In This Report:
Key Findings
- The number of uninsured children declined during the COVID-19 pandemic largely due to federal law which has protected access to health care for Medicaid beneficiaries by requiring states to keep them enrolled during the federally declared COVID-19 public health emergency in exchange for enhanced federal funding. This reverses the trend from 2016 to 2019 when the number of uninsured children had been going up. Medicaid protections helped ensure coverage for children whose families lost their employer-sponsored coverage during the early period of the pandemic. The continuous coverage protection also prevented eligible children from losing coverage due to “procedural reasons,” which is a common occurrence for children under normal operating procedures in many states. Procedural losses occur when eligible children fall off the program because their coverage isn’t renewed due to administrative barriers.
- Twelve states saw significant declines in their rate and/or number of uninsured children with Oklahoma, Connecticut, Indiana, Colorado, and Texas seeing the largest improvements. Despite the improvement, Texas continues to rank last in the country with the highest rate (11.8 percent) and number (930,000) of uninsured children
- Idaho, Maryland, and New York went in the wrong direction with Idaho seeing the largest jump in the number of uninsured children—an increase of 46 percent.
- Children in low-wage working families with annual incomes between $30,305 and $54,900 (for a family of three) saw the biggest reductions in their uninsured rates.
- These coverage gains are at risk when the Medicaid continuous coverage protection lifts at the end of the federal COVID-19 public health emergency. According to a separate analysis conducted by Georgetown University Center for Children and Families researchers, an estimated 6.7 million children are at risk of losing coverage and the child uninsured rate could more than double if states do not do a good job of keeping eligible children enrolled when the continuous coverage protection ends. Most of the children losing coverage will remain eligible but their coverage will be dropped due to procedural rather than eligibility reasons. As of this writing, the public health emergency is expected to remain in place until at least April 11, 2023.
Data released by the U.S. Census Bureau’s American Community Survey (ACS) for 2021 finds that nationally the estimated number and rate of uninsured children went down slightly from 2019 to 2021. This data provides the first comprehensive look at what happened to children with respect to this metric during the first part of the COViD-19 pandemic—as standard ACS data were not available for 2020.
Prior to the pandemic, the number and rate of uninsured children had been rising for the first time in many years. Substantial job losses in the early months of the pandemic led many to fear that large increases in the rate of uninsured children and adults would ensue. Fortunately, this prediction did not pan out, and in fact, as these new data show, the uninsured rate for children got slightly better. This reversal of fortune during a difficult period is generally attributed to federal protections put in place that ensure that no one can be disenrolled involuntarily from Medicaid during the federally-declared COVID-19 public health emergency—in return for enhanced federal funding to support state Medicaid programs. Medicaid enrollment has increased substantially during the pandemic with child enrollment increasing by 16.1 percent from February 2020 (prior to the continuous coverage protections being established in march 2020) to June 2022.
Enrollment increases in the Affordable Care Act’s Marketplace due to enhanced subsidies and greater outreach and enrollment efforts have also played a positive, albeit smaller, role for children. Overall, increases in public coverage (primarily Medicaid) more than offset any losses of employer-sponsored coverage early in the pandemic. Medicaid's continuous coverage protections also minimized loss of coverage common in normal times for low- and moderate-income children due to procedural reasons—also known as administrative “churn.”
Procedural (non-eligibility) losses at renewal occur when there is insufficient information to verify ongoing eligibility. Disenrollment for procedural reasons is more prevalent in states that have not kept pace with others in automating their renewal systems to efficiently and accurately verify ongoing eligibility using income and other electronic data available to the state. In turn, families in states that have not modernized have to navigate their way through more administrative hurdles in order to keep their children enrolled in Medicaid. This leaves open many potential points of failure in the system that could leave more children uninsured. For example, if families never receive the paper renewal notice in the mail or find it confusing, and are unable to get through to the call center for assistance, or the state loses their paperwork, coverage is terminated. Procedural disenrollments are a bureaucratic failure to streamline the process and remove unnecessary administrative barriers to enrollment and retention. In addition, some states have done a better job than others in working with providers, plans, and community-based organizations to educate and engage families in the enrollment and renewal processes.
The number of uninsured children declined from 4.375 million in 2019 to 4.165 million in 2021—a five percent decline of 210,000. The rate of uninsured children nationally declined from 5.7 percent to 5.4 percent. both of these changes are statistically significant. This slight decline followed a period of rising numbers of uninsured children from 2016 to 2019 when an estimated one million more children became uninsured. Prior to 2016, the number of uninsured children had been declining for many years largely as a consequence of expansions of public coverage for children through Medicaid and the Children’s Health Insurance Program (CHIP) and steps to make it easier for eligible children to enroll. Other federal data sources show an even sharper decline in the child uninsured rate from 2019 to 2021 with approximately 700,000 fewer uninsured children.
