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Edwin Park: I will, get started in about a minute. Thanks so much.

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Edwin Park: Well, I think we will get started. Thank you for joining today. My name is Edwin Park. I'm a research professor at the Georgetown University Center for Children and Families, and I'll be moderating today's webinar.

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Edwin Park: We are, gonna take a look at the, data from the, Census Bureau, from the American Community Survey, related to child health coverage trends. The ACS data was released, on Thursday with the,

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Edwin Park: health insurance data from this current population survey released on Tuesday. So we'll first hear from Joan Alker, who'll go through the health coverage trends. She is the executive director of the Center for Children and Families, and she's also a research professor at the McCourt School of Public Policy.

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Edwin Park: We'll then proceed to Q&A, where we'll hear questions… we'll take questions from just the media, and for members of the media, if you do have a question, you can use the Q&A function at the bottom of the screen to submit a written question, and we'll get to all of your questions in the remaining time.

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Edwin Park: So with that, I will now turn it over to Joan, who will walk through her analysis of the American Community Survey health coverage numbers that just came out yesterday.

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Joan Alker: Thanks so much, Edwin. As Edwin just noted, my name is Joan Alker, and I am the Executive Director of Georgetown Center for Children and Families, and a research professor at the McCourt School of Public Policy.

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Joan Alker: I want to start by thanking the incredible work of my colleagues in pulling this together so quickly, particularly to Yulia Yefimenka, who did the work of getting the data as soon as it came out and analyzing it. We've had a lot of folks

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Joan Alker: hands, in the pie here to bring this all to you so quickly this year, and just want to thank everybody on the team, Sargon Singh, Kathy Hope, Edwin, Melody, Yulia. It's been a terrific, effort.

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Joan Alker: So, as I think most folks on this call know, the Center for Children and Families is a nonpartisan policy research center. We are based at the McCourt School of Public Policy at Georgetown University. We are celebrating our 28th anniversary this year. And, we're public policy researchers with a mission, and our mission is to ensure that all

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Joan Alker: Children and families have access to high-quality, affordable healthcare in the United States.

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Joan Alker: So, every year, we do examine this data provided by the American Community Survey, or ACS. This does provide the most comprehensive look, nationally and by state, at a number of important trends impacting America's families, including health insurance.

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Joan Alker: This year, we… our analysis is focused, as it always is, on health insurance status of children 18 and under.

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Joan Alker: And we looked at all 50 states in the District of Columbia, because that's what we can look at. We can't look at the territories, unfortunately.

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Joan Alker: We examined a 2-year period, From 2022 to 2024.

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Joan Alker: And, the reason that we chose this period to look at is that during this period, all states started, and most states completed.

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Joan Alker: their Medicaid unwinding process. Many of you are very familiar with what the Medicaid unwinding is, but this was an unusual and historic event in Medicaid policy, where pandemic-era protections of continuous coverage in Medicaid eventually were lifted.

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Joan Alker: And states had to check eligibility for tens of millions of Americans who were enrolled in Medicaid.

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Joan Alker: As you know, we were very worried about eligible children being disenrolled by mistake during this unwinding process, especially in states that did not approach the process with the utmost care.

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Joan Alker: Because children are much more likely than their parents or other adults to be eligible for Medicaid or CHIP,

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Joan Alker: With a national median income eligibility level of about 255% of the federal poverty level, which is much higher than adults.

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Joan Alker: Large numbers of children losing coverage, losing their Medicaid coverage during the unwinding was a sign that children who remain eligible and should have been covered in Medicaid were probably being disenrolled in error due to procedural reasons, essentially failures of the process.

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Joan Alker: We monitored these trends very closely, tracking indicators of how well states were meeting the unwinding challenge, and we found very wide variability in state performance at the time.

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Joan Alker: And this huge state variability is now reflected in the data that we're going to examine today about, how many children are uninsured by state.

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Joan Alker: Before I get into the findings, I want to talk for a minute about why having health insurance is important for children and females. Sometimes, inside the Beltway here especially, we hear hints being dropped in small debates that having health insurance is not that important.

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Joan Alker: I would say for most American families, perhaps those who are extremely wealthy, there really is no need to explain why having health insurance is important for their children. No parent wants to have to think twice about cost.

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Joan Alker: When taking their child to the doctor, or picking up their prescription at the pharmacy.

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Joan Alker: Healthcare is expensive, and it continues to become more expensive, and families can be bankrupted by even a short gap in coverage for their child. An accident on the playground, or untreated asthma can result in trips to the emergency room, which costs thousands of thousands of dollars.

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Joan Alker: Potentially sending families into debt in bankruptcy.

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Joan Alker: This is just common sense.

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Joan Alker: But there's also plenty of research that makes clear that having Medicaid covered for children results in better access to care, improved health, educational, and economic outcomes in adulthood.

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Joan Alker: Covering children is a good deal for taxpayers, as the Congressional Budget Office has made very clear.

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Joan Alker: 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 greater worry and economic stressors, and that children will have less access to needed care.

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Joan Alker: When care is delayed due to lack of insurance, children become sicker, they can wind up in the hospital requiring more expensive care.

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Joan Alker: So, it really should go without saying that children, families, and our country at large are better off when all children are insured and have the healthcare they need to succeed.

