’s health care replacement cuts federal Medicaid spending.
“@KamalaHarris 1 in 2 Californian children depend on Medicaid. This plan’s cuts to Medicaid attacks those who need heath care most. twitter.com/politico/status/835182553183174658 …,” she tweeted last month.
Harris probably didn't expect the hostility and ridicule that erupted in response. Dozens of tweets poured in suggesting that California’s policies are overly generous and expand health care to those who don’t need it, wasting taxpayer money.
"Aren't you horrified that half of the children in CA are that poor," said one. “That is COMPLETELY disgusting that 1 in 2 children depend on Medicaid in CA! What the hell is the matter with you Liberals?!” wrote another.
Was Harris’ tweet correct?
Yes, according to Kaiser Family Foundation data and California health officials, 53.6 percent of California's 9.1 million children are enrolled in Medicaid, which the state brands as Medi-Cal. That's 5.18 million California individuals under age 19, as of November 2016.
Many reasons may account for these numbers. Income thresholds to qualify for Medi-Cal are more lenient than in many other states. Employers may cover fewer families with dependents, or charge more to their employees for covering children. And last May, a new state law allowed children in the country without authorization to receive the same benefits under Medi-Cal as children here legally.
California is far from an overly liberal outlier.
The state does “a reasonably good job covering children, ... and they’ve extended (Medicaid) coverage to undocumented children (implemented in May of 2016) which only a handful of states have done,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University and an expert on Medicaid and children.
“But they’re certainly not at the head of the pack.”
Ten states offer coverage to a larger percentage of children than California does, and 13 states besides California have more than half of their children enrolled in Medicaid, according to two Kaiser foundation tables showing Medicaid enrollees under 19 at a point in time, and the estimated population of all children under 19 in each state.
Those 13 states represent about 38 percent of the nation’s population, and include New York (54.9 percent) and Florida (57.6 percent). Other states, ranging from 51.1 percent to 67.13 percent, are Montana, Oklahoma, Kentucky, Alabama, South Carolina, West Virginia, Arkansas, North Carolina, Mississippi, Louisiana and New Mexico.
What’s more, California isn’t that far above the national average of 46.03 percent. Nationally, 36 million of 78.2 million children in the United States under age 19 were enrolled in Medicaid last November. Texas, with 46.6 percent of its under age 19 population on Medicaid, was above that national average too, as were Pennsylvania (47.83 percent) and Illinois (46.29 percent).
Richard Kronick, who resigned last year as director of the Agency for Health Care Research and Quality and now is on the University of California San Diego family and preventive medicine faculty, acknowledged that California “is among the more generous states in the country on eligibility, but is not the most generous.”
From state to state, rates vary dramatically. Why? As it goes in health care, and as President Donald Trump has discovered, it’s complicated.
Experts offered several reasons.
Those here without papers
One variable is a state’s policy on covering unauthorized migrants with critical medical needs. The Medicaid benefit allows the use of federal funds to cover critically needed “restricted services,” such as dialysis for people with end stage renal disease or emergency care.
But last May, California took a much broader step. It joined four other states and the District of Columbia with a new law, referred to as Senate Bill 75, the Full Scope Medi-Cal for All Children, which expanded eligibility for full Medi-Cal to any child under age 19 in a family earning up to 266 percent of the federal poverty level, regardless of legal status.
Since it began, 120,614 unauthorized children enrolled in “restricted services” have transitioned to full scope coverage, according to the last tally posted Feb. 2, so they could access non-emergency care, surgery and preventive services just like legal Medi-Cal beneficiaries. An additional 56,285 unauthorized children under age 19 were newly enrolled, for a total of 176,899, or 3.5 percent of all California children enrolled in Medi-Cal.
While federal funds may be used only to cover costs for certain “restricted services,” like emergencies and pregnancy-related care, only state funds cover other health care expenses for children here without authorization.
In San Diego County, 8,282 children have been enrolled. Of those, 5,569 were transitioned from restricted benefits programs and 2,713 were new enrollees as of February. Los Angeles County has 66,400 enrollees, Orange County, 13,600 and Riverside, 9,300.
But SB 75 may soon be in the state’s cross hairs if GOP reforms slice federal Medicaid funds to states starting in January. Months after starting to receive services, the state could end the program’s funding.
