As readers of SayAhhh! know, Georgetown CCF does an annual report on children’s coverage every fall using the most recent data from the Census Bureau’s American Community Survey (ACS), which is typically released in September. This year, the 2023 data will be released on September 12th; the Census Bureau’s Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC), which contains related data on poverty, income, and health insurance, will be released on September 10th. Together, these surveys are important annual assessments of how the country is doing across a range of economic and social indicators – including reducing the number of uninsured people and tracking how sources of coverage are changing.
Of course, 2023 was the year that the Medicaid “unwinding” began as pandemic-related continuous coverage protections lifted. As of this writing, net Medicaid enrollment has declined by about 14 million people overall and 5.2 million children, according to our tracker which provides the most up to date numbers available on this key metric. We have written about how much variability there has been in state performance – with three states (Texas, Florida, Georgia and California) accounting for half of the decline in net child Medicaid enrollment. Texas alone accounts for 24% and has 1.3 million fewer children enrolled.
Since as readers of SayAhhh! know, the majority of children who lose Medicaid coverage remain eligible. So we have been very worried about the child uninsured rate going back up as many of the children losing their Medicaid coverage during unwinding were disenrolled for procedural reasons and likely were still eligible. In 2021 and 2022, thanks largely to the continuous coverage protections, the child uninsured rate declined to 5.1%. However, if even 1 in 7 of the 5.2 million fewer children enrolled ended up uninsured, the uninsured rate could go up by a full percentage point. And it’s likely that a greater share ended up uninsured.
Undoubtedly, large numbers of children in certain states have been experiencing gaps in coverage; we have heard countless stories from families and pediatricians of coverage loss. Our hunch though is that we won’t see lots of movement in the ACS data. There are a few reasons why.
First, ACS data are collected monthly and reflect individuals’ coverage at the time they fill out the survey. Since states began unwinding at different times — and some states had not started coverage terminations until October — unwinding didn’t really get going until the second half of the calendar year. Three quarters of the Medicaid child enrollment decline happened in the second half of the year as the graph below shows. This means that individuals who responded to the survey earlier in the year may have still had Medicaid coverage, even if they later lost that coverage when their state began unwinding.
Second, it has been long established that the ACS undercounts Medicaid coverage compared to administrative enrollment numbers, and that this undercount got substantially worse during the pandemic. Additional research shows that children overall — particularly young children — are also undercounted in Census data. If the ACS data has many fewer children with Medicaid coverage measured in the first place, relative to administrative data, we might not see the same subsequent large coverage declines we’ve been observing in our enrollment tracker (although the undercount is not unique to Census data).
Third, more people have had more than one source of coverage during the pandemic, including Medicaid coverage. For example, ACS data indicate that the share of children with two or more types of health insurance rose from 5.9% in 2019 to 7.5% in 2021 and 2022. If some of these individuals lost Medicaid coverage but already had another type of insurance, we may not necessarily see the uninsured rate rise as much as we expect.
Finally, other 2023 survey data we do have hasn’t shown major coverage changes despite the clear impact of Medicaid unwinding. The CDC’s National Health Interview Survey (NHIS) didn’t indicate a statistically significant change in either the overall or child uninsured rate from 2022-2023. And even more recent analysis of the Census Bureau’s Household Pulse Survey hasn’t shown widespread changes in uninsurance from March 2023 through July 2024 either (the survey doesn’t include children).
However, it is possible that the ACS will show some significant change in large states that started unwinding in the first half of the year and had high rates of child disenrollment in 2023 – most notably Texas (started in May; 23% decline in 2023), Florida (April; 19% decline in 2023) and Georgia (May; 17 percent decline in 2023). We shall see.
It’s important to note that the ACS is still one of the best data sources we have about the children and families who don’t have health insurance coverage — especially by state, age, income, and race and ethnicity. But we may have to keep waiting to see more of the impact of unwinding and where people land in each state: data for 2024 will not be available until the fall of 2025.