Q: How Many Children Were Uninsured in 2020?

A: We won’t ever know, but we do know a lot more could become uninsured in 2022.

As regular readers of SayAhhh! know, we investigate this question every year with our annual report using data from the Census Bureau’s American Community Survey. Last year we found discouraging news for 2019 – the largest jump in recent memory in the number of uninsured children. A combination of factors including more red tape barriers, a “chilling effect” on immigrant and mixed-status families, and cuts to outreach and enrollment during the Trump years all resulted in a reversal of a long positive trend in reducing the number of uninsured children.

And given that 2020 was – well 2020 – we were anxious to get the data this fall to see if the number had gotten worse or better. But last week the Census Bureau announced that, due to concerns with unreliable data collection and low response rates during the pandemic, it will not be issuing the American Community Survey one-year estimates this fall. So we won’t be able to do our annual report with 50 state + DC data that we have been doing for some time now.

What do we think happened in 2020? Well, needless to say a lot of things happened that were not good — including widespread job loss and a recession as a consequence of the COVID-19 pandemic. Early estimates of how many folks were going to lose health insurance as a consequence abounded; however, there is general agreement now that pandemic-related coverage losses were relatively small.

For kids, their reliance on employer-sponsored insurance is lower than for adults because public coverage through Medicaid and CHIP is more generous – with a national average of 255 percent of the federal poverty line.[1] So ESI losses hit adults harder than children. But of course, some children were no doubt impacted by their parents’ loss of jobs and health coverage.

A key countervailing force mitigating against coverage loss in 2020, however, was the adoption of a disenrollment freeze in Medicaid that took effect under the Families First Act. The disenrollment freeze came into effect at the end of March 2020 and is tied to the declaration of the COVID public health emergency by HHS Secretary Becerra.

Sadly, the pandemic appears to be far from over as the delta variant has made clear – and in any event –  it is unlikely the Biden Administration will lift the PHE before the end of 2021. When the PHE is lifted the situation for children and adults could become extremely problematic with large scale coverage losses. As recently reported, Medicaid enrollment now exceeds 80 million people – and over 38 million of these enrollees are children.

My colleague Tricia Brooks recently blogged on how CMS could improve forthcoming guidance on what states must do to minimize the disruption when the freeze is lifted. More to come from us when that guidance is released.

The disenrollment freeze does not apply to CHIP. Recent data from Utah, which had applied the disenrollment freeze to CHIP nonetheless, provides us with an example of what may lie ahead when the Medicaid disenrollment freeze is lifted. A whopping 41% of kids on CHIP lost their coverage in Utah after the CHIP disenrollment freeze was lifted mostly for procedural reasons – even though many are likely still eligible. It is a scary thought to apply that kind of percentage to the number of kids on Medicaid – even if you cut the losses in half.

So we will never know what happened to the uninsured rate in 2020, but we do know that kids and families face extremely choppy waters in 2022 unless major efforts are undertaken by federal and state policymakers, plans and providers, child health advocates and others.

[1] Brooks et al

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