An Excerpt: “Children’s Health and Well-Being: Recommendations for a Post-Pandemic World”
By Chenyu Lin and Julie Woodman Ph.D.
Chenyu Lin is a 2021 recipient of the Center for Public Justice’s Hatfield Prize. Lin (Colorado Christian University ‘23) and faculty advisor Julie Woodman, Ph.D., detail how COVID-19 exacerbated racial and socioeconomic disparities in children’s health and underscore the importance of strengthening policies like the Children’s Health Insurance Program (CHIP) to ensure that all children have the opportunity to thrive.
DISCOVER
In December 2019, a novel coronavirus emerged in Wuhan, China. Americans watched, first with curiosity and then with terror, as the coronavirus spread across borders and crept into new countries, finally arriving in the United States in early 2020. Throughout 2020, scientists learned the coronavirus did not discriminate in who it infected, though many predispositions, both physical and socioeconomic, made some more vulnerable to this deadly viral infection. At the time of writing this report, COVID-19 has claimed the lives of over 600,000 people in the U.S. and even more worldwide.
COVID-19 triggered dual health and economic crises that impacted nearly every sector of society. To slow the spread of the coronavirus, many businesses closed, schools transitioned to remote learning, and many workplaces transitioned to remote work. Essential workers like grocery store employees, child care providers, and transit operators had to make the difficult decision to risk infection or lose their jobs. Millions of Americans lost their jobs, which meant that many were living in a pandemic with no health insurance.
At the nexus of every sector experiencing drastic changes due to COVID-19 was the family. While the impacts of COVID-19 on family life are vast, this report will focus on children’s health, which is necessarily bound to family health and well-being. Good physical and mental health — and access to health care to meet these needs — is essential to family flourishing. COVID-19 strained every family in a myriad of ways, but low-income families experienced disproportionate health and economic impacts.
Though children are less likely to suffer severe symptoms of COVID-19, the conditions children adapted to as society attempted to mitigate the effects of the pandemic had far-reaching effects on their health. Many children worried about their parents or grandparents becoming ill and suffered the loss of the community and safety of their school environment. Furthermore, in many cases, children’s health slipped under the radar as developmental screenings, routine vaccinations, and other preventative measures also halted. These effects were exacerbated in families that were already or newly under-resourced. Racial and socioeconomic disparities in children’s health were present before the pandemic but worsened through the trials of 2020 and 2021.
While there are various definitions and indicators of childhood well-being, this report defines childhood well-being as the areas of behavioral, physical, cognitive, and social health that provide a child (defined as ages 0-19) with safety and contentment. An indicator of child wellbeing is the achievement of optimal health, which considers the areas previously listed. Childhood well-being therefore relies heavily on the idea that one’s basic needs are met.2 While there are many factors that contribute to the holistic well-being of a child, this report focuses largely on physical and mental health.
The American Academy of Pediatrics recommends all children and young adults ages 0 – 19 receive annual health checkups and more specific treatments as needed (e.g., getting glasses for poor eyesight). Young children, ages 11 and under, benefit from preventive services such as vaccinations against infectious disease and routine dental care as well as age-appropriate developmental screenings. Older children, 12 and up, have the added need for mental health care and public health education. The unique needs that accompany maternal health should also be considered as a component of child well-being, as the health of a mother during pregnancy can have lifelong effects on the child. Preventative care, primary care, and emergency medical services are fundamental to children’s health. While these services are essential, they are often contingent upon a family’s access to health insurance. Health insurance plays an important role in a family’s safety and stability. Children rely upon their parents or legal guardian to make critical health care decisions and to secure adequate health care to meet their basic needs; studies show that children are more likely to obtain health insurance if their parents have also obtained health insurance.
