Child Uninsured Rate Could Rise Sharply If States Don't Proceed with Caution by Joan Alker and Aubrianna Osorio Key Findings zz Medicaid and the Children's Health Insurance Program estimated that as many as 6.7 million children are at risk of (CHIP) successfully brought down the child uninsured losing coverage during the unwinding. The vast majority rate and proved to be a critical lifeline for more than half of children (73.6 percent) losing coverage will remain of the nation's children during the pandemic. A highly eligible for Medicaid but are likely to lose coverage due successful pandemic-era law that helped keep to bureaucratic snafus.3 The uninsured rate for children children and families continuously covered will lift could easily more than double if states have inadequate gradually starting on April 1, 2023 exposing children staffing levels and overwhelmed call centers and do and families to a greater risk of becoming uninsured. not take the time and care needed to properly conduct zz In March 2020, Congress and former President Trump eligibility checks after the federal protections lift. enacted a bipartisan provision to stabilize health coverage zz Medicaid/CHIP enrollment grew by 28 percent nationally for low-income children and families by increasing the from February 2020 to August 2022. In some states children federal government's contribution to state Medicaid account for the majority of Medicaid/CHIP enrollment programs while requiring states to maintain continuous growth-primarily in states that offer coverage to very few coverage for all Medicaid beneficiaries for the duration non-pregnant or non-disabled adults. Georgia leads the of the COVID-19 public health emergency. The recently nation with 69 percent of its Medicaid/CHIP enrollment enacted Consolidated Appropriations Act, 2023 delinks growth attributable to children; South Dakota, Texas, and that continuous coverage protection from the declaration Kansas are close behind with children comprising about 64 of the public health emergency starting April 1, while percent of their enrollment growth. Children also account for phasing down the enhanced federal Medicaid funding for the majority of Medicaid/CHIP enrollment growth in Wyoming states over the course of 2023. States have until May and Mississippi. In states that have not adopted the 2024 (though some will act more quickly) to complete Affordable Care Act Medicaid expansion, the unwinding the unprecedented task of conducting Medicaid process will primarily put at risk coverage for children, eligibility checks for 83.5 million people, including very poor parents, and new mothers. more than 34.2 million children, who are now enrolled.1 zz Nationally 54 percent of all children are covered Approximately four million children enrolled in CHIP- through Medicaid/CHIP. Black and Latino children financed Medicaid will need to be renewed as well.2 and children living in rural areas are likely covered at zz Millions of people are expected to lose Medicaid coverage higher rates though this data source does not allow during this so-called "unwinding" process for two reasons: for disaggregation. The five states (excluding DC) with 1) Their income has risen and they are no longer eligible; the highest percent of children covered through Medicaid/ 2) Red tape barriers or inadequate communication or CHIP are: New Mexico, Louisiana, Mississippi, Florida, and support from their state prevents families from renewing Alabama. Thirty states and the District of Columbia have at their coverage even though they remain eligible. We have least half of their children insured through Medicaid/CHIP. February 2023 CCF.GEORGETOWN.EDU Child uninsured Rate could rise sharply 1 Policy Lanscape Medicaid is the backbone of the nation's health care system In recognition of the risk of children becoming uninsured, the providing coverage to those for whom private insurance is Consolidated Appropriations Act requires states to provide not available or affordable and is now the primary coverage 12 months of continuous Medicaid and CHIP eligibility to source (along with CHIP) for America's children. Medicaid children under age 19 beginning on January 1, 2024 if they do covers approximately 83.5 million people (including 34.2 not already do so. Continuous eligibility, which is an existing million children)-a 31 percent increase since prior to the state option, ensures that parents who take on extra shifts, COVID-19 pandemic.4 This increase in enrollment reflects a receive a raise at work, or have seasonal employment do not federal protection ("continuous coverage") that has been in risk losing their child's Medicaid or CHIP coverage. Currently place since March of 2020 whereby states cannot disenroll 17 states and the District of Columbia do not have continuous anyone from Medicaid involuntarily in exchange for an increase eligibility for Medicaid or CHIP for any children with additional in the federal Medicaid matching rate. As a consequence of states providing continuous eligibility only in one program the Consolidated