How Tennessee Became an Outlier in the Rising Number of Uninsured Children and What Must Happen to Reverse the Trend

August 6, 2019 / Author: Christopher Coleman

According to a study of U.S. Census Bureau data by the Center for Children and Families at the Georgetown University Health Policy Institute, Tennessee saw a 20% increase in the number of uninsured children in 2017. It was one of only nine states to see a statistically significant increase in the percentage of uninsured children. This fact demands the attention of Tennessee state officials. On an issue as important as ensuring that all children have health coverage, why is Tennessee an outlier? Are state policies contributing to the rise in the number of uninsured children? Can the state take any steps to address the problem?

The first places to look in attempting to answer these questions are the state’s public health insurance programs: TennCare, the state’s Medicaid program, and CoverKids, the state’s Children’s Health Insurance Program (CHIP), which together have traditionally covered over half of Tennessee’s children. Those crucial programs have seen a marked decline in enrollment over the past two years, coinciding with the overall decline in the percentage of Tennessee children with health coverage. According to TennCare data, the number of children enrolled in TennCare between December 2016 and June 2019, enrollment declined by a net figure of over 66,000. CoverKids enrollment declined by over 30,000 in 2018 alone. (CoverKids enrollment data for 2017 is not available on TennCare’s website.) As will be discussed below, those net enrollment numbers include new children enrolling in the programs. The net figures, though disturbing in themselves, therefore understate the much larger total of children cut from the two programs.

The increasing percentage of uninsured children in Tennessee suggests that many of the children losing TennCare or CoverKids are not moving onto private coverage through a parent’s employer, but instead are being left with no health coverage at all.

State officials claim that the declining enrollment in TennCare and CoverKids is the result of the state’s improving economy since the Great Recession, which they claim has made many children ineligible for state programs. This assertion does not stand up to scrutiny. According to state data supplied to the Tennessee Justice Center in response to a public records request, between 2016 and 2018,  TennCare terminated coverage for at least 220,000 children because of alleged problems with paperwork, not because the state determined that the children were no longer eligible. The state has no way of knowing how many of those children remain financially eligible for TennCare or CoverKids. Given Tennessee’s eligibility rules that broadly cover children, most children undergoing the redetermination of eligibility should have remained eligible, had the state correctly assessed their eligibility and not simply cut them off for administrative reasons.

This policy brief examines the state policies and administrative problems that have contributed to the rising number of uninsured children in Tennessee. Specifically, it suggests that TennCare’s five-year delay in implementing its new computerized TennCare eligibility determination system (TEDS) has forced the state to rely on an unreliable, ad hoc, and highly manual process for redetermining the eligibility of TennCare and CoverKids enrollees, which has caused many children to lose coverage despite remaining eligible for these programs.

TennCare should reinstate all children who have had their health coverage terminated until it has accurately determined that they do not meet current eligibility requirements. TennCare should also promptly investigate why so many children lost coverage on administrative grounds. Only then can the state determine whether it is taking all reasonable steps to ensure that every child who is eligible for TennCare and CoverKids is enrolled and receiving the important health benefits of coverage.