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Joan Alker: So, let's turn now to the findings.

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Joan Alker: We're gonna start with our first slide, is just to provide a little bit of context and table setting.

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Joan Alker: Now, we couldn't go further back on this slide, because we would run off the page, but this is really just to underscore that over the years, there has been widespread bipartisan support for reducing the number of children without insurance for many decades.

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Joan Alker: Going even further back than what you see on this chart to the 1980s, when Medicaid expansions for poor children were passed by Democratic Congress and President Reagan.

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Joan Alker: Of course, 1997, with the passage of the Children's Health Insurance Program, was a very important marker for bipartisan support of success.

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Joan Alker: And over the years, as states implemented CHIP, and CHIP was further refined in 2009 by the CHIP Reauthorization Act, the number continued to go down, and this continued…

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Joan Alker: Preceded the passage of the Affordable Care Act in 2010 and implementation in 2014, but the ACA also helped children. It was much more important for adults, but it helped children too.

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Joan Alker: So we reached a historic low of 4.7% of uninsured children in 2016.

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Joan Alker: Now, during President Trump's first administration, unfortunately, that number started going in the wrong direction, and we'll… we'll talk about that a little bit later. But then the pandemic hit, and then we had continuous coverage, children didn't lose their Medicaid, and the numbers started going in the right direction again.

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Joan Alker: So, Lau, let's get to today's finding.

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Joan Alker: Next slide, please.

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Joan Alker: So, from 2022 to 2024, the rate of uninsured children increased almost a percentage point from 5.1 to 6%.

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Joan Alker: I'll just note for the record that the uninsured rate for adults did not go up during this period.

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Joan Alker: This is… we can go to the next slide.

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Joan Alker: This is a statistically significant change.

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Joan Alker: It is the highest rate of uninsured children you can see that we've had in nearly a decade, from 2014, since the ACA era.

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Joan Alker: came.

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Joan Alker: And, unfortunately, we believe it's only going to get worse, and we'll talk about that more later. So, this is a reversal to the progress that our nation has made, very good progress over the years, in reducing the number of uninsured children. You can go to the next slide.

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Joan Alker: So here you can see this is the number of uninsured children, and the increase in the period we're looking at, essentially, which is sort of pre-unwinding.

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Joan Alker: To post unwinding is an increase of 18% in the number of uninsured children nationwide.

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Joan Alker: Next slide.

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Joan Alker: So, we took a look at children by race and ethnicity, and let's spend as any going through their findings here.

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Joan Alker: So, the rise in the number of uninsured children was seen in all races and ethnicities, with one exception, as you see here. Asian children, their coverage level remains steady.

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Joan Alker: White children saw an increase, black children saw an increase. But you'll see in this slide a couple of things I just wanted to flag for you. First of all.

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Joan Alker: Black children, this is one of the few metrics where we have not seen, a disparity between black and white children very much over the years in recent history.

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Joan Alker: Their coverage levels have been about the same.

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Joan Alker: Unfortunately, here, and I know this was a trend in some of the other census data, we do see that Black children had a bigger jump in their uninsured rate than white children.

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Joan Alker: Native children, American Indian, Alaska Native children had a big jump, and they, of course, as you can see, have the highest…

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Joan Alker: Rate of uninsurance, so that's very troubling.

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Joan Alker: And then, as you see on the right, Hispanic Latino children, who can be of any race.

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Joan Alker: Have always had a very high uninsured rate, and that also jumped considerably, and this is certainly a group we'll be keeping a sharp eye on as we talk about later.

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Joan Alker: Okay, next slide.

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Joan Alker: So, let's look at state trends now. Now, this is… I know there's a lot of, numbers on this page. We have 50 state tables that look at the change in number and rate for this period. We will pop those in the chat so you can look at

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Joan Alker: Your state, look at those tables.

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Joan Alker: But let me sum up for you, sort of here, the bottom line. And it's important to note that child eligibility levels did not change during this time frame, by and large, except for Arizona, where they raised their CHIP eligibility level slightly at the end of this period.

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Joan Alker: But… and historically, most uninsured children are actually eligible for Medicaid or CHIP, but they're not currently, enrolled.

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Joan Alker: So… Looking at the state trends.

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Joan Alker: 22 states, Art, can you hear me okay now? I just saw your note.

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Joan Alker: I'll try to get closer.

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Joan Alker: 22 states saw an increase in the rate of uninsured children. This is a statistically significant increase in their rate of uninsured children from 2022 to 2024.

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Joan Alker: Only one state, and they're not on this table, New Hampshire saw its rate of uninsured children

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Joan Alker: actually go down by 1.1 percentage points during the period, so congratulations to the Granite State.

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Joan Alker: The remaining states that are not on this list.

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Joan Alker: saw small movement in either direction that was not statistically significant. So, basically, their uninsured rate for children did not change as a consequence of unwinding.

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Joan Alker: Now, diving into this table, let's take a closer look at the states where the number of uninsured children rose.

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Joan Alker: The worst state, unquestionably, for children's access to health insurance is Texas. Texas ranks 51.

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Joan Alker: Texas led the country.

