NUR5133 Module 3 health policy issue analysis example

Covered for Twelve Months, Then What? Continuous Medicaid Eligibility for Children After the Pandemic Protections Ended, and What It Asks of a Children's Hospital's Nurse Leaders

Student Name

American College of Education

NUR5133: Knowledge of the Healthcare Environment

Module 3 Assignment

Instructor Name

September 21, 2027

The Issue

Medicaid and the Children's Health Insurance Program pay for 58% of patient days at the composite children's hospital described in the earlier modules. Whether a child stays enrolled from one month to the next therefore affects not only the family but the hospital's finances and the nurses who plan that child's discharge. Over five years, federal policy on this question changed three times. During the COVID-19 public health emergency, states that accepted extra federal funds agreed not to disenroll Medicaid members, so children stayed covered continuously. In April 2023 that protection ended, and states began redetermining eligibility for everyone enrolled, a process widely called the unwinding. Then, from January 2024, federal law required states to provide children under 19 with 12 months of continuous eligibility, so that a child found eligible stays covered for a year regardless of changes in family income (Eliason, Howland, et al., 2025). States now face a narrower question: whether a year of guaranteed coverage is long enough, or whether the youngest children should be covered without interruption until they start school, as a handful of states have asked federal permission to do.

What the Evidence Shows

Research on the unwinding shows that coverage losses among children were large and varied with state policy. One analysis of monthly federal enrollment data from 49 states and the District of Columbia found substantially lower Medicaid and CHIP enrollment among children during the unwinding than during the pandemic protections, and smaller declines in states that already guaranteed children 12 months of continuous eligibility and in states whose CHIP program was structured separately or as a Medicaid expansion rather than as a combination of the two (Eliason, Nelson, et al., 2025). After the national 12-month requirement began, children's enrollment rose, and the gains were larger in states that had not previously offered continuous eligibility (Eliason, Howland, et al., 2025).

Coverage loss affects care, not only paperwork. In a national analysis of pharmacy data, Chua et al. (2025) found that children living in states with the largest Medicaid enrollment losses during the unwinding had greater decreases in days with active prescriptions for at least one class of chronic medication and a greater increase in paying cash for prescriptions in three classes, including medicines for attention-deficit/hyperactivity disorder, depression, epilepsy, psychosis and asthma, with even larger effects among young adults. A child who loses coverage does not lose the asthma; the family loses the inhaler, and the hospital sees the child again.

Stakeholders and Their Interests

Families want stable coverage without repeated paperwork, and many lost coverage during the unwinding for procedural reasons, such as a renewal form sent to an old address, rather than because they were no longer eligible. States must balance the cost of continuous coverage, since some children remain enrolled after their family income rises, against the administrative savings of fewer redeterminations and the health benefits of stable care. Medicaid managed care plans gain from stable enrollment, which allows them to manage care over time, but bear the cost of members who remain enrolled while using services. Children's hospitals, pediatricians and pediatric nurses have generally supported longer continuous eligibility, because coverage gaps lead to missed care, emergency visits and uncompensated costs. Taxpayer and budget advocates tend to favor regular eligibility checks to limit spending on people who no longer qualify.

Effects on the Children's Hospital and Its Nurses

The hospital felt each phase directly. During the unwinding, the share of its admissions arriving without active coverage rose from about 2% to nearly 5%, and its financial counselors, who had helped fewer than 20 families a month to re-enroll before 2023, helped more than 70 a month at the peak. Many of those families were identified by nurses, often at discharge, when a prescription could not be filled because coverage had lapsed. On the medical-surgical floors, the author's unit saw children with asthma readmitted after running out of controller medication and adolescents with depression discharged without a way to pay for antidepressants, the same patterns the national pharmacy data describe.

The 12-month rule has reduced these problems but not ended them. Children can still lose coverage at their annual renewal, and families who move or change phone numbers may not receive renewal notices. Nurses remain the staff most likely to discover a coverage problem, because they are present when a family is asked to fill a prescription, schedule a follow-up visit or arrange home equipment.

What Remains Uncertain

The evidence on continuous eligibility is still young, and a careful analysis should say what it cannot yet show. The studies of the unwinding describe enrollment and prescriptions, not hospital admissions, emergency visits or health outcomes, so the link between coverage loss and the readmissions seen on the author's unit rests on local observation rather than on published data. The national 12-month requirement began during the unwinding itself, which makes it hard to separate the effect of the new rule from families simply re-enrolling after being dropped. And the cost of longer continuous eligibility for states is debated: it keeps some children enrolled after their families' incomes rise, but it also reduces the administrative cost of repeated eligibility checks and the churn of children leaving and returning to coverage within months. For the hospital, these uncertainties argue for collecting its own data. The finance and case management departments will track, for each discharged child, coverage status at admission, at discharge and 90 days later, and link it to readmissions. Within two years the hospital will be able to describe the effects of coverage policy on its own patients, which will make its advocacy more credible than national figures alone.

Options and Recommendation

Three state policy options are under discussion: keep the federal 12-month minimum, extend continuous eligibility for children from birth to age six through a federal waiver, or reduce the administrative burden of renewal by using data the state already holds to renew families automatically. The evidence that states with prior continuous eligibility lost fewer children during the unwinding supports longer guaranteed coverage, and automatic renewal addresses the procedural losses that longer coverage alone would not.

The recommendation for the hospital is to support the state's pending waiver for continuous eligibility from birth to age six and to advocate for automatic renewal, through the state children's hospital association and through testimony by nurses and physicians who see the effects. Within the hospital, nurse administrators should act in three ways. First, add a coverage check to the admission nursing assessment, so that lapsed or expiring coverage is flagged on the first day rather than the last. Second, ensure that every child discharged on a chronic medication leaves with a supply or a confirmed way to obtain it, working with the outpatient pharmacy and financial counselors. Third, give nurses a simple script and a direct referral route to financial counseling, so that finding a coverage problem leads to help rather than to a note in the chart.

References

Chua, K.-P., Constantin, J., Kenney, G. M., Conti, R. M., & Simon, K. (2025). Changes in chronic medication dispensing to children and young adults during Medicaid unwinding. Pediatrics, 155(6), Article e2024070380. https://doi.org/10.1542/peds.2024-070380

Eliason, E., Howland, R. E., & Vasan, A. (2025). Children's Medicaid enrollment increased during first year of Consolidated Appropriations Act. Health Affairs, 44(11), 1344-1348. https://doi.org/10.1377/hlthaff.2025.01000

Eliason, E., Nelson, D., & Vasan, A. (2025). Continuous eligibility policies and CHIP structure affected children's coverage loss during Medicaid unwinding. Health Affairs, 44(3), 288-295. https://doi.org/10.1377/hlthaff.2024.01099