For the past six years, my colleagues and I here at Georgetown University’s Center for Children and Families have reported on state-by-state and national trends in children’s health coverage. Thanks to the hard work done by Medicaid and CHIP over the past few decades, we have seen a steady decline in the rate of uninsured children (with one exception in 2013) in all of our reports.
Today we are releasing our 6th annual report which examines data from 2013 to 2015 – a period during which major provisions of the Affordable Care Act were implemented. The news is even better this time around. The rate of uninsured kids dropped from 7.1 percent to 4.8 percent – the sharpest decline in a two-year period on record.
The number of uninsured children declined by 32.5% between 2013 and 2015, meaning that about 1.7 million children gained coverage during this time period. Since 2008, the number of uninsured children has been cut in half, from 6.9 million uninsured children in 2008 to 3.5 million in 2015.
Yet, the American public is largely unaware of this success. A recent PerryUndem poll found that only 28 percent of respondents correctly responded that the number of uninsured children is going down while 49 percent actually thought the number of uninsured children was going up.
Coverage gains were widespread, with 41 states showing a statistically significant decline in the percent of uninsured children, while one state (Wyoming) showed a significant increase in the rate of uninsurance among children and nine states saw no change. Typically we have seen at least 20 states moving in the right direction, but we have never seen this many states with significant declines in their numbers of uninsured children. Nevada saw the largest percentage point decline (7 percentage points), cutting its rate of uninsurance from 14.9 percent in 2013 to 7.6 percent in 2015.
States with high rates of uninsurance are concentrated in the Mountain West, but also include Alaska, Arizona, Florida, Georgia, Indiana, Missouri, Oklahoma, and Texas. The South is home to 38 percent of all children but fully half (50 percent) of all uninsured children. One in five uninsured kids now live in Texas.
While children saw improvements across age groups, racial categories, and income ranges, some groups continue to lag behind. For example, Latino children continue to be disproportionately uninsured among the remaining uninsured kids. Stay tuned for our upcoming report with the National Council of La Raza that will focus on health coverage rates for Hispanic children. Children living just over the poverty line (100-200 percent of poverty) have the highest rates of uninsurance (6.8 percent) among the income breaks we examined.
What explains this success? As regular readers of Say Ahhh! know, children’s uninsurance rates have been coming down for longer than we have been writing this paper. Thanks to expansions of Medicaid starting in the 1980s that were phased in over time to all children below the poverty line and the passage and implementation of CHIP starting in 1997, we have seen a steady decline. While largely targeted at addressing the much higher rate of uninsurance among adults, the Affordable Care Act built on the success of Medicaid and CHIP to bring uninsured rates down even lower for kids.
At the heart of the ACA’s strategy of building on success is the “maintenance of effort” provision, which requires states to maintain their current eligibility levels for children’s coverage in Medicaid and CHIP. At CCF, we believe the MOE provision has been critical to ensuring that progress for kids has been protected and accelerated. One only need to look to the state of Arizona, which until recently had no active CHIP program, to understand why we cannot assume all states will do right by children.
Other important trends that likely contributed to the sharp declines in uninsured children include:
- The “welcome mat” effect: As parents learned and signed up for newly available Medicaid or marketplace coverage, and an individual mandate kicked in, many children were likely signed up as their parents enrolled. Since the majority of uninsured children are already eligible for Medicaid and CHIP but are not enrolled, the “welcome mat” effect is critical.
- Eligibility was aligned across families in Medicaid (i.e “stairstep” kids): Eighteen states were required by the ACA to move children ages 6 to18 with family incomes between 100 to 138 percent of the FPL from their separate CHIP programs to Medicaid. This eliminated premiums for some children, which had been a barrier to enrollment.
- Subsidies on the marketplace: Premium tax credits help subsidize the cost of coverage on the newly available marketplaces. Approximately 790,500 children enrolled in marketplace coverage in 2015 – though we don’t know how many of those children were uninsured prior to being enrolled in the marketplace, this undoubtedly contributed to the improvement in kid’s coverage rates as well. Some of the early kinks in the system were ironed out and enrollment proceeded more smoothly in the second year. Still, issues remain. You can learn more about how to strengthen the marketplace for kids in our recent report.
So, as we gear up for considerable change here in Washington DC, the key message where kids coverage is concerned is: “don’t mess with success”. With many challenges facing our nation, it is terrific that there is something that we can all feel good about – the success of Medicaid and CHIP and the ACA in reducing the numbers of uninsured children to historically low levels.