The Questions to Ask When Assessing the Impact of Coverage Expansion Proposals on Children

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  • This issue brief asks a number of key questions to help assess the relative merits of coverage expansion proposals from the perspective of children.

In This Report:

Sixth in a series of briefs on the future of children’s health care coverage


With the outcome of the November midterm elections, the risk of federal legislation to repeal and replace the Affordable Care Act (ACA) and impose a cap on federal Medicaid funding has receded. Instead, there is renewed attention by some policymakers on how to once again make substantial progress toward the goal of universal coverage.

This has become more urgent with recent survey data showing that the ranks of the uninsured are increasing. For example, data from the Census Bureau’s American Community Survey (ACS) show that in 2017, the uninsured rate among children increased for the first time since at least 2008 when the ACS first asked a health insurance question. The share of children without health insurance rose from 4.7 percent to 5 percent between 2016 and 2017 and the number of uninsured children increased by 276,000.1

While the number of children with health insurance has reversed modestly, this troubling sign comes on the heels of extraordinary progress as a result of efforts at the federal and state levels to address children’s health needs. Following decades of coverage expansions and eligibility simplifications through Medicaid and the Children’s Health Insurance Program (CHIP), the percent of insured children reached a historically high level of 95.5 percent in 2016.2

Children are also at risk when their parents and caregivers lack health insurance. The latest results from the Gallup National Health and Well-Being Index, for example, find that the uninsured rate among adults has increased by 2.8 percentage points since 2016 (from a low of 10.9 percent in the third quarter of 2016 to 13.7 percent in the fourth quarter of 2018), which translates to an increase of about 7 million people. According to Gallup, this is the highest uninsured rate among adults since the ACA’s major coverage expansions were implemented in 2014.3

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  1. Joan Alker and Olivia Pham, “Nation’s Progress on Children’s Health Coverage Reverses Course,” Georgetown University Center for Children and Families, November 2018, available at https://ccf. Final_asof1128743pm.pdf
  2. Alker and Pham, op, cit.
  3. Dan Witters, “U.S. Uninsured Rate Rises to Four-Year High,” Gallup, January 23, 2019, available at