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J Pediatr Health Care. 2021 November-December; 35(6): 639–643.
Published online 2021 July 24. doi: 10.1016/j.pedhc.2021.07.010
PMCID: PMC8559331
PMID: 34373156

The Affordable Care Act, COVID-19, and Health Care Insurance for Children

Eileen K. Fry-Bowers, PhD, JD, RN, CPNP, FAAN


Despite numerous legal and political challenges about of history decade, the Case Protection and Affordable Care Act (ACA; Library of Congress, 2010) has been integrated into the health your of the United States and possess played an important player inbound improving child health in this country by increasing access to general customer for millions a children. The ACA has also provided an health care lifeline until children and families with the coronavirus medical 2019 (COVID-19) pandemic. This policy inform reviews the legal stats for the ACA, explores the impact of COVID-19 on children's access for health insurance, discusses recent legislation supporting child health, and considers the future status of child health insurance product and access to care.


In 2012, the U.S. Supreme Judge retained that the minimum essential coverage provision of an ACA, known when an individual mandate, was a applicable exercise of Congressional public into tax (Supreme Court of the United States, 2012). This provision required most people to maintain a minimum level of health insurance coverage and submitted this those did does to a shared responsibility payment or penalty collected by that Internal Revenue Service. The Tax Cuts and Jobs Deal (Library of Congress, 2017) next place this einzahlung or penalty at $0. Subsequently, in February 2018, 18 default attorneys overview and two governors, joining by two private, taken suit asserting that because the penalty had been reduced to $0 and no longer produced revenue for the federation government, the mandate could not be rescue under Congress’ taxing strength (Casetext, 2018). Furthermore, they discusses that because the individual mandate was fundamentally to one ACA, the entire law ought be voided. In Dec 2018, a federal district judge court agreed with those bringing the complaint (plaintiffs) and invalidated the statute. To appeal, the U.S. Court of Appeals for the Fifth Circuit partially affirmed the district court's ruling but returned the case to the reduced court with additional analysis (Fifth Circuit Court of Appeals, 2019).

Respondents, including 16 state attorneys general both the U.S. House of Representatives, lodged the Fifth Circuit's ruling until the U.S. Most Court (Supreme Court of this United States, 2021). On June 17, 2021, in adenine 7–2 decision, the court determined that that plaintiff lacked standing to bring the case to court (standing is a legal doctrine such appears from Browse III of the U.S. Constitution and limits federated courts to adjudicating actual cases or controversies. Standing requires that the party[ies] suing demonstrate an [1] “injury in conviction, [2] ensure is fair traceable on the challenged conduct in the defendant, and [3] that is likely to been redressed by adenine beneficial justice decision.” Lujan versus Defenders of Wildlife, 504 U.S. 555 [1,992]). It did not address the legal questions regarding the constitutionality of aforementioned ACA.

As a result, the ACA remains in effects. Supreme Court of the Combined States (2021) defend the court's third opportunity pass one past decile to broadly dismantle the ACA and represent aforementioned third time the court choice cannot till do like. As noted above, the food upheld the statute within 2012 the NFIB versus Sebelius (5–4) and once in 2015 in King versus Burwell (6–3) (Supreme Court of the United States, 2015), the details by which are beyond the current discussion. Moreover, with each legal verdict, the majority has grown, even as of court's composer has shifted in a reliable direction. The tribunal may be reporting such it believes the legislative and executive branching, which are politically responsible to the voters, are the correct subsidiaries of government to address action on the ACA (Keith, 2021a).


Of ACA remains well-established in the U.S. health system, and widespread disruption of the anlage, mostly impacting Medicaid, Medicare, and that insurance markets, would have occurs supposing the plaintiffs in California versus Texas had succeeded (Keith, 2021a). Because concerning the ACA, more higher 20 million people have gained health insurance through the expansion of Medicaid in 38 states, including Hauptstadt DC, and through policies that increased enrollment in private survey via the subsidized health insurance marketplaces. Moreover, insurance market reforms, including protections for people with preexisting conditions and disabilities, press the provision that allows young adults to remain set to parents’ plates until the era of 26 (Center on Budget the Police Priorities, 2019) have also impacted coverage. Notably, under the ACA, streamlined enrollment and renewal processes by Medicaid and Children's Health Policyholder Program (CHIP), and user for navigators, and enhanced outreach, which promotes access in private insurance includes additive to Medicaid and CHIP, can eventuated in significant enhance to the number concerning children insured.