Child Health and Well-Being Before the Pandemic
Well before the pandemic, millions of children did not have access to consistent and routine health care. In 2019, an estimated 4.4 million children did not have health care coverage, putting these children and their families in an economically and medically vulnerable position. Lack of health insurance can be attributed to a variety of causes, including financial hardship and limited knowledge about insurance programs. Within this uninsured population, low-income children of color were disproportionately represented. Nine percent of Hispanic children, 14 percent of American Indian children, and five percent of Black children lacked health insurance, as compared to four percent of white children. Disproportionate rates of health care coverage contribute to health disparities, defined by the Centers for Disease Control and Prevention as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”
Even for families who have health insurance, a child’s well-being can be compromised if the insurance is inadequate. An example of inadequate health insurance is having a medical bill from a treatment — like chemotherapy for children with cancer — that results in medical debt, financial stress, and/ or the postponement of treatment because of cost. A study by the Journal of Public Health Research found that older children were more at risk for inadequate coverage than younger children. Meanwhile, Hispanic and Black children were more likely to experience inconsistent coverage, which is measured by the maintenance of coverage within the last year without any periods of being uninsured. According to the National Research Council, children of color typically receive a less diverse range of procedures, from basic checkups to high-technology interventions, when compared to white children. Additionally, these groups are more likely to be readmitted into a hospital with post-procedure complications.
In the United States, the quality and accessibility of health services widely varies. Some families access health care through public insurance programs like Medicaid, a program for low-income Americans. Other families access health care through their employers or by purchasing a private health insurance plan. Many families, however, fall in the gap of public and private health insurance options. These families, who often have incomes high enough to disqualify them from Medicaid but cannot afford private health insurance, are often overlooked.
Child Health and Well-Being During the Pandemic
The circumstances that had already threatened child well-being prior to 2020 were exacerbated when COVID-19 arrived in the United States. Pandemic-related stress and fear emerged, and children and families faced unprecedented circumstances including, in many cases, a loss of in-person schooling, child care, health insurance, and family income.
“COVID-19 strained every family in a myriad of ways, but low-income families experienced disproportionate health and economic impacts. ”
Child well-being was also impacted by the loss of adequate health care services. While research that specifically focuses on child health insurance coverage during the pandemic is scarce, health coverage in households with children has been recorded. In the fall of 2020, one in eight households (12 percent) with children lacked health insurance, as opposed to 5.7 percent from the previous year. Even in households that maintained adequate health insurance during the tribulations of 2020, many children still experienced deficits in health care due to a loss of preventative services. Widespread fear of the coronavirus impacted many parents’ decisions to delay preventative and ongoing care for children to avoid risk of exposure at doctors’ offices. Some patient services were also cancelled or delayed as doctors’ offices had to change their protocols due to fewer personnel, lack of medical equipment like PPE, and new COVID-19 restrictions like social distancing. Reports show that the “rate of vaccinations, child screenings, dental services, and outpatient mental health services” sharply declined as the country battled COVID-19.
Some services, like non-emergent surgeries and maternal health services, became more difficult to access with limited capacities and social distancing guidelines. Health care workers from unrelated departments were transferred to COVID-19 units out of necessity. In addition, routine immunization campaigns were temporarily paused, and the impacts were seen in every city in the United States, including New York City where vaccinations of children over two years of age dropped by 91 percent. New or exacerbated financial hardship due to job loss and illnesses associated with COVID-19 left families with children worried about the cost of treatment and preventative care. In 2020, more than one-third (34 percent) of families with children reported they delayed seeking medical care due to fears of viral exposure.
Millions of children and parents experienced a variety of emotions, from fear and uncertainty to loneliness and exasperation. Grief was prevalent in many families, whether from a loss of normalcy or loss of loved ones. Parental stress and shared fear translated to unique mental health needs for children. Feelings of hopelessness and depression were reported in one out of five (21 percent) people who lived in households with children. Early research even showed increases in younger children who struggled with irritability, fear, and separation anxiety. Compared to 2019, the rate of mental health emergencies in 2020 increased by 24 percent for children aged 5-11 and 31 percent for children aged 12-17. While some parents sought treatment for their children at the onset of mental health issues, many children’s symptoms went untreated due to inadequate health care services.