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Joan Alker: by disenrolling 1.3 million children during the Medicaid unwinding, and we were very concerned about this at the time.

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Joan Alker: And, as you see here, Texas's child uninsured rate, already very high, twice the national average, rose from 10.9% to 13.6%.

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Joan Alker: During the time period. A 2.7 percentage point change. Really shocking.

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Joan Alker: So, this was a 29% increase in the number of uninsured children in Texas, which was already very high.

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Joan Alker: With 1.1 million of the uninsured children in this country live in the Lone Star State in 2024. Almost a quarter of the nation's uninsured children live in Texas.

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Joan Alker: And when you look at this table, you can see that if all states had done as poorly as Texas did with the unwinding, we would have seen a much higher jump.

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Joan Alker: in the uninsured rate of children nationally, because we have some big states that are not on this table, thankfully. States like New York and California and Arizona, Pennsylvania, who have

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Joan Alker: Fairly large numbers of children who did not see a change in their child uninsured rate.

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Joan Alker: Other states to note that had large increases in their child uninsured rate, and I'm going in order here, include Idaho and Delaware that tied for second in the country.

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Joan Alker: With a 2.4% point increase in their child uninsured rate.

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Joan Alker: During the period, New Mexico comes in fourth behind them.

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Joan Alker: Arkansas, Kansas, and South Dakota are tied for 5th.

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Joan Alker: And Georgia comes in close behind there.

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Joan Alker: So those are really the states with the sharpest increases.

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Joan Alker: The remaining states also saw significant, statistically significant increases in their child uninsured rate.

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Joan Alker: And they are Alabama, Colorado, Oklahoma, South Carolina, Tennessee, Florida, Ohio.

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Joan Alker: Washington, Michigan, Missouri, Virginia, New Jersey, North Carolina, and Massachusetts.

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Joan Alker: So, again, we have 50 state tables, and they'll show you, all of the states, their ranks, and their change.

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Joan Alker: Next slide, please.

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Joan Alker: So, in terms of raw numbers, and obviously this metric looks, a state's size is gonna be…

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Joan Alker: consequential in… when you're looking at raw numbers. The states where we saw the biggest growth in the number of uninsured children.

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Joan Alker: By a wide margin, these were the top 3 states. Texas seeing an additional 246,000 uninsured children during the period.

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Joan Alker: Florida's seeing an additional 67,000 children during the period, and Georgia, seeing an additional 48,000 uninsured children.

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Joan Alker: So, let's go to the next slide. Another point I want to make is that states that have not picked up the Affordable Care Act Medicaid expansion for adults

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Joan Alker: Saw much greater increases in the child uninsured rate, and they were higher to begin with.

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Joan Alker: than those states have expanded Medicaid for parents and other adults.

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Joan Alker: This is an important finding for two reasons.

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Joan Alker: In the recently concluded congressional debate over the HR1, the one big, beautiful bill, the proponents of making significant cuts to the Medicaid expansion that happened in that bill for adults

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Joan Alker: often argued that it was necessary to do so, because the expansion was harming and undermining Medicaid for traditional and more deserving beneficiaries like children. We heard that a lot.

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Joan Alker: From many, many, leaders of these… proponents of these cuts and supporters of these cuts.

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Joan Alker: This argument is false for many reasons, and this slide underscores one of those reasons.

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Joan Alker: Children in these non-expansion states are not doing better, in terms of having health insurance. In fact, they're doing worse than children in expansion states. And note, as I mentioned before, the only state that bucked the trend and actually made things better for children was New Hampshire, which is an expansion state.

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Joan Alker: And arguably, you know, if these supporters of

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Joan Alker: almost a trillion dollars of cuts to Medicaid and H.R. 1 were correct, that states that don't have expansion do a better job of focusing on their traditional, quote, enrollees. They should have done a better job for children.

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Joan Alker: And they had, more opportunities to focus on them, since, for the most part, they're the largest single group. But yet, they did not, and you'll see in the list.

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Joan Alker: Of states was change, statistically significant change, where the uninsured rate went up, that 7 out of the 10 non-expansion states are on that list.

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Joan Alker: Next slide, please.

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Joan Alker: So…

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Joan Alker: 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 that states made during the unwinding

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Joan Alker: process, including how quickly they went, how successfully they automated their process, did make a critical difference in outcomes. And here you see the states that are in dark blue are higher than the national average in terms of their child uninsured rate.

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Joan Alker: States that are in light blue are doing better than the national average, and the states that are in sort of white, grayish color are right on the national average.

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Joan Alker: Next slide.

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Joan Alker: So, where do we go from here? I guess, actually, why don't we stick on the map, for a little bit?

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Joan Alker: Where do we go from here? So, as these trends are, this is data from 2024.

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Joan Alker: And, of course, we're in 2025, and the world has changed a great deal.

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Joan Alker: There are many reasons that the situation for children's access to healthcare will substantially worsen, we fear.

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Joan Alker: One of the mitigating factors preventing larger increases in the child uninsured rate, and also protecting adults, as we saw earlier this week in the census data, was the growth of the subsidized coverage in the marketplaces.

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Joan Alker: Children's enrollment in marketplace coverage pales in comparison to the importance of Medicaid and CHIP for children, but it has grown substantially thanks to the enhanced subsidies enacted in 2021.

