Editor’s note: As more and more states create bureaucratic hurdles over which families must climb in order to qualify for benefits such as Medicaid, SNAP and free or reduced-price school lunch, more and more Americans are losing these needed benefits. The following piece, cross-posted with permission, examines the recent increase in the number of uninsured children in the U.S. and the reasons behind this increase. The author of the piece, Joan Alker, is Executive Director and Co-Founder of the Center for Children and Families, and a Research Professor at the Georgetown University McCourt School of Public Policy.

By Joan Alker

Poverty and health have always been entwined. A sick parent can’t work to support his or her family. A sick child can’t succeed in school. An unexpected health crisis such as a trip to the ER due to a playground injury can wipe out savings and leave families with crushing medical debt.

Medicaid coverage provides families with better financial security and helps children get the care they need to succeed in school and life. Research shows us that children with Medicaid coverage have better health outcomes even as adults, are more likely to graduate from high school, and have higher earnings as adults than children who were uninsured. Research also shows Medicaid is among the most effective anti-poverty programs and had a larger effect on child poverty than all non-health, means-tested benefits combined. That is why it is so alarming to see that our nation is moving backwards as kids are losing Medicaid coverage and more of them are joining the ranks of the uninsured.

Our latest report found the number of uninsured children increased by more than 400,000 to more than four million nationwide between 2016 and 2018, reversing a long-standing positive trend and erasing many of the gains achieved after major provisions of the Affordable Care Act took effect. Behind these numbers are millions of families struggling to make ends meet and get their kids the health care they need to succeed. Our new interactive data hub provides insights into who these children are in each state.

In many cases, these uninsured children qualify for Medicaid and CHIP, which provide health coverage to nearly 40 percent of U.S. kids. But their families are increasingly facing more red tape when they try to sign their kids up or re-enroll them. Or, as in the case of many immigrant parents, they are scared to interact with the government to enroll their children.

This “chilling effect” among immigrant families stems from a climate of fear and confusion that has been created by the Trump Administration’s actions and rhetoric. In most cases the children are citizens but one or more of their household members are immigrants, and they are worried about being deported or having trouble adjusting their status in the future and being separated from their families.

“Mainly what we see is a lot of fear among our families,” said Marivi Wright, a community outreach coordinator with the Players Center for Child Health at Wolfson Children’s Hospital in Jacksonville Florida. She recalled an immigrant family who sought health coverage shortly after their child was born in a Florida hospital, only to withdraw the application for fear of the repercussions. Weeks later, the baby was rushed to the hospital, and the family put their fears aside and enrolled their child in Medicaid.

Her colleague, Tamiko Spears, recounted many of the red tape barriers families face with the state demanding more paperwork and different information for enrollment in one program versus another. In one case, a child went without insurance for two to three months as her mother tried to deal with conflicting program rules about whether alimony counted as income or not.

These red tape barriers imposed by states are being put up either with the explicit encouragement or not-so-benign neglect by the Trump Administration. That can take the form of added paperwork requirements, including verifying income more frequently. Other states are moving more quickly to cut off a child when the renewal paperwork isn’t filed within a very brief window.

The red tape is added under the guise of cracking down on fraud, but that is the wrong target for anyone serious about program integrity. Policymakers focused on program integrity should follow the money and put safeguards in place where the funding enters the health care system, largely through lightly regulated Medicaid managed care organizations, not make life harder for parents simply trying to take their children to the doctor.

Our report also found the child uninsured rates are rising three times faster in states that have refused to accept federal funding through the Affordable Care Act to expand Medicaid to low-income parents and other adults in low-wage jobs. This is because children often gained health insurance when their parents were newly enrolled in Medicaid. Children in the fourteen remaining non-expansion states are about twice as likely to be uninsured as those in expansion states.

It is particularly troubling that the child uninsured rate is going up at a time when the unemployment rate is low and the economy is relatively strong. A recession will surely worsen these trends. Our nation’s leaders must put politics aside and redouble their efforts to enroll children and their parents in Medicaid and CHIP. These programs are essential to make sure that children grow up healthier and better able to succeed as adults.