For part two of an ongoing series, we're once again looking at the numbers of U.S. children enrolled in the federal government's Children's Health Insurance Program (CHIP). As I discussed in my last blog post, several U.S. states have either widened eligibility for CHIP, or are considering doing so now that the federal Covid emergency has ended.

As a recap, in the spring of 2023, a process called "Medicaid unwinding" took place where people were once again eligible to lose their Medicaid coverage based on changes in their life circumstances. To soften the blow of that unwinding, several states agreed to expand Medicaid eligibility to include more children.

Despite this, however, the unwinding has led to millions of people losing Medicaid coverage. This issue has drawn national headlines, such as this recent NBC News story that focused on large numbers of people losing their Medicaid coverage in Colorado. What the story leaves out is that Colorado has taken steps to correct this, which we'll get to in a minute.

According to Medicaid data, the numbers of children enrolled in Medicaid through Colorado's CHIP program have been on a steady decline ever since they hit a high of 652,517 enrollees in February of 2023. This is the month before the Consolidated Appropriations Act of 2023 decoupled the Medicaid continuous enrollment provision from the Covid-19 public health emergency (PHE) on March 31, 2023 and resumed Medicaid disenrollments.

Currently, CHIP enrollments in Colorado are at 520,641. Here is a graph that shows the overall decline in the state up until August of 2024, the last month for which data is available:

Data courtesy of Data.Medicaid.gov

To combat these declining numbers, Colorado's Department of Health Care Policy & Financing (HCPF) recently announced that it will be extending its CHP+ coverage eligibility for children. According to the department's press release detailing the particulars of the expansion, "The policy will support continuous coverage for children from birth to age three who are eligible for Health First Colorado (Colorado’s Medicaid program) or Children’s Health Insurance program (CHP+). This expands continuous coverage for young children to 36 months, rather than the current continuous coverage of 12 months."

The change was made possible by an amendment to a Medicaid section 1115 demonstration waiver. "Through this amendment," the press release states, "HCPF expects to prevent coverage gaps for an average of 31,000 children over a 5-year demonstration period." The program goes into operation on January 1, 2026, so it will likely be a while before we see CHIP enrollment numbers start improving in the state.

Colorado is one of 41 states and the District of Columbia that have expanded Medicaid. While 10 states have elected not to increase access to this safety net program, some (like Kansas) are still debating expansion. In our last blog post, we highlighted enrollment numbers in the expansion states of Maine and Arizona, a blue and swing state, respectively; for the remainder of this post, we'll zoom in on expanded enrollment in two reliably conservative states, namely North Dakota and Kansas.

Updated numbers from CMS for August 2024 CHIP enrollment were released at the end of November, so those are the numbers we'll use. As a quick reminder, there is a lag of several months in the data, so we won't be able to get up-to-the-minute numbers. That being said, let's dive in and look at the circumstances surrounding North Dakota's Medicaid expansion, how it stacks up against those of Maine and Arizona, and how the state's enrollment numbers performed through August of 2024.

As stated in our previous blog post, we chose to include North Dakota and Kansas in the mix because North Dakota is a solidly conservative state while Kansas, which is overall a conservative state, is still home to an interesting combination of conservative and liberal tendencies. Together with Maine (liberal) and Arizona (swing state), these four states constitute a spectrum of political leanings.

According to the North Dakota Health & Human Services website, "CHIP is intended to meet the needs of working families, who cannot afford health care coverage for their children, yet earn too much to qualify for Medicaid."

"To qualify," the website continues, "a family's Modified Adjusted Gross income (MAGI) must be greater than the Medicaid level, but cannot exceed 205% of the federal poverty level." This seems to be a stable benchmark that hasn't changed much in recent years.

Medicaid expansion was first enacted in North Dakota in 2014 as a result of the Affordable Care Act. While Medicaid expanded again in North Dakota as of April 1, 2024 for "individuals between 19-64 with household incomes up to 138% of the federal poverty level (FPL)," the CHIP component of the state's Medicaid program doesn't seem to have been affected.

So although North Dakota qualifies as a Medicaid expansion state, not much work seems to have been done in opening up healthcare access to more children in the state. But it's still worth asking: now that more adults are eligible for Medicaid there, might that also mean that increased awareness around enhanced Medicaid availability will prompt those adults who earn too much to qualify for Medicaid but who also still need help insuring their children to seek out insurance under the state's CHIP program?

I'm not sure how many residents fall into this category, so the premise of the question might be a long shot. But we're all about long shots here at Dragon Tree, so let's dig into the numbers and find out. First, here is a graph that looks at CHIP enrollment numbers between early 2023 and August of 2024.

Data courtesy of Data.Medicaid.gov

As you can see, CHIP enrollment is down year-over-year in the state, having declined 17.2% since the unwinding began in April of 2023. An interesting data point reported by the Kaiser Family Foundation that undercuts my premise stated above is that​, "During the unwinding of the Medicaid continuous enrollment provision, over 25 million people were disenrolled and over 56 million had their coverage renewed. Overall, 31% of people whose coverage was redetermined during the unwinding were disenrolled, but that share ranged widely across states."

Given that 45% of people were disenrolled from the state-run Medicaid program during the unwinding, that puts North Dakota in the upper fourth of states. So, although Medicaid eligibility criteria have become marginally more generous in North Dakota since the spring of 2023, not only have overall Medicaid enrollment numbers gone down, but there's also been a similar – although less drastic – downward trend of children enrolling in the CHIP program in the state.

Expansion of Medicaid is still only an aspiration of some lawmakers in Kansas. Still, it's worth establishing a baseline understanding of where CHIP enrollments stand so that, in the event the state does expand Medicaid eligibility in the near future, we can track its progress more effectively.

Let's start by looking at current qualifications for CHIP enrollment in Kansas. The Division of Health Care Finance (DHCF) is responsible for purchasing health services for children through CHIP. According to the DHCF website, "Kansas provides low-cost health insurance coverage to children who are under the age of 19, do not qualify for Medicaid, have family incomes under 232% of the federal poverty level, and are not covered by private health insurance."

That means that CHIP enrollment eligibility in Kansas is more generous than in North Dakota and is on par with Arizona, where annual family income limits will soon be 225% of the federal poverty level (FPL). It isn't, however, as generous as Maine, which sets limits on household income at 300% of the FPL.

Next, let's look at CHIP enrollment numbers over the past couple of years in Kansas. Like the other states on our list, there was a drop in enrollment in March of 2023 from which the state hasn't yet bounced back:

Data courtesy of Data.Medicaid.gov