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Joan Alker: Compared to 2020 enrollment, children under age 18, their marketplace's, enrollment is up more than two and a half times. So the number of children has really increased in the marketplace like it has for everybody else.

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Joan Alker: But these enhanced subsidies are due to expire at the end of this year in the absence of Congress taking action. This will make more children become uninsured, because enrollment has grown for them as well. So that's one,

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Joan Alker: One factor that is cause for concern.

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Joan Alker: Secondly, 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, it's probably happening as we speak.

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Joan Alker: 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. 1 out of four children in the United States has an immigrant parent.

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Joan Alker: With the extraordinary fear that's gripping these communities today, based on aggressive deportations, as well as the unprecedented sharing of personal Medicaid data by federal CMS with ICE,

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Joan Alker: The concerns that parents have about sharing their information with the government right now are very, very real.

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Joan Alker: We've already heard many anecdotes about children not going to well child or sick visits and other medical appointments as a consequence of this fear and this climate of intimidation that has been created by the Trump administration.

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Joan Alker: In addition, cuts to outreach, limits on marketplace enrollment periods.

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Joan Alker: Chaos and confusion caused by misinformation and discussions of cuts to come all erode the more welcoming climate that existed in recent years.

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Joan Alker: Finally, we haven't even talked yet about the implementation of H.R. 1, the Budget Reconciliation bill, which has an unprecedented cut of almost $1 trillion to Medicaid and CHIP.

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Joan Alker: This 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.

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Joan Alker: As their parents get disenrolled due to onerous red tape, more frequent renewals, work reporting requirements, which will affect parents of older children and may affect parents of younger children, if exemptions are not implemented properly, or misinformation runs rampant, which is likely.

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Joan Alker: We know that this means that, eligible children will lose coverage too, even though they shouldn't. We call this the, quote, unwelcome mat effect, which is the opposite of the welcome mat effect we see when parents are, in a more,

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Joan Alker: welcoming climate, or there's an expansion of coverage for adults, picks up children, too, since, as I mentioned, most uninsured children are eligible for Medicaid or CHIP, but just not enrolled.

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Joan Alker: The restrictions affecting state financing of Medicaid will result in deep cuts, and those will affect everybody who's covered by Medicaid, including children and the providers who serve them, and we've already seen states move to cut provider rates across the board.

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Joan Alker: So the storm clouds are gathering for people, who rely on public health insurance and Medicaid, but for children, sadly, they are already here. Thank you. Edwin, I'll pass back to you.

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Edwin Park: Thanks, Joan, for the very informative presentation. Just a reminder to members of the press, if you have any questions for Joan, you can submit them in the Q&A function at the bottom of your screen, and we'll get to them

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Edwin Park: shortly. I'll start off by asking Joan, since the American Community Survey has a data lag, it's a year behind.

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Edwin Park: How can CCF help keep track of these coverage trends on a more timely basis?

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Joan Alker: Yeah, so if we actually want to go back to the resource slide that was just up, we have a lot of data on our website, and you'll all be pardoned if it's hard to find some of it, but I wanted to flag

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Joan Alker: a couple of things. The top item that you see here, Medicaid Enrollment Tracker, this is something that we started during unwinding, and we're currently in the process of updating it, and we plan to, to…

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Joan Alker: build on this and keep this as up-to-date as we can. So what this Medicaid Enrollment Tracker does is that we go directly to state websites, state administrative data, and we can get it from most states, not all states, but many states.

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Joan Alker: And we can see on a monthly basis how their Medicaid enrollment is changing, both for children and total enrollment.

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Joan Alker: And so, we are going to keep a very sharp eye on that data. Of course, CMS does, roll up this data too, but it takes… there's a lag between when, states submit it and CMS posts it.

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Joan Alker: You know, it changes a little bit, but it's really not much change at all from what you see directly on the state websites, and…

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Joan Alker: So we are… we are hoping to really keep this tracker up to date. So that's going to allow us to pinpoint when we see large, declines for children, or for adults, or, for example, in the expansion group, when the work requirements are implemented.

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Joan Alker: We're gonna keep a very close eye on that, and people should be able to look at any particular state.

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Joan Alker: in that tracker. We have a lot more resources available on our website, and our blog is keeping folks continuously updated, but I just wanted to flag that enrollment tracker. This is something that we want to, to make sure that everybody, you know,

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Joan Alker: journalists, everybody else can use. This is a resource we really want to make available, so that we have some accountability and we can see what's going on in real time.

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Edwin Park: Oh, just a reminder to members of the press to submit questions through the Q&A function. While we're waiting, Joan, you talked a lot about,

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Edwin Park: state-by-state variation in how they performed during unwinding of the pandemic-related continuous coverage protection. Looking ahead to the Medicaid cuts in H.R. 1,

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Edwin Park: How do you think that, variation in how states implement those cuts could affect, children's coverage between states?

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Joan Alker: Yeah, no, that's a great question, and actually, one of the reports on here, it says State Readiness Tracker. Our colleagues put together a wonderful report, and again, we're going to keep tracking these metrics in real time.

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Joan Alker: Looking at, features of a state's eligibility enrollment system.