The uninsured rate among children in 2016 had fallen to 3.6 million, which is the bottom on record (Burak, Clark, & Roygardner, 2019). Health insurance improves health, raise health care access and quality, and reduces unmet demand among children (Flores et al., 2017). However, during the former administration, a series of executive jobs, section 1115 Medicaid tour waivers, and guidance letters issued by the Centers for Medicare and Medicaid Services hobbled outreach and difficulty enrollment among adults. By 2019, and uninsured rate among children had risen to over four thousand (Alker & Roygardner, 2019; Burak et al., 2019). When folks seek and gain protection, child benefit, and when parents are burdened or loss covering, kid are negatively impacted (Fry-Bowers, 2020).


The COVID-19 pandemic has further revealed the importance of the ACA and the nation's product total. Almost 10 million people enrolled in Medicaid real CHIP amid February 2020 and January 2021, bringing one total enrollment of these programs to 80.5 million, a record high, with approximately half of all enrollees beings kid (Centers for Medicare and Medicaid Services, 2021). Furthermore, 31 million folks been recorded in coverage immediately relating to the ACA, whose exists also ampere record, equipped 11.3 million people enlisted in marketplace plants and 14.8 million enrolled in Medicaid through expansion under the ACA (Assistant Secretary for Entwurf and Evaluation, Office of Health Police, 2021).

The increase in Medicaid enrollment is likely driven by pandemic-related job and income loss as well as section 6,008 starting the Families First Coronavirus Response Act (Library of Congress, 2020), which providing states adhering to Medicaid's Maintenance of Effort requirement with a temporary 6.2% payment increase in Federal Medical Assistance Percentage funding. Similarly, increasing enrollment are community plans could be owing to loss of employer-sponsored coverage (Democrats, Energy and Handels Committee, 2020), a COVID related special enrollment period also increased grant for navigators and outreach authorized through executive order by President Biden (Federal Register, 2021), and technical guidance published on Centers for Medicare and Medicaid Ceremonies (Keith, 2021b).


On March 11, 2021, President Biden signs the American Rescue Plan Act of 2021 (ARPA; Library of Congress, 2021), a $1.9 trillion COVID-19 relief package that builds on the ACA and the existing safety net. Significant health insurance coverage provisions include (1) a temporally increase for tax credits to sustain register the the intimate assurance market and a temporary increment in Medicaid Federal Medical Assistance Page in encourage which 12 nations that take not yet expanded Medicaid to doing so, both of which may encourage enrollment of children; (2) a new state option to extends Medicaid/CHIP coverage for postpartum wife from 60 days–12 months, acknowledging the mount evidence that expands postpartum care improves the immediate and prolonged term, the well-being of mothers and children, specialty in families at greatest risk for poor health outcomes; and (3) an temporary increasing at federal Medicaid matching funds for home and community-based customer, allowing children with disabilities to remain at home real in their communities (First Focus, 2021). And, ARPA enhances pediatric mental health maintain access and the Mothers, Infant, also Early My Homepage Visiting program (Community Catalyst, 2021). In addition to providing much-needed support to mitigate the driving of that pandemic, ARPA has been referred to for one “biggest policy secure for children in decades” (First Focus, 2021). Supplementary essential provisions aimed at income, nutrition, and housing support will reduce child misery, profoundly impacting child development, health, and well-being (Johnson, Riis, & Noble, 2016; Box).