Appropriations Act,5 this federal protection or only for some children. (See Figure 1.) Immediately will lift gradually on April 1, 2023. Eligibility will have to be implementing this provision for all children as unwinding takes checked for all 83.5 million people enrolled in Medicaid and place would be highly beneficial for children; otherwise, there approximately four million children whose coverage is financed will likely be a gap in coverage before this provision becomes by CHIP but provided through Medicaid.6 States have until effective. This continuous eligibility requirement does not May 2024 to complete this process-it is likely however that apply to parents or other adults leaving low-income families some states will act more quickly. This is commonly referred to exposed to unpaid medical debt and health care needs. as the "Medicaid unwinding." Figure 1. 12-Month Continuous Eligibility for Children Under Age 19 in Medicaid and CHIP Multi-year continuous eligibility for young children 12-month continuous child eligibility 12-month continuous child eligibility (CHIP only) 12-month continuous child eligibility for some No 12-month continuous child eligibility Source: Georgetown University Center for Children and Families, "Medicaid and CHIP Continuous Coverage for Children" (Georgetown Center for Children and Families: October 2022). Note: Washington and New Mexico have pending section 1115 demonstration waivers to provide multi-year continuous converage for young children. California has passed legislation calling on the state to submit an 1115 waiver to adopt mulit-year continuous coverage for children up to age 5. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 2 With the majority of the children in the United States receiving their health insurance through Medicaid today, children have Because the structure of public coverage differs much at stake during the unwinding. Because the structure of for children and adults, policymakers must public coverage differs for children and adults, policymakers must consider the needs of children separately. Researchers consider the needs of children separately. have consistently projected that millions of people will lose Medicaid during this process, many of whom will become of inappropriately losing coverage.8 We have previously uninsured.7 With respect to children, because Medicaid/CHIP projected that the uninsured rate for children could easily income eligibility levels are much higher than for adults (see double especially in states that do not take adequate time Figure 2), there is widespread agreement that the vast majority and care with the process, are less adept at using electronic of children losing coverage will remain eligible for Medicaid but data sources in their Medicaid eligibility system, and/or have lose coverage due to procedural errors of one sort or another. more complicated and onerous public coverage features for Prior to the continuous coverage protection taking effect, children-such as separate CHIP programs which include children eligible for Medicaid would churn off and on coverage premiums or more frequent income checks.9 due to bureaucratic barriers, confusing renewal notices or This paper examines Medicaid/CHIP enrollment growth during notices getting lost in the mail, technology hiccups, or slight the continuous coverage period, which states have seen the income fluctuations. Children with parents who are hourly most substantial growth, and where children's enrollment has employees, work seasonal jobs, or work more than one part- constituted a larger share of the growth. Finally, we look at time job are particularly susceptible to losing coverage as the percentage of children now covered by Medicaid/CHIP in their family income is more likely to fluctuate and temporarily each state. Unfortunately, this data source does not allow us put them over the Medicaid or CHIP eligibility levels. The to disaggregate the data by race, ethnicity, age, or geography. continuous coverage protection nearly eliminated churn, Recent estimates from the National Health Interview Survey protecting children from gaps in health coverage. underscore the enormity of the stakes for families of color- A report from federal researchers finds that 72 percent with 68 percent of Black children and 60 percent of Latino of children losing Medicaid will remain eligible and that children now enrolled in public coverage.10 Latino and Black children and families are at greater risk Figure 2. Median Income Eligibility for Children and Adults by Expansion Status, 2022 300% 266% Median child 250% income eligibility 216% Median adult 200% income eligibility 150% 138% 100% 50% 39% 0% Expansion states Non-expansion states Source: Tricia Brooks et al., "Medicaid and CHIP Eligibility and Enrollment Policies as of January 2022: Findings for a 50-State Survey" (Georgetown University Center for Children and Families and Kaiser Familiy Foundation, March 2022). February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 3 Background Children have the highest rate of