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Joan Alker: that may or may not be working so well. Probably the most important feature, and this was certainly true during unwinding, is what percentage of renewals is a state doing using what's called the ex parte method? And that's where states are using available data sources, and they don't have to ask the family for a lot of information.

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Joan Alker: And so states that do ex parte well, are… are… did better, in… in the unwinding, and Texas barely did ex parte at all. And that's, I think, one of the reasons that we saw such a terrible result in Texas. So…

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Joan Alker: You know, there's a lot of talk about using technology, a lot of claims that using technology will make

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Joan Alker: sure that the work requirement is implemented well, not like what we've seen to date in Arkansas and Georgia. But, the reality is that, we've already got a really important tool that is, technology-based, to move away from paper enrollments, and it's called ex parte renewal. So, states, particularly for children,

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Joan Alker: whose income doesn't bop around a lot, ex parte is really critically important. And so, all of these metrics, call center wait times, many, you know, how long it takes the state to process applications, etc, those are the metrics that we have there in our readiness tracker.

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Joan Alker: And, again, we fear that, you know, these systems, as we saw during unwinding, in many cases, are going to start getting really backed up as soon as these things start being implemented.

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Edwin Park: We do have a question from Kyle Fanensteel. I hope I'm pronouncing that right. He's with the, Idaho Capital Sun. He asks, to what extent did Medicaid unwinding contribute to these rise in uninsured rates for children compared to other factors?

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Joan Alker: Yeah, so,

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Joan Alker: So, I think, you know, the answer is, first of all, obviously, this is, this is very quick, data analysis here, but I think the basic answer, our hunch, is a lot.

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Joan Alker: When you look at the states that saw increases in their child uninsured rate, you know, Texas is one, Idaho, where you're from, Kyle, is another. Idaho moved very, very quickly, as you'll recall. They were very anxious to move ahead, and we saw large numbers of children losing Medicaid, and

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Joan Alker: We didn't see, in a state that has a separate CHIP program, which Idaho does, you know, the census data doesn't allow us to look at the movement between Medicaid and CHIP.

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Joan Alker: But in states where you crosswalk that, if there's a separate CHIP program, there was not the kind of movement you would expect. Like, there… you know, I don't know what the exact number is for Idaho, but if you had 100 kids losing Medicaid, you would think that CHIP would be the natural place for them to go, because their income

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Joan Alker: family's income had gone up during the pandemic, and they were now CHIP eligible. But, but we didn't see large-scale movement to CHIP. Now, Idaho does have low

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Joan Alker: Chip eligibility levels compared to the country, very low, so you could certainly have children, who are uninsured because they're over-income eligible.

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Joan Alker: For CHIP, and then should be eligible for subsidized coverage. But, of course, we did see increases there in the marketplace, so we know that provides some protection.

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Joan Alker: So, so I think, you know, when you look at the trend data that you see in, the census data that came out this week, Medicaid went down, ESI in the CPS data

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Joan Alker: it went up, but it wasn't statistically significant. It was direct coverage through the marketplace that went up. So, I think you have to conclude in a state like Idaho that the Medicaid unwinding absolutely contributed to the sharp rise in your child uninsured rate.

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Edwin Park: Thanks, Joan. We have a question from Hyatt Norming.

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Edwin Park: from the Idaho Statesman, can you speak to why you expect these numbers to get worse in 2025, and how do you expect partisanship, Republican versus Democratic leadership in these states that are weighing their own Medicaid policies to affect these numbers?

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Joan Alker: Well, so yes, I can say I'm just going to review why we think these numbers are going to get worse, or in 2025 and 2026, potentially, too. So, trends that we believe are already at work in 2025 are what I talked about called the chilling effect.

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Joan Alker: Where we have children who are citizen children, but their parents are immigrants, and they're very scared right now to interact with the government, to enroll children, to share information, particularly since Federal Centers for Medicare and Medicaid

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Joan Alker: Services has handed data over to ICE. So, so that's a trend that's happening right now.

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Joan Alker: As we talked about earlier, more children are in the marketplace. I believe, and Edwin, you'll correct me if I'm wrong, there's about 2.5 million children in the marketplace. It used to be about a million before the enhanced subsidy, so if those enhanced subsidies go away.

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Joan Alker: That's another reason we expect this to get worse in 2026. And then, of course, we have states starting to kick in in their budget sessions.

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Joan Alker: they will be, starting to make cuts. And, those will affect children as well, perhaps,

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Joan Alker: in access, first of all, as providers see their rate cuts, which we've already seen in a couple of states, Idaho and North Carolina, to name a few.

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Joan Alker: So, you know, look, you can see on that list of 22 states, there are Democratic governors on that list, there are Republican governors on that list. I didn't…

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Joan Alker: do the math and, you know, figure out how many are D's and R's. We just run with the data, in a nonpartisan way, but I think that 100% commitment from the top

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Joan Alker: is essential to make, make these systems work for children and families. And whether or not a governor, of either party is really committed to ensuring that eligible people and eligible families

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Joan Alker: stay enrolled, is hugely important. That's where the priorities are set.

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Joan Alker: And everything flows from there, because, you know, there are a lot of things states, can do to try to make their process more smoothly. Now, I will say that certain states are taking bigger cuts.

