Last month, the Urban Institute released a report detailing uninsurance rates between 2019 and 2022 for families with young children (under age 3).  The report revealed significant drops—for the children, for fathers, and most significantly, for mothers.  There were multiple factors contributing to these rises in coverage rates—pandemic-era continuous enrollment policies such as the Families First Coronavirus Relief Act of 2020, increased marketplace subsidies, and a 7-state increase in ACA Medicaid expansion (ID, ME, MO, NE, OK, UT, VA).  But even with coverage gains the bottom line is that 2.1 million young children and their parents remained uninsured in 2022. Parents of infants and toddlers account for the majority of that figure.

Early childhood is a critical time for development—the first few years of life are foundational to a child’s lifelong health and brain architecture, and early experiences with challenges like sustained financial hardship or unmet health needs, can contribute to serious physical or behavioral conditions that, if left unaddressed, impact academic achievement and ability to thrive in the long term. The key to positive early development is the strength of the child’s relationship with parents and caregivers.  Young children do not exist in a vacuum — their parents’ and caretakers’ health and access to care plays a significant role in their physical, behavioral, and emotional development. The importance of parent health on children’s development is why the American Academy of Pediatrics recommends parent depression screening during well-child visits. But without their own health coverage, accessing needed mental health care to address depression or other health conditions is more challenging.

Parent coverage matters for children, especially young children. Young families are especially susceptible to immense stress, financial instability, and emotional fatigue given the big changes and adjustments that come from welcoming a new baby into the household or family.  These stressors weigh on parents, which in turn impacts the entire family system.  Multiple bodies of research on Medicaid expansion show that covering parents and caregivers boosts child health outcomes and improves economic security for families.

The study conducted by Urban disaggregated American Community Survey (ACS) data between mothers, fathers, and the children themselves.  Overall, uninsurance dropped 0.4 percent (4.5 to 4.1) for young children, 2.9 percent (12.3 to 9.4) for their mothers, and 1.8 percent (14.1 to 12.3) for their fathers.  That’s nearly three percentage points for mothers and two for fathers within a three-year period.  Between the 7 states that expanded Medicaid under the Affordable Care Act, these drops were even greater with mothers’ dropping 4.8 percent and fathers’ dropping 3.6 percent.  Despite the difference in rate change — children experiencing the least drastic drop — parents of young children remained far more likely than their children to be uninsured.  (Mothers were over twice more likely and fathers over three times more likely to be uninsured.)  Moreover, noncitizen parents in 2022 were more than three times as likely to be uninsured as their citizen counterpart parents.

Non-expansion states and states that were implementing Medicaid expansion during the 2019-2022 period experienced the most significant drops from these policies.  Despite this, 2022 uninsurance rates remained higher among young children and their parents in non-expansion states (see Figure 7, above)– nearly one in five fathers were without health coverage – and the gap has certainly widened since the Unwinding of the continuous coverage protection began in April 2023.  To those familiar with Medicaid expansion, this is not surprising.  Since its passage, the ACA has been shown to be incredibly effective at shrinking uninsurance rates for children, bettering the health of families overall and especially for prenatal-to-three populations.  CCF’s report details the connection between ACA implementation and lowered uninsured rates for children– including that “while the majority of all children live in expansion states, the majority of uninsured children live in non-expansion states.” 

Ten states have still not adopted Medicaid expansion and, given that many adults and parents fall in between the eligibility levels for traditional Medicaid and the Marketplace, an estimated 3.5 million uninsured adults would become eligible for Medicaid if these states expanded income eligibility to 138% of the FPL.  This expansion would help young families across the board, improving access and timeliness of prenatal care, stabilizing families’ economic security, and even increasing healthy birth outcomes.  

While the data on young families’ uninsurance rates today are not yet available for analysis, it is safe to say that millions of young families are still without access and coverage of critical health care– and this report points to concrete examples from the 2019-2022 period of tangible policy changes that improve coverage rates for this group.  It also highlights that the more parents get coverage, the more their children will, too – expansion is an essential policy decision for any state looking to improve maternal, infant, and child health outcomes.  Given the unwinding and other developments in the coverage landscape, Urban Institute’s report lays out six forward-thinking policy recommendations for mitigating uninsurance rates for young children and their parents:

• Robust implementation of Medicaid/CHIP continuous eligibility for children and postpartum extensions
• Continuation of enhanced Marketplace subsidies beyond 2025
• Enrolling more uninsured people in Medicaid, CHIP, or heavily subsidized Marketplace plans
• Adoption of Medicaid expansion in the remaining non-expansion states
• Expansion of access to affordable coverage for immigrants
• Addressing access to care and other basic needs facing families of young children.