By Genevieve M. Kenney, Jennifer Haley, Clare Pan, Victoria Lynch, and Matthew Buettgens, Urban Institute, Funded by the Robert Wood Johnson Foundation

We recently examined how children’s coverage fared during the first year of implementation of the major coverage provisions of the Affordable Care Act (ACA). We found increases in participation in Medicaid and the Children’s Health Insurance Program (CHIP) in 2014, with 91.0 percent[i] of eligible children participating – up from 88.7 percent in 2013 and increasing almost 10 percentage points since 2008. Increases were widespread across subgroups of children and states, with a majority of states now seeing participation rates of more than 9 in 10 eligible children. This growth in participation translated into a decline in uninsurance among children; between 2013 and 2014, the number of uninsured children who were eligible for Medicaid or CHIP but not enrolled dropped by over 700,000.

However, 4.5 million children remained uninsured in 2014, with an estimated 62.1 percent (2.8 million) eligible for Medicaid or CHIP but not enrolled. Among the 37.9 percent (1.7 million) of uninsured children who were not found to be eligible for Medicaid or CHIP, 27.6 percent had family incomes that were too high to qualify and 10.3 percent met the income requirements but did not meet their state’s immigration requirements.

Profile of Medicaid/CHIP Eligibility Among Uninsured Children Ages 0 to 18, 2014

Source: Urban Institute tabulations of the 2014 American Community Survey.

Given the distribution of eligible but uninsured children across the country, further progress rests on increasing participation in a relatively small subset of states. In 2014, 444,000 eligible uninsured children lived in Texas, with another 329,000 in California and 218,000 in Florida. Overall, nearly half (47.8 percent) of all eligible uninsured children lived in one of 6 states – Texas, California, Florida, Georgia, Pennsylvania, and New York together were home to 1.3 million eligible but uninsured children.

Other research shows that the vast majority of low-income uninsured children have parents who say they would enroll their child in public coverage if told their child was eligible, many of whom have prior experience with Medicaid and CHIP. Thus, targeted policy efforts to enroll, and particularly retain, eligible children in public coverage could have substantial payoffs.

Estimated Number of Medicaid/CHIP Eligible Uninsured Children (Ages 0 to 18), by State, 2014

Source: Urban Institute tabulations of the 2014 American Community Survey.

[1] Participation rates are defined as the ratio of Medicaid/CHIP-eligible enrolled children to Medicaid/CHIP-eligible enrolled children plus Medicaid/CHIP-eligible uninsured children. For more information on data and methods, see Kenney, Genevieve, Jennifer Haley, Clare Pan, Victoria Lynch, and Matthew Buettgens. 2016. “Children’s Coverage Climb Continues: Uninsurance and Medicaid/CHIP Eligibility and Participation Under the ACA.” Robert Wood Johnson Foundation.