poverty in the United Prior to the pandemic, children from low-wage working States, compared to other age groups.11 This, along with the families, particularly those in families of color, often more generous public coverage levels that exist for children experienced periods of uninsurance in part due to through Medicaid and CHIP and the fact that employer- administrative churn.14 Families may have difficulty completing sponsored coverage is far more expensive for families than the renewal process successfully if they have language individual workers, among other factors, and the continuous barriers or inadequate support throughout the process. Even coverage requirement have resulted in Medicaid being today "returned mail" can and does lead to a child losing their the single largest source of coverage for children-with 54.3 health insurance coverage in "normal" times.15 Given the percent of all children enrolled in Medicaid and CHIP.12 considerable housing instability for low-income families and changes in employment patterns and child care due to the During the early days of the COVID-19 pandemic, Congress pandemic, there has likely been a great deal of movement and enacted a number of relief bills to address the public changes for these families over the past two years.16 Many health and economic crises the nation faced. One of the of these families are likely to have outdated addresses and first such bills, the Families First Coronavirus Response information in the Medicaid eligibility systems. Act (FFCRA), included enhanced federal funding for the Medicaid and CHIP programs. To qualify for the extra 6.2 Any gap in coverage is problematic for children and families percentage points in the federal Medicaid match rate, as they are exposed to large medical bills in the event of states have been required to meet specific maintenance of a child becoming sick or breaking a bone. It is even more effort provisions. The most important of these provisions challenging for families with children who have chronic prohibited states from disenrolling anyone involuntarily who conditions like asthma or complex medical needs that require was enrolled in Medicaid on or after March 18, 2020. This regular access to health care services. Uninsured children are provision is referred to in different ways-most commonly also less likely to receive needed primary and preventive care as the Medicaid "continuous coverage requirement" or the for conditions such as asthma that can worsen and land a Medicaid disenrollment freeze. This policy also applied to child in the emergency room. While children are not expensive CHIP children enrolled in Medicaid, but not to CHIP children to cover, they need access to regular preventive and primary enrolled in separate state programs. care to grow and thrive as states begin to unwind. There is clear evidence that the Medicaid continuous coverage requirement has been an extremely important policy tool to avoid increases in the number of uninsured people during the pandemic. The number of uninsured people generally rises during economic downturns as people lose their jobs and health insurance, but national survey data suggest that the uninsured rate actually went down. For children the Medicaid protections have been key to reversing coverage losses of the period prior to the pandemic and stabilizing the uninsured rate.13 February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 4 What has happened to Medicaid enrollment? We examined federal administrative data on Medicaid and expansion for low-income adults as a result of voter-backed CHIP enrollment growth from February 2020 to August 2022, referenda during the period. (See Appendix Table 1.) While all the most recent month for which consistent data from nearly states experienced enrollment growth during the period, growth all 50 states and the District of Columbia were reported to rates (excluding Oklahoma and Missouri) ranged from a high of the Centers for Medicare and Medicaid Services at the time 57.5 percent in Indiana to a low of 16.7 percent in Connecticut. of this writing.17 Specifically we looked at total enrollment Varying growth rates are likely the result of many factors growth, child only enrollment growth, and analyzed the share including differential economic impacts of the pandemic, state of enrollment growth that was attributable to children during policy choices such as suspending premiums or other barriers this period. Finally, we examine the percent of children overall like periodic income checks during the COVID-19 public health in each state enrolled in Medicaid/CHIP as of August 2022. emergency, and, most especially, the level of pre-pandemic burdens imposed by states associated with renewing coverage Unsurprisingly, the top two states with the largest total during "normal" times which results in higher or lower shares of enrollment growth are Oklahoma and Missouri as both of children and families eligible but not enrolled in Medicaid/CHIP. these states implemented the Affordable Care Act's Medicaid Which states have