Child Uninsured Rate Hits Historic Low – Thanks Goes Mainly to ACA, Medicaid & CHIP

Like many of you I was super excited to see the first round of data from the Census Bureau looking at health insurance rates in 2014 when it came out in late September. Needless to say, 2014 was a big year for health policy changes!

Today we are releasing our annual report focused specifically on children and their rates of health care coverage in all 50 states and how that changed from 2013 to 2014. Nationally, the rate of uninsured children dropped to a historic low of 6% in 2014, we believe in large part as a result of the implementation of the Affordable Care Act (ACA) – which for kids was building on more than a decade of success by Medicaid and CHIP working together. Approximately 4.4 million children remain uninsured in the U.S.

As we discuss in the report, the ACA did expand affordable coverage options for children but was more focused on expanding affordable health insurance options for adults, a group with considerably higher uninsured rates. Since a majority of uninsured kids were already eligible for Medicaid or CHIP coverage before the ACA, eligibility expansions — while still an issue for some populations (immigrant kids, higher income kids with family glitch problems) — are just a piece of the puzzle.

There were several important policy changes in the ACA that affected kids directly or indirectly. In 2014 about half of a million children were receiving marketplace coverage – some of whom were previously uninsured though we don’t know how many yet. The maintenance-of-effort provision, which meant states were not able to roll back their eligibility levels for kids, is certainly at the top of my list for ensuring that kids coverage levels continue to move in the right direction. In addition, the removal of premiums for some “stairstep” kids between 100-138% FPL when they moved from separate CHIP programs to Medicaid likely helped in some states.

The ACA also removed other red-tape barriers like asset tests and in-person interviews. The health reform law encouraged states to streamline the application and renewal process through generous financial support to upgrade IT systems. It also required states to attempt to verify eligibility through trusted data sources, like the Social Security Administration, before requesting paperwork from applicants which not only simplifies the process for families, but is also more efficient administratively. These policies have had positive benefits for kids already and hopefully more will benefit as states continue to remove barriers and simplify their enrollment and renewal processes.

Then of course there is the “welcome mat” effect as we like to call it. Because the Affordable Care Act drew so much attention in 2014 (good and bad!), and there were so many outreach and enrollment activities, parents who came in for coverage often found out that their kids were eligible for Medicaid or CHIP and signed them up.

States that expanded Medicaid for parents saw bigger improvements in their children’s uninsured rates – likely as a result of a stronger “welcome mat” effect. You may have noticed that Medicaid expansion is a hot issue in some states — and not often discussed as affecting children. But we know from past research that covering parents results in a strong welcome mat effect for kids. Our report found that children living in Medicaid expansion states saw nearly double the rate of improvement in their uninsured rates than kids in non-expansion states. The gains for kids in Medicaid expansion states is even more impressive when one considers that they already had lower child uninsured rates making improvements harder to achieve. So while most states likely had a welcome mat effect, those that expanded Medicaid appear to have had a stronger one.

The declines were widespread across the country, but we still see significant differences between states. The clear winner for the most improved award goes to Nevada – which had the largest drop in its uninsured rate for children moving from almost 15% to just under 10% in one year. Next came Colorado, West Virginia, Mississippi and Rhode Island – and West Virginia and Rhode Island were already doing very well so it was even harder for them to achieve further gains.

Texas is now the state with by far the largest number of uninsured children – even though they saw a decline in their numbers they still have approximately 800,000 uninsured kids and rank 50th in the country with an uninsured rate way above the national average at 11%.

As in past years, we found that uninsured kids are more likely to live in the South, be school aged and of Hispanic descent. My co-author Alisa Chester will be blogging shortly with more information about the profile of uninsured children.

So I encourage you to take a look at our report and dig in to all the data presented there. It’s always a pleasure to share good news and underscore that when our communities and our leaders work together, often across party lines, positive outcomes can happen for kids. But ongoing vigilance and commitment will be required going forward to ensure that progress continues, and we achieve a day in which no child in the U.S. is uninsured.

Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy.