Executive Summary

There is no debate over the fact that children are losing Medicaid and Children’s Health Insurance Program (CHIP) coverage. Overall, more than 828,000, or 2.2 percent, fewer children were enrolled in Medicaid and CHIP, combined, at the end of 2018 than the previous year.^{1 2} A drop in child enrollment is unusual; between 2000 and 2016, enrollment declined in only one year—2007—by 1.1 percent.³ During this period, the nation achieved historic success in covering children with the rate of uninsured children reaching an all-time low of 4.7 percent in 2016. In 2017, child enrollment in Medicaid and CHIP was basically flat while the uninsured rate for children increased for the first time in a decade to 5 percent despite the strong economy.⁴

The decline in children’s enrollment in Medicaid and CHIP reinforces serious concerns that this alarming trend could continue—and perhaps even worsen. At a time when the economy is strong, the critical question is whether these children are moving to private coverage or becoming uninsured—a question that will not be answered definitively until the U.S. Census Bureau’s American Community Survey data become available this fall.

Introduction

In 2018, enrollment in Medicaid and CHIP declined by 912,000 children in 38 states while only 13 states experienced gains in enrollment. Despite a strong economy, there is negligible evidence that any significant economic factors have substantially increased access to affordable private or employer-sponsored insurance. It appears that both national and state-specific factors played a role in the decline.

While enrollment growth slows during periods of economic growth, it is uncommon for there to be an actual decline in enrollment. The 2018 decline follows the first year in a decade that the number of uninsured children increased, rising by 276,000 children. The uninsured rate rose from 4.7 percent to 5 percent, both statistically significant increases. If health insurance coverage trends continue, the rate of uninsured children is likely to grow again.

This paper examines the significant decline in children’s combined enrollment in Medicaid and CHIP during 2018 reported in federal/state administrative data; what may be happening to coverage for these children; and why it occurred. Most importantly, we describe what can be done to regain the country’s momentum in providing health coverage to children and ensure that eligible children are not losing access to the health care they need to succeed in school and in life.

Full Report and Executive Summary

Read the full report and executive summary.

1. Georgetown University Center for Children and Families Analysis of Centers for Medicare and Medicaid Services, “State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data” (Washington: U.S. Department of Health and Human Services, 2019), available at https://data.medicaid.gov/Enrollment/State-Medicaid-and-CHIP-Applications-Eligibility-D/n5ce-jxme/data. Note, this estimate does not include Arizona, the District of Columbia, and Tennessee, states that do not report a breakdown of children in their submission of enrollment data; Arizona Health Care Cost Containment System, “AHCCCS Population Demographics” (Phoenix: Arizona Health Care Cost Containment System, January 2019), available at https://www.azahcccs.gov/Resources/Downloads/PopulationStatistics/2019/Jan/AHCCCS_Demographics.pdf; District of Columbia Department of Health Care Finance, “ Monthly Enrollment Report – March 2019” (Washington: District of Columbia Department of Health Care Finance, March 2019), available at https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Enrollment%20Report_Mar%202019.pdf; Tennessee Division of TennCare, “TennCare Enrollment Report for January 2019” (Nashville: Tennessee Division of TennCare, January 2019), available at https://www.tn.gov/content/dam/tn/tenncare/documents2/fte_201901.pdf, and Tennessee Division of TennCare, “CoverKids Monthly Enrollment Report for January 2019” (Nashville: Tennessee Division of TennCare, January 2019), available at https://www.tn.gov/content/dam/tn/coverkids/documents/Enrollment0119.pdf.
2. CMS enrollment data is subject to retroactive changes. Previous blogs posted by Georgetown CCF have reflected different estimates at different times due to retroactive changes.
3. Enrollment trends for 2000 – 2013 were based on Medicaid and CHIP Payment and Access Commission (MACPAC) MacStats, “Exhibit 7: Medicaid Beneficiaries (Persons Served) by Eligibility Group” (Washington: Medicaid and CHIP Payment and Access Commission, 2013), which examined data extracted from the Medicaid Statistical Information System, available at https://www. macpac.gov/publication/medicaid-beneficiaries-persons-servedby-eligibility-group/. Enrollment data after 2013 has not been reported by MACPAC. To examine the enrollment trends for 2013 – 2017, Georgetown University Center for Children and Families analysis of Centers for Medicare and Medicaid Services, op. cit. These data only reflect states that reported data to CMS at the beginning and end of the period examined. Enrollment changes in 2014 reflects difference between enrollment in January 2014 and December 2014 reported by 36 states, as December 2013 was not reported. The change in 2015, 2016, 2017 and 2018 compares enrollment in December year to year. In 2015, data for 46 states is included. In 2016 and 2017, data is reported for 48 states. 2018 data reflects enrollment from all 51 states, including state level data for Arizona, the District of Columbia, and Tennessee.
4. J. Alker and O. Pham, “Nation’s Progress on Children’s Health Coverage Reverses Course” (Washington: Georgetown University Center for Children and Families, November 2018), available at https://ccf.georgetown.edu/2018/11/21/nations-progress-onchildrens-health-coverage-reverses-course/.