No one knows how many Utah children remain uninsured after health insurance companies recently decided to stop selling child-only policies.
But whether it's two dozen or 2,000, advocates for children want them covered. And they think they've found a way to make it affordable for families while costing the state nothing.
It's called a Medicaid buy-in, a program that would allow families with incomes above the usual cutoff limits to enroll their youngsters in Medicaid or the Children's Health Insurance Program (CHIP) as long as they pay a "premium" to cover what the state would typically pay for their care.
Currently, the federal government matches every $1 that the state pays into Medicaid with $3. That money could be used to subsidize families' contributions, keeping the coverage affordable.
"With families paying [the state's] full freight ... I think policy leaders would be open to that," said Lincoln Nehring, a senior health-policy analyst at Voices for Utah Children, who is pushing the idea.
The notion is still in its infancy, with no legislation pending. But buy-in programs exist in at least a dozen other states, and they are being eyed by others as a refuge for children excluded from the private insurance market those with disabilities and chronic health problems.
Medicaid and CHIP benefits are comprehensive, and the out-of-pocket costs for families are generally low, Nehring said. Most important, there's no loophole allowing the programs to discriminate against sick children.
The new federal health overhaul bars commercial insurers from rejecting children with pre-existing conditions. But to avoid absorbing a disproportionate share of these high-cost customers, insurance companies in Utah stopped selling child-only plans, doing away with an attractive option for parents who can't afford to insure the whole family but want to protect their children.
How many children were affected is a mystery, even to officials overseeing the state's high-risk pools.
Of the state's 300,000 uninsured, 14,000 to 18,000 are estimated to be uninsurable. "But we really don't know how many of those are children," said Tomi Ossana, who directs the pools.
Ossana's programs are supposed to be the safety net for them. But enrollment has remained stagnant at about 4,200, fewer than 7 percent of whom are under 19 years of age. Even its subsidized premiums are too costly for many cash-strapped families.
But the Utah Comprehensive Health Insurance Pool is unable to offer steeper discounts. As it is, the program operates at a loss for every premium dollar collected, it spends $1.44 on claims, tapping state dollars to pay the bills.
"It's these numbers that scare the carriers because now they're going to have to take on that risk," Ossana said.
House Speaker David Clark, R-Santa Clara, said on Tuesday he'd "entertain the idea" of creating a Medicaid buy-in program, which would tap federal money instead of state dollars to subsidize families' coverage.
The true test could be winning over the insurance industry, which might see any expansion of government as a threat.
None of the carriers in Utah plans to re-enter the child-only market. But they do allow parents to add children sick or healthy to their family plans, with limits.
Intermountain Healthcare's insurance arm, SelectHealth, is the only carrier accepting applications year-round. The rest take children only twice a year during state-sanctioned enrollment periods.
"This is helpful for consumers," said SelectHealth spokesman Spencer Sutherland. "However, it also results in us taking on more risk because individuals may choose to wait until they need medical care to apply for coverage."
To discourage families from dropping their commercial plans in favor of CHIP or Medicaid, some states offer only partial coverage, providing only services that private insurers don't offer.
Utah insurers aren't raising immediate objections.
"We welcome any solution that both allows more people to gain access to coverage and assures consistency across all carriers," Sutherland said.
Mike Tatko, a spokesman at Regence BlueCross BlueShield, said: "It's a policy decision for the state, and we will support the state in the actions it may decide to take."
Utah would need federal approval to create a program allowing parents to buy coverage from Medicaid or the Children's Health Insurance Program for their youngsters. But it's a path already paved by other states.
Massachusetts boasts the country's oldest buy-in program. It's limited to children and adults with disabilities. Families pay a premium on a sliding scale based on their income and whether they're applying for full or partial benefits.
Vermont opens Medicaid to families with incomes at 225 percent to 300 percent of the federal poverty level who are uninsured, or who need supplemental coverage for mental health, dental care or prescription drugs. Premiums max out at $60 a month.
North Dakota limits its program to severely disabled, low-income children. Premiums are set at 5 percent of a family's gross monthly income.
Source: Catalyst Center at Boston University's School of Public Health