Child Uninsured Rate in 2021: Medicaid’s Continuous Coverage Provision is Helping

Children’s uninsured rate decreased from 2020 to 2021, according to new Early Release data from the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS). According to the NHIS, uninsurance for children under age 18 fell to 4.1 percent in 2021. Using this data source, the uninsured rate had remained steady at 5.1 in 2019 and 2020.

As readers of SayAhhh! know, the child uninsured rate started going up from 2016 to 2019 and jumped a full percentage point from 4.7 percent to 5.7 percent, according to the Census Bureau’s American Community Survey (ACS). This increase during the Trump Administration was the first time in a long time that progress reversed after many years of reductions in the number of uninsured children. We attributed those increases to a few factors – a “chilling effect” of anti-immigrant policies, more red tape losses (where children are eligible for Medicaid/CHIP but lose coverage for procedural reasons), and cuts in outreach and enrollment funding.

But due to problems associated with the pandemic, the Census Bureau did not release the ACS, our usual source of data, for 2020. So the NHIS can serve as a first look at reliable national data. While the percentages above should not be strictly compared as they are from different data sources, what seems clear is a reversal of the negative trend on children’s health coverage that we saw during the Trump Administration.  In other words, the U.S. is once again going in the right direction.

What’s behind the coverage gains? The NHIS shows that public coverage for children has increased, from 41.4 percent of children in 2019 to 44.3 percent in 2021. Indeed, enrollment data from the Centers for Medicare & Medicaid Services (CMS) show that child enrollment in Medicaid and CHIP increased by more than 14 percent between February 2020 and December 2021, equal to about 5 million kids gaining coverage. Based on this data, we think the actual share of children insured by public coverage is even higher than under the NHIS, at about half. (CMS counts children as everyone under age 19, whereas NHIS only counts children as those under 18. Additionally, surveys like NHIS and even the ACS tend to substantially undercount Medicaid and CHIP coverage.)

So this suggests that key Medicaid policies enacted during the pandemic have not only prevented increases in uninsurance but have actively helped stabilize and strengthen children’s coverage. Of the more than 41 million children who were enrolled in Medicaid and CHIP by the end of 2021, we have previously estimated that more than 37 million children who get their coverage through Medicaid are protected by the continuous coverage requirement, which applies during the public health emergency.  The requirement means that states cannot disenroll beneficiaries from coverage without sacrificing an extra 6.2 percentage points in their federal Medicaid match rates.

Additionally, a record number of children are now enrolled in ACA Marketplace coverage, aided by enhanced premium subsidies that made coverage more affordable for millions (although these subsidies are currently set to expire at the end of 2022 unless Congress acts to extend them).

Who’s still getting left behind? Children in families making at least 200 percent of the federal poverty level (FPL) saw their uninsured rate decrease from 4.3 percent in 2019 to just 2.7 percent in 2021, but children at lower income levels haven’t seen the same coverage gains. The uninsured rate for children below the poverty level and for children between 100 and less than 200 percent FPL was more than double the rate of higher income children in 2021, at 6.1 percent and 5.6 percent respectively. Although these groups saw small declines in their uninsured rate from 2020 to 2021, the changes were not statistically significant.

Nonetheless, this is an encouraging sign that children have made significant coverage gains despite challenges in recent years. Coverage is the price of admission to our health care system and protects against medical debt and potentially severe economic consequences for families during tough time. It is also an important reminder of what is at stake as states consider their plans for resuming regular operations when the public health emergency terminates and the continuous coverage protection lifts.

A note about the data: The NHIS Early Release Program publishes estimates ahead of final editing and weighting to provide timely access to its data. The estimates are typically very reliable, though they may differ from final estimates. The NHIS also adjusted its data collection procedures during the pandemic, which they note changed respondent characteristics, including income, and may affect comparisons between April-December 2020 and other time periods, so we include comparisons to 2019.