That program is in extreme jeopardy, said Dr. Ted Mazer, president-elect of the California Medical Association.
“It’s going to be a huge hot button issue if anything close to what’s going through Congress goes through,” Mazer said.
“Because dollars are not going to come from the federal government – the dollars for Medi-Cal already are going to be reduced,” he said. To maintain anywhere near its current Medi-Cal program, the state will obviously look to slash SB 75, he said, even though it has just gotten off the ground.
Dr. Stuart Cohen, a San Diego pediatrician who is chairman of the American Academy of Pediatrics, California, had a similar response.
The money has been helping undocumented children with cancer get followup procedures, medication and continuity of care after emergency cancer surgery, he said.
“I can give you 1,000 reasons why they shouldn’t drop this program, but it goes back to the philosophical differences between the current administration (in Washington) and the other side of the aisle. There are a lot of horrible things happening that are going to affect vulnerable populations, like the elderly, and undocumented kids that are now covered might be one of those. That’s going to be one of the first things to go.”
The state has little choice if it’s facing a loss of billions in federal dollars. “It’s going to have to cut eligibility, benefits or provider payments, so obviously the undocumented will be the first to go.”
Under SB 75’s state funds, unauthorized children can receive surgery for crossed eyes, and prescriptions for glasses to help them see and function better in school, said Dr. David Granet, director of the Ratner Children’s Eye Center of the Shiley Eye Institute at UCSD.
Premature babies in the intensive care unit, whose parents went without prenatal care, often have retinal problems that SB 75 helps pay to fix, he added.
“We watch those children on a weekly and sometimes on a daily basis and intervene with laser surgery … to pre-empt the blinding changes that occur so that they will have a lifetime of sight when they would have been blind otherwise,” Granet said.
State Sen. Ricardo Lara, D-Bell Gardens, was the author of the SB 75. His office did not return calls. Several San Diego County community clinics that have enrolled thousands of unauthorized children in the program also declined to comment.
Other states that cover full medical expenses for unauthorized children are Illinois, Massachusetts, New York, Washington and the District of Columbia.
Employer-paid health plan coverage
Another factor that can account for variations among states in coverage of medical care for children is how many employers cover health benefits, and extend those at a reasonable cost to the employees’ dependents.
For example Utah, with the second lowest percentage of children and teens on Medicaid, 22.7 percent, “has very high rates of employer-sponsored coverage, so Medicaid and CHIP (the companion Children’s Health Insurance Program) fill a much smaller gap there,” said Genevieve Kenney, co-director of the Health Policy Center at the Urban Institute.
Eligibility thresholds
California may be liberal, but not the most liberal, in setting federal poverty thresholds to determine eligibility for children and teens. It is set at 266 percent of the federal poverty level ($53,625.60 for a three-person household with one child).
Kaiser Family Foundation tables show the following eligibility thresholds for children under 19:
New York (405 percent), New Jersey, (355 percent), the District of Columbia (324 percent), Connecticut and New Hampshire (323 percent), Maryland (322 percent), Pennsylvania, (319 percent), Illinois (318 percent), Vermont, Alabama and Washington state, (all 317 percent), Hawaii, (313 percent), Iowa, (307 percent), Wisconsin (306 percent), and Massachusetts, Missouri, New Mexico, Oregon and West Virginia (305 percent) are all higher.
Tricia Brooks, senior fellow at the Center for Children and Families at Georgetown University, said states with highest costs of living, like New York, New Jersey, Connecticut and Washington, D.C., like California, tend to have higher eligibility thresholds.
Outreach and income
Another important distinction is how difficult it is to enroll for medical care and stay enrolled.
Brooks said that 24 states including California offer 12-month “continuous eligibility” for children.
California has been particularly aggressive, “especially at onset of the Affordable Care Act, identifying not just newly eligibles, but also prior eligibles who hadn't applied,” said Mazer, president-elect of the state medical association. “We adopted expansion early, which may have pushed our kids enrollment up.”
Income distribution in a state is also key, Kronick said. “If there are two states with the same eligibility criteria, but one is poor and the other rich, the poor one will have a much higher percentage of children enrolled,” he said.
While California and other states have eligibility thresholds around 260 percent, she said, “the majority of kids (enrolled in Medicaid are in families with) incomes below 200 percent of the federal poverty level,” Kenney said.
