In This Report:
The number of uninsured children was on a downward trajectory for many years,1 but in 2017 started going back up, rising a full percentage point between 2016 and 2019 (see Figure 1).2 This issue brief examines the incidence and characteristics of children who experienced a period of uninsurance over the course of a recent year during this uptick and some of the consequences. 3 This is a considerably larger group than the number of uninsured children reported by the Census Bureau’s American Community Survey (ACS), which measures those who are uninsured at a point in time during the year, or by the Census Bureau’s Current Population Survey (CPS), which measures those who reported being uninsured for all of the prior year.
Any gap in coverage is a problem for children and their families. Cost barriers lead to avoidance of care, especially for low-income families, and children need regular care.4 Well-baby and well-child visits are essential to track developmental milestones, receive immunizations and identify and treat acute or chronic conditions so they do not get worse. By age 16, 40 percent of girls and 64 percent of boys will have experienced at least one bone fracture.5 This requires urgent/emergency care that can result in serious medical debt for families should it occur during a gap in coverage. While families with higher incomes tend to have more steady coverage, low and moderate income families experience more coverage churn and periods of uninsurance.
How many children experience a gap in coverage during a year?
As Figure 2 shows, over the course of twelve months, approximately one in ten experienced a gap in coverage. (Gaps in coverage are defined as being uninsured for one or more months during the year.) This is almost double the number of children who are uninsured under the more static ACS data. Looking just at children whose families are low or moderate income (below 250 percent of the federal poverty line), the number rises to 13 percent of children who experienced a gap in coverage over the course of a year.
What are the characteristics of children who experience gaps in coverage?
By Race and Ethnicity: Gaps in coverage are more likely to impact children in communities of color. Fourteen percent of Latino children experienced a gap in coverage over the course of a year and nearly 12 percent of Black children had a gap in coverage. In comparison, White children experienced gaps at a lower rate than the national average—although gaps in coverage still affect a sizeable 7.3 percent. This is an especially important and troubling finding with respect to Black children, whose uninsured rate overall using the more static ACS data is similar to that of Non-Hispanic White children (4.6 percent v. 4.3 percent in 2019, respectively)6
By Region: Children are most likely to see gaps in coverage if they live in the South. Children living in the Northeast are least likely to experience a gap in coverage.
How do gaps in coverage affect children’s access to care?
Children who are uninsured for some period during the year have more trouble accessing health care. More than one in four (26 percent) children with a gap in coverage lack a usual source of care, three times the rate of children who are covered yearround (see Figure 5). Furthermore, while 43 percent of children with stable coverage saw a doctor at least twice, more than half of children with a gap in coverage did not see a physician during the year (see Figure 6).
Children who were uninsured during the year are also more likely to live in families who had trouble affording care. This could mean that they did not receive treatment because they couldn’t afford it, they had delayed treatment because of cost, or they lived in a family with someone who had trouble paying or was unable to pay their medical bills. .
The number of children who experience a gap in coverage over the course of a year is an important, but often overlooked, issue for federal and state policymakers. This group is considerably larger than commonly assumed and coverage gaps during a year are more prevalent among Black and Latino families. Moreover, the number of children experiencing coverage gaps would likely grow if a longer period of data were examined.
In addition, children with gaps in coverage are considerably less likely to see a doctor and have a usual source of care than children whose coverage is stable. Families with gaps in coverage, predictably, are more likely to have trouble affording care.
While children are relatively inexpensive to cover, they need frequent routine and episodic care. These findings suggest troubling patterns that underscore the need for children to have continuous coverage and the ability to maintain a continuous connection with their pediatricians.
Why is Medicaid/CHIP Continuous Eligibility So Important for Kids?
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The data presented in this brief come from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS). This analysis pools MEPS Household Component full-year consolidated data files for 2018 and 2019 in order to increase sample sizes and allow for subgroup analysis. Data are weighted using provided MEPS person-level weights for each year.
This brief also refers to data from the Census Bureau’s 2019 American Community Survey (ACS). These data are meant to show the differences between how many children are considered to be uninsured under different measure definitions. ACS data should not be directly compared to MEPS data due to differences in survey methodologies.
Only children under age 19 who had valid health insurance data reported for each month of the year were included in this sample. Health insurance status was determined using MEPS-constructed monthly insurance indicators. MEPS considers respondents uninsured in a given month if they were not covered by Medicaid/CHIP, Medicare, TRICARE, Veteran’s Administration (VA), or other public or private medical or hospital insurance; Indian Health Service (IHS) care is not considered a source of health insurance coverage. Children are considered uninsured during the year if they were uninsured in any month. Children are considered to be covered year-round if they had a source of health insurance coverage in every month of the year.
Standard Errors, Statistical Significance, and Data Suppression
Estimates, standard errors, and coefficients of variation are calculated in STATA statistical software. As recommended in “Using Statistical Software Packages to Produce Estimates from MEPS Data Files,” standard errors are calculated using the Taylor-series linearization method. Standard errors are not presented in this report but are available upon request.
Statistical significance is determined using the U.S. Census Bureau “Statistical Testing Tool” with a confidence interval of 90 percent.
- The Future of CHIP and Children’s Coverage, Report to Congress from the Medicaid and CHIP Payment Advisory Commission (MACPAC), March 2017, p. 7, available at https://www.macpac.gov/wp-content/uploads/2017/03/The-Future-of-CHIP-and-Childrens-Coverage.pdf.
- Alker, J. and Corcoran, A., “Children’s Uninsured Rate Rises by Largest Annual Jump in More Than a Decade” (Georgetown University Center for Children and Families, October 2020), available at https://ccf.georgetown.edu/wp-content/uploads/2020/10/ACS-Uninsured-Kids-2020_10-06-edit-3. pdf.
- Georgetown University Center for Children and Families analysis of Agency for Healthcare Research and Quality’s 2018-2019 Medical Expenditure Panel Survey data. See methodology for more information.
- Krutika, Amin et al., “How does cost affect access to care?” Peterson-KFF Health System Tracker, available at https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care/#item-start.
- Bachrach, Laura. “Casting More Light on Pediatric Fractures,” Pediatrics August 2019, available at https://doi.org/10.1542/peds.2019-1594.
- Alker and Corcoran, op cit. p. 9.