School closures were another contributing factor that increased children’s health care disparities. A Kaiser Family Foundation poll found that 67 percent of parents were concerned for the well-being of their children, including their emotional and social health, due to school closures. Since children often received free mental health services through school screenings, school counseling, and school-based clinics, the services became less available when schools closed. The closure of schools was accompanied by decreases in activities that promote physical health such as sports and clubs. Not all schools, however, continued with remote learning during the 2020-2021 school year. According to a survey from the National Association of Independent Schools, only five percent of private schools were virtual in the fall of 2020. In comparison, more than 50 percent of public elementary and high school students attended virtually in the fall of 2020. The children attending in-person schools had greater access to the tools and benefits offered by the institutions. This dichotomy magnified a key disadvantage of low-income neighborhoods that relied on public schooling for critical resources for child well-being. Further, it is important to note that homeschooled children also experienced disruptions in their communities as co-ops, in-person learning groups, and other extracurricular activities were canceled or became virtual during the pandemic.
What’s at Stake?
Poor child health outcomes — changes in health that are measured through health interventions and treatments — before and especially as a result of COVID-19-related pressures, have immediate as well as long-lasting effects. Child health begins with maternal health. Poor maternal health during pregnancy can lead to developmental disorders, prematurity, and an increased risk for infant mortality. Children without health insurance coverage are less likely to receive preventative services like immunizations, dental care, and wellness checkups. They are also less likely to receive treatment for chronic conditions like asthma. Chronic illness that goes undiagnosed is exacerbated when screening is inadequate. Anxiety and behavioral disorders go unchecked, making it difficult for children to learn in school. Poor health leads to increased school absences, which decreases the quality and consistency of a child’s education. When children fail to finish high school due to health issues, they are more likely to become incarcerated, unemployed, and teenage parents. These effects cause social and economic strain in the United States as poor or absent schooling reduces educational attainment and economic opportunities later in life. Furthermore, such health disparities accompany a decreased life expectancy. A Missouri case study highlights these poor health outcomes. Predominately white residents in a neighborhood whose median household income is $103,000 maintain a life expectancy of 83 years old. Only three miles away in a predominately Black neighborhood, the median household income is $30,500 with a life expectancy of 70 years of age. These economic disparities, compounded by potential medical bills and poor health, can lead to paralyzing debt. During a child’s medical emergency or even routine care, a family without adequate health insurance must worry not only about their child, but also the financial debt that may come with the treatment.
The Role of the Children’s Health Insurance Program
For many families living at the financial margins, a variety of economic or social factors make it difficult for children to receive adequate health care services. The social safety net, then, becomes essential to promoting child and family well-being and contributes to mitigating disparities in children’s health. The institutions that comprise the social safety net — government, community and faith-based organizations; houses of worship; and businesses — aim to support individuals and families by providing for basic needs during a period of economic hardship.
“In 2019, an estimated 4.4 million children did not have health care coverage”
One of the federal government’s primary programs for promoting children’s health and well-being is the Children’s Health Insurance Program (CHIP), which provides health coverage to children in families with low to moderate incomes who do not qualify for Medicaid. CHIP serves 9.6 million children and 370,000 pregnant women in the United States annually0 Administered by the United States Department of Health and Human Services, CHIP is a state-federal partnership that provides coverage for dental care, vaccinations, well-baby and well-child care (visits to a health care provider that checks on the child’s growth, development, and general health), behavioral health care, inpatient and outpatient hospital services, laboratory and x-ray services, and physicians’ medical and surgical services. Additional benefits, which vary by state, include hearing services, prescription drug coverage, vision services, and mental health services. Enrollment fees for CHIP are determined by the state office administering CHIP and a family’s income. Once enrolled, an enrollment card gives access to the services and benefits that CHIP provides. Some states charge a monthly premium, but it is never more than five percent of the family’s income for that year. Similarly, copayments for utilizing services depend on the family’s income. Every state allows for annual checkups and developmental screenings that are free with CHIP coverage.
