As readers of Say Ahh! know, we’ve been closely tracking data from around the country related to the lifting of the COVID-19 pandemic related continuous coverage protections in Medicaid. The tracker is going up very quickly now– we hit one million on Halloween, two million on Thanksgiving and today three million fewer children are enrolled in Medicaid. We hit three million and counting as Florida posted its November data which was fitting – as Texas and Florida account for over one million of the children who have lost coverage. Total Medicaid net enrollment decline for adults and children due to the unwinding is now at approximately 7.8 million.

States are moving at different speeds to reassess eligibility for everyone covered by Medicaid – and as feared the process has laid bare the indifference of some elected officials — as well as the systemic challenges of conducting redeterminations for approximately 90 million people even in states where top officials are deeply committed to protecting against coverage loss.

Our tracker looks at the cumulative net decline in child and total enrollment in Medicaid by state using the latest available data for each state and comparing it to the month before the state began redeterminations. These numbers represent net change — so more children have been impacted or faced a gap in coverage. It’s especially problematic to see large declines in child Medicaid enrollment because most of those losing coverage likely remain eligible suggesting that the number of uninsured children is rising rapidly.

Coincidentally the Biden Administration released its own data today on the numbers of children losing coverage, more guidance about what states should and can do, and Secretary Becerra sent individual letters to nine Governors (TX, FL, GA, OH, AR, SD, NH, ID, MT) with the worst records in the country on disenrolling children. We’re parsing through the many pages of information and will have more to say, but we’re very pleased to see that the Biden Administration has put children at the top of their list as the Christmas break looms and recognizes the gravity of the crisis and the number of children losing coverage keeps going up.

As discussed below, we don’t know how many of these children are becoming uninsured but there is good reason to worry. In 2022, 3.9 million children were uninsured, so even if the majority of children losing Medicaid have other sources of coverage, the number of uninsured children is rising sharply.

Prior to the unwinding, administrative data we examined found that more than half of children in the United States had Medicaid coverage. Unwinding is a huge challenge for low and moderate income communities across the country – especially rural areas which are more reliant on Medicaid as a coverage source – but Medicaid’s importance for children and the providers who serve them is significantly higher. Families of color are also at greater risk of coverage loss. And prior to the pandemic, the majority of uninsured children were eligible but not enrolled in Medicaid or CHIP – especially in states with more red tape barriers at enrollment or renewal.

States with the highest child enrollment loss in numeric terms include Texas which is leading the pack with almost 654,000 fewer children enrolled. Next up is Florida with a net child decline of just under 380,000 and California with about 219,000. I will say it again — Texas and Florida alone account for one-third of the child coverage loss.

Some small states are also seeing huge percentage declines in the number of children enrolled in Medicaid with Utah and South Dakota leading the way shedding one-quarter of their Medicaid child enrollment (26.7% in Utah and 23% in South Dakota), with New Hampshire not far behind at 17 percent. CMS data also highlights Arkansas, Idaho, and Montana in this regard.

Where might these children losing Medicaid be picking up other coverage? Employer-sponsored insurance is a possibility and little data is available – especially with respect to children. Low-income families are less likely to have an offer of employer-sponsored insurance, and in particular, for family coverage.  Moreover, the discouraging news on this front, though, is that the affordability of employer based family coverage gets worse every year – with average employer based family premiums rising 7% in 2023 and workers expected to pay on average $6,575. So children are less likely to be landing here as opposed to a parent eligible for employee coverage – or parents may be paying very unaffordable premiums – not recognizing that their children still may be Medicaid eligible.

The marketplace is not a big source of coverage for children since most are Medicaid or CHIP eligible even if their parents are enrolled in the marketplace. So far, as my colleague Edwin Park has blogged about, Marketplace enrollment remains a valuable source of affordable coverage for those losing Medicaid but only for a small proportion of adults and an even smaller proportion of children. While the lifting of the family glitch was a positive policy change, there is little evidence to suggest that there has been any sizeable increase in the proportion of children enrolling in the Marketplace; it may be having a bigger impact on spouses’ access to coverage.

The most likely place that children should be going if their families’ incomes went up during the pandemic is CHIP, but as we’ve blogged about before, separate CHIP programs are not seeing large increases in most places – and in some states CHIP enrollment is actually going down. We’ve updated our data and increases in separate CHIP enrollment offset only 7.9 percent of the decline in Medicaid child enrollment in states with separate CHIP programs. We will have another blog unpacking the CHIP data by state soon.

Almost all states are seeing Medicaid enrollment declines, a few states have seen child enrollment tick back up (MN, NM VA), but not enough to account for cumulative losses. Some of these may reflect actions states have taken to reinstate coverage for children after the error in ex parte redeterminations was discovered over the summer. Rhode Island, a very small state, has held steady for children’s enrollment and Oregon, Kentucky and Massachusetts have seen very small declines. You can check your state’s enrollment changes if you scroll down here.

More importantly, the governors of Kentucky and North Carolina have made a bold choice to protect children in their states and taken up an “(e)14” flexibility offered by CMS to pause renewals and therefore keep all children currently enrolled for another year. This choice not only protects children — who largely remain eligible anyway — but allows states to focus on getting it right for adults and people with disabilities. These states can turn back to children in a year’s time when things calm down. And of course North Carolina is implementing Medicaid expansion for adults which is keeping them busy.

States must take bold action to prevent a large increase in their uninsured child population. Three million losing Medicaid and counting is a terrible way to ring in the new year.