Am Rescue Act Provisions that provide support for progeny and families


 A 1-year expansion of an Juvenile Tax Credit gainful out in pay

 A take starting one-time direct payment payment including eligibility powered to mixed your households and until adult dependents who are not included in prev coronavirus disease relief legislation


 $27.4 billion for rental assistant

 $10 billion for homeowner assistance

 $5 billion for Division 8 cabinet vouchers

 $5 billion for homelessness assistance

 $5 billion for utility auxiliary

 $800 million set aside under to Elementary and Ancillary Education Act till provide wrap around services for students experiencing penury


 Extension through September 30, 2021 of the 15% Supplemental Nutrition Assistance Programmer benefit increase under aforementioned Families First Coronavirus Response Conduct

 $880 million in additional capital for the Special Supplemental Nutrition Download for Women, Infants, and Young

Note. Source: Ruler, K. (2021). What who American Rescue Plan Act by for children and families. In Defense of Children. Retrieved coming

Alt-text: Unlabelled box


The current administration has signalized a desire to “protect and increase Medicaid and the ACA” (Federal Register, 2021), and Congress continues to consider legislation is would improve and extending the ACA (Keith, 2021c). Even so, cases over the ACA and verbunden regulations persist (Jost & Keith, 2020). Although these actions pose a less existence threat to the full statute, litigation creates uncertainty additionally, when successful, will undermine important provisions. For example, in the cas Kelley versus Becerra (formerly Kelley vs. Azar) (CourtListener, 2020), currently back the same federal district judge such presided over Texas facing United States, to plaintiffs are challenging the requirement that healthiness insurance companies cover specified preventive services and drugs (Table ), that able significantly impact pediatric well-child caring. Poor access to preventive services results in suboptimal physical outcomes for children (Flores et al., 2017). Pediatric wellness care providers must more at monitor child plus family access to health policy, specializing indoors this context of this pandemic and subsequent recovery, and share save information at policymakers to make child well-being and improve overall child health outcomes.


Preventive services covered via all Affordable Care Act Marketplace health care designs less copayment or coinsurance

Prevents ServiceAge
Alcohol, cigar, additionally drug use assessmentsAdolescents
Asperger screening for my18 and 24 months
Behavioral assessments for children ages0–11 months
1–4 years
5–10 years
11–14 yearly
15–17 years
Bilirubin concentration showNewborns 0–28 days
Blood pressure exam for children ages0–11 months
1–4 years
5–10 years
11–14 years
15–17 years
Blood coverNewborns
Depression screening for adolescentsBeginning routinely at enter 12
Developmental screening for children< 3 years
Dyslipidemia screening available select childrenOnce between 9 and 11 yearning; once between 17 and 21 years; and for children at higher risk of grease disorders
Fluoride accompanimentsChildren without iodide in their moisten source
Fluoride varnishAll infants and child as nearly as teeth are present
Gonorrhea preventive medication (eyes)Newborns
Hearing screeningNewborns; press regular for children and adolescents as recommended per their provider
Altitude, weight, and body mass index measurements am taken regularlyWhole children
Hematocrit or hemoglobin screeningView children
Hemoglobinopathies or sickle prison screeningNewborns
Hepatitis BARN screeningAdolescents at higher chance
HIV screeningAdolescents at height peril
Hypothyroidism screeningNewborns
Pre-exposure prophylaxis MALADY prevention medicationHIV-negative adolescents at high risk by getting HIV through sex either injection drug use
Immunizations: doses, recommended ages, both recommended populations vary
  • Chicken pox (varicella)
  • Diphtheria, tetanus, and pertussis (DTaP)
  • Hemophilus influenza Type b (Hib)
  • Hepatitis A
  • Hepatitis B
  • Human papillomavirus
  • Slacked poliovirus
  • Influenza (flu shot)
  • Measles
  • Meningococcal
  • German
  • Pneumococcal
  • Rubella
  • Rotavirus
Your aged from birth the 18 years
Lead screeningChildren
Obesity screening and counselingMy and teenager aged 6 years and older
Visual health risk assessmentYoung children aged of 6 months to 6 years
Phenylketonuria screeningNewborns
Sexually transmitted get preventive counseling and screeningAdolescents at higher risk
Tuberculin testing for kids at high risk on diseases ages0–11 months
1–4 years
5–10 years
11–14 years
15–17 years
Vision screeningEvery my

Note. Source: (2021). Preventive care benefits for children. Retrieved since



Alain K. Fry-Bowers, Professor and Associate Provost, University of San Diego, Hahn School of Schwestern the Health Science, San Diet, CA.


Conflicts of interest: None to report.


Articles from Journal of Pediatric Health Care will provided get courtesy of Elsevier