Every year we examine data provided by the U.S. Census Bureau’s American Community Survey (ACS) which provides the most comprehensive look nationally and by state at important trends impacting America’s families – including health insurance. Today we are sharing our analysis of data that came out just yesterday for calendar year 2024. Our analysis is focused on health insurance status of children 18 and under, and we looked at all 50 states and the District of Columbia. We examined a two-year period from 2022 to 2024. During this period, most states started and completed their “Medicaid unwinding” process – an unusual historic event in Medicaid policy where pandemic era protections of continuous coverage were lifted and states had to check eligibility for tens of millions of Americans covered by Medicaid.
As many of you know, we were very worried about eligible children being disenrolled by mistake during this process – especially in states that did not approach the process with the utmost care. Because children are much more likely than their parents or other adults to be eligible for Medicaid/CHIP – with a national median income eligibility level of about 255% of FPL – large numbers of children losing coverage during the unwinding was a sign that children who remain eligible were being disenrolled for procedural reasons. We monitored these trends very closely tracking indicators of how well states were meeting the unwinding challenge and found wide variability on state performance. This huge state variability is reflected in the data we are examining today.
Before I get into the findings, let’s talk about why having health insurance is important for children and families. Sometimes we hear hints being dropped in policy debates that health insurance is not important. For most American families (except perhaps the uber wealthy) there is no need to explain why having health insurance is important for their children. No parent wants to have to think twice about costs when taking their child to the doctor or picking up their prescription at the pharmacy. Health care is expensive; and families can be bankrupted by even a short gap in coverage for a child. An accident on the playground, or untreated asthma can result in trips to the emergency room which cost thousands and thousands of dollars. This is just common sense, but there is also plenty of research that makes clear that having Medicaid coverage for children results in better access to care, improved health, educational and economic outcomes in adulthood. Covering children is a good deal for taxpayers as the Congressional Budget Office has made clear. Having health insurance is not a guarantee that you will be healthy, but NOT having health insurance is a guarantee that parents will be subject to worry and economic stressors, and that children will have less access to needed care. When care is delayed due to lack of insurance, children can become sicker and wind up in the hospital requiring more expensive care. It goes without saying that children, families and society are better off when all children have the health care they need to succeed.
There has been widespread bipartisan support for reducing the number of children without insurance for many decades and as this chart shows the number was going down for many years following the passage of CHIP in 1997 – and going further back would also show reductions as a consequence of Medicaid expansions for poor children that were passed in the 1980’s by a Democratic Congress and President Ronald Reagan.
From 2022 to 2024 the rate of uninsured children increased from 5.1% to 6%. This was a statistically significant change and equates to an 18% increase in the number of uninsured children nationwide. This is the highest rate of uninsured children in nearly a decade, and unfortunately, we believe it is only going to get worse – full stop. This is a dramatic reversal on the progress our nation had made improving child health coverage.
This rise in the number of uninsured children was seen across all races and ethnicities with one exception, Asian children, whose coverage level remained steady. American Indian/Alaska Native children have the highest uninsured rate (12.4%), followed by Hispanic/Latino children (9.7%).
It is also worth noting that the uninsured rate for adults did not rise during this period. It’s important to note that child eligibility levels did not change during this time frame. Historically, most uninsured children are eligible but not enrolled in Medicaid or CHIP coverage.
Let’s look at state trends now: Twenty-two states saw a statistically significant increase in the rate of uninsured children over the two-year period. One state, New Hampshire, saw its rate of uninsured children go down by 1.1 percentage points – so congrats to the Granite state. The remaining states saw small movement in either direction that was not statistically significant.
Let’s take a closer look at the states where the number of uninsured children rose. The worst state, unquestionably, for children’s access to health insurance is Texas – which led the country by far disenrolling 1.3 million children during the unwinding. Texas’ child uninsured rate rose from 10.9% to 13.6% from 2022 to 2024 – a 29 percent increase in the number of uninsured children in Texas with 1.1 million uninsured children in the Lone Star state in 2024 – almost one quarter of the nation’s uninsured children live in Texas. If all states had done as poorly as Texas did with unwinding, we would have seen a much higher jump in the number of uninsured children nationwide.