What Has Happened at the State Level?
Twelve states saw statistically significant improvements in the number or rate of uninsured children or (in most cases) both during the examined period; the largest number of children gaining coverage was in Texas with 65,000 more children insured—although Texas continues to have the largest number of uninsured children in the country by far with 930,000. Three states saw significant increases in their number and/or rate of uninsured children (Idaho, Maryland, and New York) with Idaho showing the largest increase of 46 percent in its uninsured child population. (See Appendix Tables for more information.)
Children in Oklahoma saw the biggest improvement with the uninsured rate declining from 8.6 percent to 7.4 percent although the state still ranks 44th in the country. in addition to the continuous coverage protection that was in place in all states, Oklahoma’s improvement is likely in part a reflection of the “welcome mat” effect of the passage of a ballot initiative to implement the ACA’s Medicaid expansion for adults—for which enrollment began in Oklahoma in June of 2021 and the number of enrollees grew quickly.
States in New England continue to have the lowest uninsured rates for children. The South is a mixed picture with Texas having the highest rate and number of uninsured children in the country, and Florida and Georgia continuing to have a large percentage of the uninsured children overall and relatively high rates in general. As a region, the Mountain West is falling most consistently behind the national average (with the exception of Colorado).
Which Children Were More Likely to Gain Coverage?
The uninsured rate for children overall has declined since 2019, but some groups of children have seen bigger coverage gains. American Indian and Alaska Native children saw the largest decline in the uninsured rate of any racial group, falling by two percentage points between 2019 and 2021. White children and Asian, Native Hawaiian, and Pacific Islander children also saw statistically significant declines in uninsurance, but the uninsured rate for children of another race or multiple races increased in 2021.
Looking at ethnicity, uninsured rates for both Hispanic/Latino and non-Hispanic/Latino children fell. The disparity between Hispanic and non-Hispanic children also narrowed somewhat in 2021, although the uninsured rate for Hispanic children is still more than twice as high as it is for non-Hispanic children.
Children in low-wage working families were more likely to gain coverage. Children in families earning between 138 percent and under 250 percent of the Census poverty threshold ($30,305 to under $54,900 for a family of 3) saw the largest gains, and children at the lowest end of the income scale also saw a significant improvement in their health coverage rates (see Table 3). The uninsured rates for children across all ages fell. For young children under age 6, the uninsured rate declined from 4.7 percent in 2019 to 4.5 percent in 2021, and the rate for school-age children fell from 6.1 percent in 2019 to 5.7 percent in 2021.
Conclusion
The improvement of the child uninsured rate has been a bright spot for children during the dark days of the pandemic. however, troubled waters likely lie ahead. Medicaid's continuous coverage protection will expire when the federal COVID-19 public health emergency ends, putting millions of children at risk of losing Medicaid. separately, we have estimated that 6.7 million children are at risk for a period of uninsurance. Of the children projected to lose Medicaid after the continuous coverage protection is removed, an estimated 3 out of 4 will still be eligible. Unfortunately, there are numerous potential points of failure in the system that put children and their families at risk of falling through the cracks as states take up the unprecedented challenge of redetermining eligibility for over 80 million people currently covered by Medicaid.
Eligible children in states with less advanced systems and more red tape and administrative barriers to enrollment will be at greater risk of inappropriately losing Medicaid while children in states with 12-month or longer periods of continuous eligibility and other strategies in place will be better protected from becoming uninsured. While there is a longstanding option for states to provide up to 12 months of continuous eligibility for children in their Medicaid and CHIP programs, as of January 2022, only 24 states did so for all children in Medicaid and CHIP. Seventeen states and the District of Columbia do not have continuous eligibility for Medicaid or CHIP for any children. Congress should consider guaranteeing 12 months of continuous eligibility for children in Medicaid and CHIP regardless of where they live. States can also pursue longer periods of Medicaid eligibility for young children through section 1115 authority as was recently approved for Oregon and is in process in Washington, New Mexico, and California. These policies will help reduce but not eliminate the perpetual problem of administrative churn that leaves children with gaps in health coverage.
Children continue to face increased threats to their health from COVID-19, RSV, and other viruses while families continue to struggle to make ends meet. The Medicaid continuous coverage provision provided stability during a tumultuous time and policymakers should proceed with caution when they remove that important protection.