To be eligible, a child must be under 19 years of age, uninsured, a resident of the state in which they are receiving CHIP, a citizen or meet immigration standards, and live in a household that falls within the state’s CHIP income eligibility range. A child is ineligible if he or she is an inmate of a public institution such as a prison or a community residence center, a patient of a mental health institution, or eligible for coverage through a family member’s employment. Individual states also create their own eligibility standards following federal guidelines. Most states provide CHIP coverage for household incomes up to or above 200 percent of the federal poverty level (FPL). To obtain pregnancy related coverage, a woman’s income must be equal to or greater than the income limits of Medicaid. States can provide Medicaid coverage to pregnant women with household incomes up to at least 185 percent of the FPL. Currently, pregnant women are eligible for CHIP coverage in 20 states.
The program is administered by states in one of three ways. Some states administer CHIP through a Medicaid expansion. Under this design, the state receives federal funding to expand Medicaid eligibility to include low to moderate-income children. Other states have a standalone CHIP program that receives federal funding to provide health coverage for uninsured, low to moderate-income children. The third option is a combination of these two options, where states receive funding to execute both a Medicaid expansion and a separate CHIP. The majority of states (40) administer CHIP by incorporating the third option. In Texas, for example, Medicaid was expanded to include children in low-income families. If the child’s household income is too high to qualify for Medicaid, but the family cannot afford private health insurance, the child can then be enrolled in CHIP.
CHIP was enacted through The Balanced Budget Act of 1997 to address the health insurance gap experienced by families who did not qualify for Medicaid but who also could not afford private health insurance. The program has gone through a series of reauthorizations since its inception, the most recent of which was in January 2018 when Congress passed the HEALTHY KIDS Act as part of a continuing resolution, which provided an extension of CHIP through 2023. Congress extended CHIP for an additional four years through fiscal year 2027 when it passed the Bipartisan Budget Act of 2018, after the Congressional Budget Office published a report that said a 10-year extension would save the United States six billion dollars as the services offered through CHIP were at a lower cost than the alternatives through Medicaid, employment-based insurance, or subsidized coverage.
Though CHIP aims to alleviate health care disparities among children, it has not always decreased the barriers in obtaining health coverage. Between 2017 and 2018, there was an increase in the uninsured rate that was driven by a decrease in Medicaid and CHIP enrollment, indicating that more individuals failed to obtain health insurance. While this decreased enrollment could be indicative of an improved economy — and therefore households obtaining private insurance — the Kaiser Family Foundation suggests instead that eligibility hurdles for enrollment were to blame. Many families experienced difficulties associated with navigating the formal process and providing accurate documentation. This data indicates that not all families who are eligible for CHIP are enrolled in the program. When a CHIP-eligible family does not obtain CHIP coverage, the uninsured 33 children miss out on services that are imperative for optimal health. This failure to secure coverage became significantly more problematic for families as they entered into a pandemic where medical care became more difficult to access and services that may have otherwise been offered through schools became unavailable.
The pandemic resulted in an unemployment rate that peaked at 14.8 percent in April 2020. As a result, there was a sharp increase in the need for health coverage and services, which by extension meant an increase in Medicaid and CHIP enrollment. This increase occurred as many households lost health insurance when a parent lost a job in which health insurance was managed by an employer. Some states expanded CHIP eligibility to meet the unprecedented need caused by COVID-19. Specific changes included the elimination or waiving of premiums, eligibility expansions, and a more streamlined enrollment process. The new enrollment process allowed presumptive eligibility, which empowered local community health centers to enroll people who they deemed eligible. Additionally, some states adopted a simplified application process. Other states permitted continued eligibility coverage for children already enrolled. Between February and June 2020, Medicaid enrollment increased by 6.2 percent, and CHIP enrollment increased by 0.5 percent (23,495 children).