Other states with large increases in their child uninsured rate (in order) include Delaware and Idaho that are tied for second in the country behind Texas. New Mexico comes in fourth, while Arkansas, Kansas and South Dakota are tied for 5th with Georgia coming in close behind.
The remaining states that saw significant increases in their child uninsured rate are Alabama, Colorado, Oklahoma, South Carolina, Tennessee, Florida, Ohio, Washington, Michigan, Missouri, New Jersey, Virginia, North Carolina and Massachusetts.
In terms of raw numbers, the top 3 states by a wide margin for increases in the number of uninsured children are Texas (+246,000), Florida (+67,000) and Georgia (+48,000).
Another point worth making is that states that have not picked up the Medicaid expansion for adults saw much greater increases in child uninsured rates (which were higher to begin with) than those that have expanded for adults. This is an important finding for two reasons: In the recently concluded Congressional debate over H.R. 1, proponents of making cuts to the Medicaid expansion for adults often argued that it was necessary to do so because the expansion was harming “traditional” Medicaid enrollees like children. This is false for many reasons and this slide underscores one of those reasons– children in these non-expansion states are not doing better in fact they are doing worse than children in expansion states. (Note that the only state that bucked this negative trend – New Hampshire – is an expansion state.) And, arguably, according to the arguments made by supporters of the massive Medicaid cuts in H.R. 1, these non-expansion states should have done a better job for children since they supposedly could focus on them as the largest single group enrolled in Medicaid for the most part. That just wasn’t the case.
Where a child lives is becoming increasingly important as to whether or not they have health insurance. We know that Medicaid enrollment is closely correlated with the child uninsured rate. And the choices states made during the unwinding process, including how quickly they went and how successfully they automated their process, made a critical difference in outcomes.
Where do we go from here?
As concerning as these trends are, this is data from 2024 and there are many reasons that the situation for children’s access to health care will substantially worsen. One of the mitigating factors preventing larger increases in the child (and adult) uninsured rate as we saw earlier this week was the growth of the subsidized Marketplaces – children’s enrollment in Marketplace coverage pales in comparison to the importance of Medicaid and CHIP – but it has grown substantially thanks to the enhanced subsidies enacted in 2021. Compared to 2020 enrollment among children under age 18, child Marketplace enrollment is up more than 2.5 times. But these enhanced subsidies are due to expire at the end of this year; in the absence of Congress taking action more children will become uninsured.
Second, for the same reasons that the number of uninsured children began to grow during the first Trump Administration we expect the number to grow again – and probably much more quickly. These reasons include most prominently a “chilling effect” on mixed status families, by which we mean citizen children living with at least one immigrant parent or other household member. One out of four children in the U.S. has an immigrant parent. With the extraordinary fear gripping these communities today based on aggressive deportations as well as the unprecedented sharing of personal Medicaid data by federal CMS with Immigration and Customs Enforcement, the concerns that parents have about sharing their information with the government right now are real. We have already heard many anecdotes about children not going to well-child visits and other medical appointments as a consequence of this climate of intimidation that has been created by the Trump Administration. Cuts to outreach, limits on Marketplace enrollment periods, chaos and confusion caused by misinformation and discussion of cuts to come all erode the more welcoming climate that existed just last year.
Finally, the implementation of H.R. 1 with an unprecedented cut of almost $1 trillion to Medicaid and CHIP cut lies ahead and children will not be spared. With almost half of the nation’s children covered by Medicaid and CHIP, they cannot be shielded from a cut of approximately 11% to Medicaid’s overall funding. As their parents get disenrolled due to onerous work reporting requirements, we know that will mean it’s likely that their eligible children will lose coverage too. (We call this the “unwelcome mat” effect as it works in the opposite way that the “welcome mat” works in which children come in the door to coverage when their parents become eligible.) The restrictions affecting state financing of Medicaid will result in deep cuts affecting everyone who is covered by Medicaid, including children. The storm clouds are gathering for people to lose health insurance, but for children they are already here.