seen the largest growth in children's Medicaid? Child enrollment growth in Medicaid and CHIP over the Table 1 shows the top ten states with respect to Medicaid and period tended to grow most quickly in states that had higher CHIP child enrollment growth which ranged from a high of uninsured rates prior to the pandemic. This is to be expected 44.8 percent in Indiana to a low of 7.7 percent in Vermont (see since the majority of uninsured children prior to the pandemic Appendix Table 2 for all states). States that had lower Medicaid were eligible but not enrolled in Medicaid and CHIP.18 The and CHIP participation rates at the start of the pandemic protective effect of the continuous coverage requirement has had more "room to grow" in child enrollment and thus would been more valuable to families in these states because they be expected to see higher enrollment growth. Indiana and tend to erect more barriers to enrollment and retention of Wyoming are good examples of this with participation rates for public coverage and/or have lower income eligibility levels. children eligible for Medicaid far below the national average prior to the pandemic.19 Table 1. Top 10 States for Child Enrollment Growth in Medicaid and CHIP February August 2019 Number Percent State 2020 Child 2022 Child Rank Uninsured Rank Change Change Enrollment Enrollment Rate United States 35,973,247 42,261,973 6,288,726 17.5% - 5.7 - Indiana 716,646 1,037,575 320,929 44.8% 1 7.1 40 Wyoming 37,242 51,421 14,179 38.1% 2 10.6 50 North Dakota 42,563 57,532 14,969 35.2% 3 7.8 43 Missouri 536,875 719,959 183,084 34.1% 4 6.5 39 Georgia 1,268,470 1,678,168 409,698 32.3% 5 7.4 41 Kansas 263,184 343,858 80,674 30.7% 6 5.8 33 Utah 184,630 236,262 51,632 28.0% 7 8.3 46 Oklahoma 502,359 639,712 137,353 27.3% 8 8.6 47 South Dakota 77,955 98,679 20,724 26.6% 9 7.8 43 Texas 3,301,272 4,172,430 871,158 26.4% 10 12.7 51 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 5 We also examined the share of enrollment growth overall that is attributable to children. The top ten states with the In states that have not expanded Medicaid, largest share of enrollment growth attributable to children children constitute 53 percent of Medicaid are shown in Table 2. All of these states cover far fewer enrollment growth as compared to about 25 non-pregnant or non-disabled adults because they have not accepted the ACA's Medicaid expansion-except percent in expansion states. for Indiana. In states that have not expanded Medicaid, children constitute 53 percent of Medicaid enrollment growth as compared to expansion states where children growth particular attention must be given to bureaucratic constitute about one quarter of enrollment growth. In every barriers, inertia, or indifference that may result in eligible children state, policymakers should consider the needs of children losing coverage. In Medicaid non-expansion states, children separately due to the fact that their eligibility levels are are far more likely to remain eligible for Medicaid or CHIP than higher so they are most likely to remain eligible even if their their parents and that large disconnect between eligibility levels parent's income is over the adult eligibility guidelines. In could cause confusion for parents, leading to children losing states that have seen a higher share of child enrollment their coverage. Table 2. Top 10 Child Share of Enrollment Growth in Medicaid and CHIP Total Enrollment Number Child Enrollment Number Child Share State Rank Change (Feb 2020-Aug 2022) Change (Feb 2020-Aug 2022) of Growth United States 19,625,124 6,288,726 32.0% - Georgia 589,931 409,698 69.4% 1 South Dakota 32,100 20,724 64.6% 2 Texas 1,354,590 871,158 64.3% 3 Kansas 126,473 80,674 63.8% 4 Wyoming 24,126 14,179 58.8% 5 Mississippi 137,170 80,308 58.5% 6 Alabama 222,233 107,965 48.6% 7 Florida 1,172,881 565,817 48.2% 8 Tennessee 298,182 130,663 43.8% 9 Indiana 768,978 320,929 41.7% 10 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 6 Which states have the largest share of all children covered through Medicaid and CHIP today? In 30 states and the District of Columbia, more than half of their child population is enrolled in Medicaid and CHIP. (See Appendix Table 4.) Ten states and DC have more than 60 percent of their children insured by Medicaid and CHIP. (See Table 3.) Access to care for children could be severely disrupted in these states if the Medicaid unwinding process does not go well. Table 3. States with 60 Percent or More of All Children Enrolled in Medicaid/CHIP 2021 Child Child Medicaid/CHIP Share of Children with State Rank Population Enrollment (August 2022) Medicaid/CHIP United States 77,831,000 42,261,973 54.3% - New Mexico 503,000 380,565 75.7% 1 District of Columbia 134,000 100,287 74.8% 2 Louisiana 1,138,000 796,152 70.0% 3 Mississippi 736,000 497,997 67.7% 4 Florida 4,534,000 2,976,759 65.7% 5 Alabama 1,191,000 768,824 64.6% 6 West Virginia 381,000 243,554 63.9% 7 Oklahoma 1,011,000 639,712 63.3% 8 Georgia 2,684,000 1,678,168 62.5% 9 South Carolina 1,188,000 742,705 62.5% 10 Indiana 1,680,000 