Today we released our ninth annual report that tracks children’s health insurance coverage at the state and national level. This report looks at two-year trends from 2016 to 2018 analyzing American Community Survey data from the Census Bureau. We believe this is the first national report to look at this two-year time period, a time during which our nation moved from implementation of the Affordable Care Act to a time when some of our leaders moved to repeal and dismantle it. This report looks at what has happened to kids during this two-year period. In a few instances we are not yet able to look at two-year trends and include only a one-year trend (2017 to 2018), as noted in the report.

Along with this report we launched a new interactive state data hub with a variety of indicators of children’s health coverage status and quality of care so please check that out too.

For many years our country has made progress improving children’s health coverage rates. This progress predated the passage of the Affordable Care Act (ACA), but the ACA was the cherry on top of the sundae for kids – and brought the uninsured rate to the lowest recorded level of 4.7% in 2016.

However, the number and rate of uninsured children started moving backwards in 2017 and this trend continued into 2018 – with over 400,000 more children uninsured in 2018 as compared to 2016. As a result, much of the gains in children’s coverage that came about as a result of the ACA have now been reversed.

The national uninsured rate for kids in 2018 was 5.2% — which means that just over four million children were uninsured in 2018. As the Census Bureau itself said last month, and we agree, the main cause for the rise of uninsured children is the loss of public coverage – most notably the loss of Medicaid/CHIP.

What is especially troubling about this trend is that things will likely get worse for children before they get better — for two reasons. First this loss of coverage came during a time of strong economic growth and low unemployment when children should be gaining coverage in the employer-sponsored market but no statistically significant change in the one-year period 2017 to 2018 is seen in that regard. During that calendar year almost one million kids lost Medicaid/CHIP coverage. Should an economic downturn occur, and we know that one will eventually occur, we would expect a lot more kids to become uninsured.

Second, the policy reasons behind the loss of public coverage for children are continuing in 2019 and perhaps even accelerating which suggests that these numbers will continue to go in the wrong direction when we get this year’s data next fall. These findings should be a a clear wake up call for elected leaders if they care about children’s health.

Key Findings:

• It is clear from this year’s report that the loss of children’s coverage is widespread with 15 states seeing an increase in the number and/or rate of uninsured children – in most cases both. This level of backwards movement at the state level has never happened since we starting writing this report ten years ago.
• States where the uninsured rate for children has gone up most rapidly are (in order) Tennessee, Georgia, Texas, Utah, West Virginia, Florida, and Ohio.
• Texas continues to have the highest rate of uninsured children in the nation, by far, at 11.2 percent – no other state is even in the double digits.
• Only one state in the nation made progress, and that was North Dakota.
• Another important finding is that states that have not expanded Medicaid to parents and other adults under the ACA saw an increase in their rate of uninsured kids three times as large as states that have. Children in these states that haven’t expanded are nearly twice as likely to be uninsured as those living in states that have expanded Medicaid. Research has consistently shown that offering coverage to the whole family will decrease kids uninsured rates which is why Medicaid expansion is a kids’ issue – though it is rarely seen as such.

Who is Losing Coverage?

In looking at the demographics of those children who are more likely to be uninsured some interesting trends emerge:

• The highest uninsured rates are not for the poorest kids, but rather for those living just above the poverty line — between 138-250% FPL. These are families who are working in low and moderate wage jobs – earning between $30,000 – $53,000 a year for a family of three). These children have the highest uninsured rate of 7.3%, and we saw the biggest jump for this group from 6.9% in 2016 to 7.3% in 2018. The median income eligibility level for Medicaid/CHIP across the country is right around 250% of poverty so many of these children are eligible but aren’t currently enrolled. Or they may live in a state that should consider an eligibility expansion.
• Children in families above this income range also saw a significant jump. This likely reflects a few things – the growing cost of employer provided coverage most especially the lack of affordability for dependent coverage, and the rising premiums in the marketplace for those who are not subsidized in 2017 and 2018.
• White children and Latino children (who can be of any race) saw their uninsured rates go up, black children actually saw a slight decline in their uninsured rate and are now covered at better rates than the national average for all children.
• Young children under age 6 saw a significant increase from 3.8% to 4.3% which is especially troubling as babies and toddlers are in need of higher levels of preventive and routine care – CCF will have a companion piece on this age group coming out in the next few weeks.

Why are fewer children insured?

As I mentioned before, Medicaid/CHIP have seen sharp declines in children’s enrollment. The serious erosion of child health coverage that we are discussing today is due in large part to the Trump Administration’s actions or inactions that have made health coverage harder to access and/or have deterred families from enrolling their eligible children in Medicaid/CHIP.  Specifically, we believe there are three main culprits:

• We are seeing clear evidence of a “chilling effect” among immigrant families – particularly for Latino children whose uninsured rates are already high and are going up. A climate of clear hostility that has been created by the Trump Administration’s many actions and rhetoric has led to a fear and reluctance among immigrant parents to enroll their children in government programs including Medicaid/CHIP. In most cases the children are citizens but the parent is an immigrant, and they are worried about being deported or having trouble in the future adjusting their status.
• Second, we see more red tape for families enrolling or renewing their kid’s coverage. These red tape barriers by states are being put up either with the explicit encouragement or not-so-benign neglect by the Trump Administration – which is ultimately is responsible for ensuring that states fulfill the mission of Medicaid and CHIP to get kids covered. These include problems like more paperwork being required and more frequently to verify income, letters being sent to the wrong addresses but a child is promptly cut off when renewal paperwork isn’t filed. The policy rationale for increasing red tape is to root out fraud and this is indeed a worthy goal. However there is no solid evidence that parents are enrolling their children fraudulently in health coverage. Policymakers who are worried about fraud, and want to be good stewards of the taxpayer’s dollars, should follow the money. No money is going to poor families in the Medicaid program. The money in Medicaid for children in most states is largely flowing to managed care organizations.
• Finally, the “welcome mat” for coverage has clearly been withdrawn. After many years of clear bipartisan leadership to get kids covered and national attention on the value of coverage, the discussion in 2017 about repealing the Affordable Care Act, cutting Medicaid and delaying funding for CHIP has had repercussions as it caused a lot of confusion about whether or not families could get coverage for their kids or not. And, just when families needed more help in navigating this complex environment, they got less help because funding for consumer assistance was cut and in the case of CHIP outreach grants were delayed – missing a critical back to school period in 2018.

The importance of continuous coverage for children cannot be overstated and has long term consequences. Children who have Medicaid have better health outcomes even as adults, are more likely to graduate from high school and have higher earnings as adults – using fewer government benefits in the long term. While 5.2 percent sounds like a small number, the world of families affected is much larger – because families whose child is uninsured even for a few months face medical debt and even bankruptcy if a child falls on the playground and breaks a wrist or has an asthma flare up and winds up in the ER. The red flags are waving in this data and it is up to our elected officials to reverse this troubling trend.

[Editor’s Note: Thank you to the American Academy of Pediatrics, Texans Care for Kids and community-based enrollment specialists in Florida for joining us in releasing this report.]

* Families looking for information on how to enroll their children in Medicaid or CHIP call 877-KIDS-NOW or visit insurekidsnow.gov.]