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Joan Alker: Than other states, and a lot of blue states are taking big cuts, and that was no accident in the way these cuts were structured. So they will have, probably states like California and New York are going to have a harder, hand dealt, and, and that's going to be tough.

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Joan Alker: For them to protect everyone. No one can be protected from a trillion dollars of cuts, and, so this is a very troubling situation, and, we're just gonna have to see how it rolls out.

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Edwin Park: Joe, we have a question from Isabel Charlie from Public News Service. Some states, like the state of Washington, had the Medicaid expansion, but still had very high increases. Was that surprising?

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Joan Alker: Yeah, it was a little surprising. They… they have a relatively low uninsured rate, and I think, you know, when you have a really low uninsured rate, some folks will notice Massachusetts was on the list, too. You know, that was… they were the lowest

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Joan Alker: the last on the list, but they did see a statistically significant increase. And when you have a low uninsured rate, you know, it's… it's a little…

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Joan Alker: easier to sort of bounce around, but it is surprising, and Washington is a state that, actually, made a great policy choice, which they said, you know, they always had problems with churn, right? This is a common problem.

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Joan Alker: with Medicaid, children in Medicaid, that they're churning on and off, even though they most likely remain eligible, that Washington was really a leader in, what's, we call the continuous eligibility policy for children 0 to 6, babies and toddlers and young children.

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Joan Alker: And Washington, pioneered that.

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Joan Alker: And I got a Section 115 waiver, and they said they really learned a lot from the continuous coverage period, and they wanted to offer that continuous coverage

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Joan Alker: A number of states followed them, and unfortunately, the Trump administration announced in July that they are rescinding that, those waivers, that they will no longer approve or continue waivers. That was a terrible decision.

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Joan Alker: For, young children, for babies and toddlers and those families.

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Joan Alker: Because, finally, we had a day in which you could really imagine no more uninsured young children, no more uninsured babies or toddlers. And I'll say, for us at CCF, this is a policy that we have long, long, like, 15 years, have been talking about.

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Joan Alker: I think we should live in a country where no baby leaves a hospital without coverage, and the parents are told they're covered till they go to school. And you don't have to worry about it. You've got plenty of other things to worry about.

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Joan Alker: And that's the road we were down, and Washington State was really a leader. So, yeah, it was a little surprising, but I think they were aware that they had some problems with their eligibility, enrollment, and retention, and that's partly why they moved that policy.

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Edwin Park: Joan, we have a question from Daniel Chang, KFF Health News. Is there an estimate of the number of children who will lose coverage if the enhanced tax credits for ACA plans expire at the end of the year?

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Joan Alker: Great question, Dan. We don't have an estimate. I know that the Urban Institute is working on a report that is looking at children and parents, I believe, in the marketplace. It's not out yet, it may be out in a few weeks. I don't know, Edwin, if you're aware of any other data sources.

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Edwin Park: No, I haven't seen a breakout by age. The Congressional Budget Office

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Edwin Park: has estimated previously that there'll be 4.2 million more uninsured, by 2034 if the schedule expiration of the enhanced credits take effect. But as Joan mentioned, the enhanced tax credits were associated with,

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Edwin Park: more than 2.5 time increase in those covered… children covered by, marketplace plans for about a million to 2.6 million as of open enrollment of this year. And it's likely that a significant contributor to that, dramatic increase,

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Edwin Park: in children's coverage in the marketplace was due to the enhanced premium tax credits. There may have been some children who newly enrolled as a result of unwinding, but certainly the enhanced tax credits are a big reason why we've seen that big increase, and so

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Edwin Park: If those credits, enhanced credits do expire, and the generosity of the credits is much, less.

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Edwin Park: then a lot fewer kids will likely be enrolled. To give a sense, kids are about 11% of marketplace enrollment today.

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Edwin Park: We have a question from Meg, Wingger, from the Denver Post, and I apologize if I didn't get the pronunciation right. She asks, are Medicaid administrators in Colorado have attributed the large number of disenrollments to people getting jobs or otherwise earning too much to qualify for Medicaid?

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Edwin Park: Does the increased uninsured rate for kids argue against that?

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Joan Alker: Great question. Thank you, Meg. I remember hearing that, both from… from Colorado's leaders, but also from many other, state officials. That was a very common

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Joan Alker: explanation, particularly in states where they were seeing large, declines, and we were worried about Colorado. So the answer is…

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Joan Alker: you have to think about this differently for adults and children. And this was one of the frustrations we had with a lot of the way this issue was talked about.

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Joan Alker: Because it's just a very different landscape. As I mentioned…

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Joan Alker: Children are eligible at much higher income levels, than their parents or other adults. In Colorado, the adults would be eligible to 138% of poverty, because it's an expansion state, but children are probably up to 300, I don't know Colorado off the top of my head.

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Joan Alker: So the reality is that, yeah, sure, some folks, got jobs, you know, there was the early loss of employment during the pandemic, and, some folks' income went up, but their children…

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Joan Alker: Probably we're still eligible for a Medicaid or CHIP.