Despite an enrollment increase, there was a decline in the usage of health services covered by CHIP. Compared to data from 2019, data from 2020 showed there were 22 percent (1.7 million) fewer vaccinations for children under two years of age, 44 percent (3.2 million) fewer screening services, and 69 percent (7.6 million) fewer dental services. At the beginning of the pandemic, the number of mental health-related emergency department visits sharply declined at 43 percent. Though telehealth visits were more widely utilized to address mental health issues, these outpatient services (telehealth or in-person) still decreased by 44 percent (6.9 million) compared to prior years. The short-term and long-term impacts of these dramatic reductions in health care services have yet to fully be appreciated.
Moving Forward: Child Well-Being Post-Pandemic
The pandemic increased the health care disparities experienced by children from low- and moderate-income households, with long-term impacts that are not yet known. Yet, there are already many valuable lessons to be learned. The foundation for children’s health care assistance has been laid by CHIP and is now ready to be strengthened through collaborative partnership. Promoting children’s well-being and family flourishing is a task not only for federal, state, and local government, but also necessitates important contributions from civil society institutions — including secular and faith-based nonprofits, schools, houses of worship, and other community institutions. These institutions play a unique and critical role to increase child well-being and flourishing that can be synergistic with the efforts of CHIP.
Read the rest of “Children’s Health and Well-Being: Recommendations for a Post-Pandemic World,” which includes the research team’s recommendations for improving children’s health through public policy and civil society, and a case study of Denver, Colorado.
Chenyu Lin is a junior nursing major at Colorado Christian University and intends to pursue her doctorate in nursing practice upon her graduation in 2023. She completed her research for The Hatfield Prize during her sophomore year. Lin desires to be a leader who creates new leaders, seen in her work as a Resident Assistant, Teaching Assistant, and Peer Tutor. She serves as the founder and president of CCU’s Nurses Christian Fellowship, is a World Changers Scholarship recipient, is a member of the Student Advisory Council for Race and Ethnicity, and is a volunteer for International Students, Incorporated. Her passion for promoting holistic health (spiritual, physical, and emotional) was shaped by volunteering with Boys and Girls Club and Street Church. In the future, she hopes to work in the mission field, empowering parents and children to focus on preventing illness and maintaining holistic health. In her free time, she is studying to become a polyglot, loves reading science-fiction, enjoys piecing together puzzles, and loves traveling to new places to learn about different people groups and cultures.
Julie Woodman, Ph.D., is an Assistant Professor of Biology at Colorado Christian University where she teaches a variety of biology-based courses, including genetics and microbiology. Julie received her Bachelor of Science in biochemistry from Colorado State University. She then received her Ph.D. in molecular biology from the University of Colorado Anschutz Medical Campus, with research that focused on chromosome dynamics and a genetic disorder called Cornelia de Lange Syndrome. Julie’s additional research interests include the identification of effective methods for STEM teaching and learning in diverse student populations as well as the public health impacts of infectious disease. At CCU, she continues her career in biomedical research while also teaching and mentoring undergraduate students. Julie was born and raised in Colorado, where she currently lives with her husband and their two daughters.
Address Children’s Health in Your Community
Inspired by what you’ve read? Consider starting a Political Discipleship group to address children’s health in your community. The Center for Public Justice’s Political Discipleship is a guide for active Christian citizenship, designed to empower people with skills and tools to shape policy and address inequality and injustice in their communities. To learn more about starting a group, visit our website or contact katie.thompson@cpjustice.org.
The Hatfield Prize is made possible through the generosity of the Annie E. Casey Foundation and the M.J. Murdock Charitable Trust. We thank them for their support, but acknowledge that the findings and conclusions presented in these reports are those of the authors alone and do not necessarily reflect the opinions of these foundations.