When it comes to recent trends in children’s coverage, much attention has rightly focused on the significant child enrollment increases in Medicaid over the past few years due in large part to the Medicaid continuous coverage requirement. Although the Marketplaces cover far fewer children by comparison, child enrollment in Marketplace plans has increased substantially for the second year in a row. New data from the Centers for Medicare and Medicaid Services (CMS) for the 2023 Marketplace Open Enrollment Period show that more than 1.5 million children under age 18 enrolled in Marketplace coverage in 2023, a 17% increase (about 222,700 more children ) from 2022. As shown in the chart below, children’s enrollment stayed relatively flat at about 1 million children from 2016-2021, but has now increased by more than 50% over the past two years.

Children aren’t the only ones seeing enrollment increases—total Marketplace enrollment also reached a new high of nearly 16.4 million people selecting plans in the Open Enrollment Period for 2023, a 13% increase compared to 2022 and a 36% increase compared to 2021 (14.5 million consumers enrolled in 2022 and 12.0 million enrolled in 2021). Because total enrollment has also increased, children still make up only about 9 % of Marketplace enrollees (since 2015, children’s share of the Marketplace population has hovered between 8% and 10% ). Children did see some of the largest gains across age groups, though, tied with adults ages 35-44 and second only to older adults ages 65 and up, although older adults still make up a very small share of the Marketplace with enrollment under 288,000.

As noted, overall, children saw a 17% increase in Marketplace enrollment. But this varied by state, ranging from a 16% decline in Kentucky (6,115 children enrolled) to increases of 30% or more in Florida (310,099), Texas (272,368), and Tennessee (23,146). States using the federal HealthCare.gov platform also saw much larger enrollment gains this year compared to those using their own State-Based Marketplaces (21% increase vs. 2% increase).

Enrollment growth was also heavily concentrated in the 12 states have not yet expanded Medicaid, with about 181,000 additional children enrolled in these states in 2023 compared to the previous year—a 27% increase, compared to just 6% more (about 42,000 additional children) in expansion states. Although Medicaid expansion applies to adults, parents often enroll themselves and their children at the same time, and child Medicaid/CHIP eligibility levels are generally higher in expansion states so more children have public coverage rather than relying on the Marketplaces. The chart below shows this relationship, comparing each state’s percent change in Marketplace enrollment to their eligibility level for children’s Medicaid coverage. Bigger bubbles indicate more children are enrolled in Marketplace coverage in that state.

States like Florida and Texas have lower Medicaid eligibility levels for children and experienced some of the highest enrollment growth increases in 2023. On the other hand, New York, which has the highest child Medicaid income eligibility level, saw zero change from 2022 to 2023, and other states with higher child Medicaid eligibility levels like California, Pennsylvania, New Jersey, and Massachusetts also saw small growth or even slight declines in Marketplace enrollment. A handful of states—West Virginia, Alabama, and Iowa—had both high Medicaid eligibility and big Marketplace enrollment increases.  However, some states like Nevada and Kentucky with relatively low Medicaid eligibility had Marketplace enrollment declines as well; this could foreshadow net coverage losses for children in those states as states unwind the Medicaid continuous coverage requirements.

The Marketplaces have been a relatively smaller but still important counterpart to Medicaid and CHIP in shoring up children’s coverage during the pandemic, particularly with the extension of enhanced premium tax credits, the family glitch fix, and the new special enrollment period for people who lose Medicaid coverage during the continuous coverage unwinding. And while previous estimates suggest that between 1.5 million and 2.7 million people losing Medicaid could become eligible for premium subsidies in the Marketplace, most children who are disenrolled from Medicaid will still be eligible for Medicaid coverage even if their parents or other adults in their lives no longer aren’t (many will also be eligible for CHIP). State-based and federal Marketplaces that work closely with state Medicaid agencies will be better able to make sure that eligible children stay enrolled in Medicaid and are not left without coverage or enrolled in the Marketplace inappropriately. Even so, with about 7 million children projected to have their Medicaid coverage terminated, record child enrollment in the Marketplaces could continue through the near future.