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Joan Alker: Or, the reality is that, for low-wage and moderate-wage workers, dependent coverage that's affordable is very hard to come by. It's often not offered at all, so maybe the adult

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Joan Alker: got a job and got health insurance, but there was no health insurance available for their children, or certainly no health insurance they could afford. And so, that's why this was, as I said, a source of frustration, very different landscape

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Joan Alker: for adults and children, both on the employer-sponsored coverage side, as well as the public coverage side, and why we said all along that if we see a lot of children losing Medicaid in their procedural disenrollments, it's not because they've been determined ineligible, that's a problem. We're going to see the child uninsured rate go up.

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Edwin Park: We have a question from Abigail Ruhman of KERA in Texas. Texas already had the worst rate in 2022, and also saw the largest loss between 2022 and 2024.

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Edwin Park: What factors cause Texas to have such a poor performance in both of these metrics? Additionally, how does this increase impact states like Texas that have such a large rural population?

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Joan Alker: Well, I'll say a couple things, and then, Edwin, you may want to jump in as well. You know, yes, you're right, you know, Texas has been down, at the bottom for a while, unfortunately, in this ranking, and

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Joan Alker: I think there are a lot of reasons for that, but specifically related to the Medicaid unwinding, there were lots of problems that we heard about, children…

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Joan Alker: not making it to CHIP, children being told they weren't eligible, or not being able to get their paperwork in, siblings being treated differently.

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Joan Alker: But fundamentally, if you had to point to one thing, as I mentioned earlier, Texas had, nationwide, the lowest, lowest rate. You know, at one point it was under 5% of renewables they were doing ex parte. And that's where, you know, states have to do this ex parte renewal, where they use available data to check, and just, they might know that that child should still be eligible, because they have data.

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Joan Alker: from SNAP, or they have data from their wage databases, and they're supposed to do that. And states that have, you know, very successful processes have high rates of ex parte renewals, but Texas

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Joan Alker: I question whether you could even say they were doing it, because it was, you know, 5% or under. It went up a little bit over the course of the unwinding. Their rate was so low. So that was just a huge red flag right there. But Edwin, is there anything else you want to say about the…

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Joan Alker: situation in Texas.

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Edwin Park: I, I don't, I don't think so. I mean, Texas,

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Edwin Park: Has had a lot of struggles with their eligibility and enrollment system, significant,

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Edwin Park: attrition among eligibility and enrollment workers in the state, with many vacant slots, even as they headed into unwinding. So I think that clearly was.

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Edwin Park: And the state has struggled with significant backlogs, so certainly those are probably key factors as well.

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Joan Alker: And I'll just comment on the rural component of your question to say that generally speaking, as many of you know, and we have data on this, children living in rural areas rely on Medicaid for their health insurance at higher levels than children living in urban areas.

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Joan Alker: So, certainly states and, you know, it's… it's a concern, too, that we pointed out, during the unwinding, for Indigenous children and, and, American Indian, Alaska Native children.

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Joan Alker: This is… this is problematic. We were worried that rural areas, it would be harder to, do a good job of unwinding without a lot of effort, because sometimes there's a lot less internet.

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Joan Alker: connectivity, you know, sometimes it's hard to even get mail, harder to do outreach, keep families informed, so we were worried about that. We haven't run the numbers yet, and we just got this data, and I think we will have to wait a little while till we get more data.

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Joan Alker: But it's a great question that would be worth looking at, which is, you know, kind of looking at the rurality, the rural counties, and see how they did to… compared to the urban counties in general.

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Edwin Park: And unlike the current population survey, the American Community Survey allows that kind of really granular analysis. John, we have another question from Adam Goldstein from State Affairs.

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Edwin Park: Do we know why states that have not picked up the Affordable Care Act Medicaid expansion for adults saw much greater increases in the child uninsured rate than expansion states, or even the national average?

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Joan Alker: Yeah, they were worse to start with, and they didn't do well by children. So I can only say that it strikes me that this is just a proxy for how much that state's elected officials

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Joan Alker: value coverage for low-income families, right? They're not…

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Joan Alker: They don't want to pick up the expansion, they don't want to get those folks covered, and, apparently they, some of them anyway, did not exhibit a great deal of care, certainly in Texas, and other of the non-expansion states on the list.

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Joan Alker: There just has to be a commitment at the top. I mean, I don't… I don't know how else to say it. There's all of these issues, but the staff has to have resources that they need.

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Joan Alker: They need to have, you know, they need to have a commitment and understand that the governor has to get out there and say, I want children to have health insurance, and I want the state to make that happen. I want to help get rid of red tape.

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Joan Alker: So I think there's just not as much commitment to having low-income families covered in these non-expansion states. And I don't want to say that, completely as a role, because, you know, there's a few of the non-expansion states that we don't see.

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Joan Alker: On this list, there's, you know, one or two non-expansion states where the governor, wants to do expansion. So it's a little more complicated than that, but to some extent, it is a proxy for commitment, and that starts at the top.

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Edwin Park: Adam has a fault to his original question. He's asking, are there any particular thoughts on, Kansas's, uninsurance rate for kids, and whether they did, well or poorly on winding?

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Joan Alker: Yeah, let us get back to you on that separately, Adam. I know some of my colleagues, I think know more about Kansas than I do, unless, Edwin, you can…

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Joan Alker: remember… I can't closely remember the specifics there, so we'll have… but we can get back to you on that. Let's just get your email address, and we'll connect you with one of our colleagues.

