By Rose Hoban

Much of the coverage on the health care legislation being debated in Congress has focused on how it would affect adults, in particular, those older people with pre-existing conditions.

But several new studies emphasize what the American Health Care Act would do to children’s coverage.

A new report from Brandeis University’s Heller School of Social Policy and Management finds about 4.7 million school-aged children, including 180,000 in North Carolina, could lose Medicaid coverage under the AHCA.

According to the Congressional Budget Office scoring of the AHCA, the changes in the bill would reduce federal Medicaid support to states by $839 billion over the coming decade. Last year, North Carolina received upward of $8.7 billion in federal Medicaid dollars, about 62 percent of the cost of the state’s $14 billion program.

The legislation recently passed the House of Representatives and is being discussed in the Senate. It would replace Pres. Barack Obama’s signature health law, known as the Affordable Care Act or ACA.

Under the ACA, income eligibility thresholds for children were raised so that more low-income children could qualify for coverage. The eligibility threshold for children between 6-19 years old went from 100 percent of the Federal Poverty Level ($24,600 for a family of four) to 138 percent of the Federal Poverty Level ($33,948 for a family of four).

But under the AHCA, states have the option of dropping that income threshold back down to 100 percent of FPL. According to the Brandeis study, 16.6 percent of North Carolina children would lose their Medicaid eligibility. No matter how the cuts come from the federal government, there will be fewer dollars to go around. How to spread them around will pass to state lawmakers.

Currently, NC Medicaid has about 1,085,000 children.

Trickling off

“A couple of things have happened under the Affordable Care Act to get kids insured that are under-appreciated in the current debate,” said Adam Zolotor, a family physician at UNC Chapel Hill and the head of the North Carolina Institute of Medicine.

He explained that because adults were mandated to get insurance under the ACA, many of them went online or visited insurance navigators to get signed up for coverage. As they purchased insurance for themselves, many parents also learned that their kids were eligible for Medicaid.

“That helped identify about 50,000 to 60,000 kids who are Medicaid eligible but who were not enrolled,” he said. Now, about 96 percent of North Carolina kids are insured, largely because so many of them were identified through this sign-up process.

“If Congress repeals the insurance mandate, those kids will trickle off Medicaid over time,” Zolotor said.

Of the kids who will lose coverage, a little less than half, 87,100 children, will be white, according to the Brandeis analysis. About 52,600 (29.3 percent) of those losing coverage under the AHCA will be black children.

A disproportionately high number of Hispanic children will lose coverage, 40,300 or 16.4 percent of the Hispanic kids getting Medicaid, the report says. Currently, Hispanics make up only 11 percent of North Carolina Medicaid beneficiaries.


“Study after study links access to health care and good quality health care with better outcomes,” said Elizabeth Hudgins, head of the North Carolina Pediatric Society, who called the Congressional bill “very concerning.”

“There’s the assurance of knowing that you can call and get in and see a doctor and get all those visits you need,” she said. “That will go away.”

Hudgins worried that if so many children lose coverage, they won’t get screened for problems such as asthma, diabetes or obesity or they won’t get vaccines.

chart showing the differences in cost between NC medicai and US medicaid.
North Carolina Medicaid spending per capita by enrollment category (2011). Data, table courtesy NC Institute of Medicine

“Vaccines have been proven effective at preventing devastating childhood diseases, and those come with the well-child visits that you get with regular access to the doctor,” she said.

“Access to primary care allows for early identification of problems and to offer early and comprehensive treatment and improve lifelong health,” Zolotor said. “For me, it means that a kid that has an untreated dental problem doesn’t have to go to school with mouth pain or a kid who has asthma can play sports.”

Zolotor’s organization recently published a brief on the AHCA, noting that North Carolina spends about $2,355 per year on a child with Medicaid, below the national average of $2,492 per child. That puts North Carolina’s 30th in the nation in spending on Medicaid for children.

“I say this a lot that about 70 percent of the Medicaid beneficiaries in North Carolina are children,” Hudgins said, noting that number includes healthy children as well as children with disabilities covered by the program.

“When you’re talking about changes to Medicaid, you’re talking about changes that could have a very large impact on children,” she said.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...