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Edwin Park: Meg, from the Denver,

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Edwin Park: Post has a follow-up question to our earlier question. You mentioned being concerned about Colorado from the start. What, what, concerned you with that?

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Joan Alker: Well, yeah, I think what I meant is that we were seeing large Medicaid disenrollment, and that's what was concerning us, is… I mentioned the tracker that we had, and so we had that tracker going, and we could see…

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Joan Alker: We could see that Colorado was losing kids. Same with New Mexico, right? We knew there were going to be problems in New Mexico, as well as Texas and Idaho and elsewhere.

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Edwin Park: We have a question from Spencer Hickey from, Hannah News Service. He asks, on the point about rural areas, can you speak to how that can compound issues of access to healthcare resources there as well?

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Joan Alker: Right, so… so that's a great question, and I think, you know, we are…

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Joan Alker: possibly today, or very soon, going to see the notice of funding opportunity available for the Rural Health Transformation Fund that was included in H.R. 1. A lot of, you know, stated, anyway, concern about rural areas. Folks know that rural hospitals have been

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Joan Alker: closing in large numbers, and particularly something that we've been tracking at Georgetown CCF is that, we've lost a lot of labor and delivery units in rural areas, and the majority of rural hospitals now do not have a labor and delivery unit, so that is

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Joan Alker: very problematic for… it doesn't matter what your insurance is, if you're not able to have a baby safely in a rural community, it's very… gonna be very difficult for that community to grow and thrive, so…

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Joan Alker: This is a huge issue because rural areas already have provider shortages, they already have these challenges with losing rural hospitals, and because they're more reliant on Medicaid, they're more at risk from these cuts that are coming this way. And when you have more uninsured

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Joan Alker: children, more uninsured people, and just to flag another question that I'm hoping we can look into and think about some more going forward is the impact of the Medicaid work requirements that are going to be implemented in 2027 for adults. You know, I think there are a lot of reasons to be worried

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Joan Alker: That rural areas are gonna suffer more.

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Joan Alker: from the implementation of these work requirements. And that… I say that for a couple of reasons. There are high rates of disability among populations living in rural areas. They tend to be older.

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Joan Alker: And, the… the job market is… can be very limited there. So, I think there really are reasons to be concerned. And when you have more uninsured people to the… for the providers that… that do hang in there, and the hospitals that do hang in there, that just…

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Joan Alker: keeps pressuring their margins, and at some point, they're just not able to keep their doors open. So, whether it's from the direct cuts.

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Joan Alker: In the provider tax limitations, or from having more uninsured people, as we're going to see from the work requirements, this is all going to add growing, growing pressure on rural communities who are already facing a tough situation.

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Edwin Park: Oh, we have a question, Joan, from Stephanie Aiken from Purbus News. Do you have any thoughts on how New Hampshire has been able to decrease its, child uninsured rate?

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Joan Alker: That's another one I'm going to say. I do not, but I know somebody who will, and her name is Tricia Brooks, one of our colleagues, and she actually lives in New Hampshire, so let's connect you with her.

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Edwin Park: There's a question we've received about, you know, why, states like, Wisconsin did not see statistically significant change, or

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Edwin Park: Is there any particular reason why we think, some of the states had no, change despite the, implementation of unwinding?

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Joan Alker: Yeah, I asked myself that question, and I think we're going to have to spend a little more time with the data, and kind of look

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Joan Alker: look at what are some of the characteristics that are common to those states. Like I said, you know, the one thing we feel very solid about is that having a higher ex parte rate is going to lead to a better outcome.

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Joan Alker: But that's, of course, not the only, the only thing at work here. So, a lot of the states that we saw on the list of states that had an increase, you know, we're not surprised to see them there at all.

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Joan Alker: A couple of them, we're a little surprised, and we're going to keep looking into that, and so yeah, stay tuned, you know, this is very fresh data, and we'll keep working with it, and we also welcome your insights. For those of you who are living and working in these states, we will learn from you as we continue to unpack what happened, because

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Joan Alker: This is important, these are important lessons going forward.

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Joan Alker: As we are going to have a Medicaid system that is less well-resourced, that is very stressed, and because of the cuts, and also because of the red tape, that's really going to be layered on, particularly for parents and adults.

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Edwin Park: We're almost at the top of the hour, so last call for any questions from the media to Joan.

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Joan Alker: And I'll just note, I think I mentioned this before, but we do have 50-state maps. They are in the chat.

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Joan Alker: I believe, but maybe want to raise those up again. We'll have a blog, it's up now, or if not, up shortly, and it'll have links to, all of the 50 state data that we have.

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Edwin Park: Well, there does not appear to be any additional questions, so we'll wrap up our webinar today. Thanks to Joan Alker for her presentation, and thanks

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Edwin Park: to you all for joining today, and if you have any additional questions, please, send it to us, and we'll get back to you as soon as we can. And as Joan mentioned, there'll be, additional data

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Edwin Park: And analysis that we'll be posting in coming weeks and months. Thank you again.

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Joan Alker: Thanks, everyone.