1,037,575 61.8% 11 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. Child population totals from U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2021, Health Insurance Historical Tables. Conclusion Medicaid is now the single largest source of health coverage adults, the Medicaid unwinding process will primarily pose for children in the United States. While some parents may risks to children, very poor parents, and postpartum women. no longer meet the Medicaid income eligibility guidelines, Coverage losses will be more likely to happen in states that children are still likely to be eligible for Medicaid or CHIP due do not reduce bureaucratic hurdles and fail to utilize effective to higher child income eligibility standards. A separate study strategies to reach and support parents through the renewal found that an estimated 3.2 million children under 18 currently process with a message that their child is likely still eligible enrolled in Medicaid will become eligible for separate CHIP for public coverage. States must also work with trusted programs-which is less than ten percent of children currently messengers to reach communities of color who are more enrolled in Medicaid.20 likely to lose coverage inappropriately. The potential impact Ensuring that children and their families navigate successfully of the unwinding process could double the nation's uninsured to new sources of coverage will be challenging; an even rate for children if not handled well, and worsen existing racial greater challenge will be retaining eligible children. These disparities in access to health coverage and care. Families children are at grave risk of losing coverage inappropriately in with high levels of recent residential instability, limited English states that do not handle the renewal process with the utmost proficiency, or limited internet access are at greater risk of care. In states that cover few non-pregnant, non-disabled losing coverage. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 7 Coverage losses can be mitigated and gaps in coverage or other clear warning signs emerge. A major challenge lies avoided by early state adoption of the soon to be required ahead, but states that take their time, work closely with 12 months of continuous Medicaid and CHIP eligibility community partners, extend continuous coverage periods for children in states that have not yet implemented it for for children (which can be even longer than 12 months with children of all ages in both Medicaid and CHIP. State leaders approved Section 1115 authority), and dedicate the needed in all states must commit to being transparent with data resources to the process could avoid large coverage losses on eligibility denials and call center statistics and halt the and even reimagine their systems for a brighter future for process if large numbers of children and adults lose coverage children. for procedural reasons, call centers become overwhelmed, Acknowledgments The authors would like to thank Cathy Hope, Edwin Park, Tricia Brooks, and Hannah Klukoff for their contributions to this brief. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America's children and families. CCF is based in the McCourt School of Public Policy. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 8 Appendix Table 1. Total Enrollment Growth in Medicaid and CHIP by State February 2020 Total August 2022 Number Percent State Rank Enrollment Total Enrollment Change Change United States 71,097,415 90,722,539 19,625,124 27.6% - Alabama 923,320 1,145,553 222,233 24.1% 36 Alaska 222,941 262,417 39,476 17.7% 50 Arizona 1,705,789 2,245,107 539,318 31.6% 20 Arkansas 802,939 1,019,232 216,293 26.9% 27 California 11,590,601 13,820,824 2,230,223 19.2% 47 Colorado 1,266,680 1,656,830 390,150 30.8% 21 Connecticut 844,967 985,813 140,846 16.7% 51 Delaware 231,742 293,136 61,394 26.5% 30 District of Columbia 241,674 287,984 46,310 19.2% 48 Florida 3,600,457 4,773,338 1,172,881 32.6% 16 Georgia 1,833,759 2,423,690 589,931 32.2% 19 Hawaii 325,667 435,501 109,834 33.7% 13 Idaho 319,534 432,974 113,440 35.5% 10 Illinois 2,829,625 3,695,126 865,501 30.6% 22 Indiana 1,337,074 2,106,052 768,978 57.5% 3 Iowa 677,141 833,293 156,152 23.1% 40 Kansas 378,292 504,765 126,473 33.4% 14 Kentucky 1,288,129 1,585,244 297,115 23.1% 39 Louisiana 1,495,354 1,866,372 371,018 24.8% 33 Maine 267,482 356,468 88,986 33.3% 15 Maryland 1,330,660 1,654,583 323,923 24.3% 35 Massachusetts 1,571,761 1,933,081 361,320 23.0% 41 Michigan 2,330,401 2,983,721 653,320 28.0% 26 Minnesota 1,044,409 1,342,340 297,931 28.5% 25 Mississippi 615,262 752,432 137,170 22.3% 44 Missouri 855,282 1,375,658 520,376 60.8% 2 Montana 252,740 315,377 62,637 24.8% 34 Nebraska 248,633 377,726 129,093 51.9% 4 Nevada 625,358 877,180 251,822 40.3% 8 New Hampshire 181,726 243,549 61,823 34.0% 11 New Jersey 1,701,569 2,159,579 458,010 26.9% 28 New Mexico 744,994 879,766 134,772 18.1% 49 New York 5,987,770 7,269,924 1,282,154 21.4% 45 North Carolina 1,770,394 2,295,141 524,747 29.6% 23 North Dakota 89,991 126,517 36,526 40.6% 7 Ohio 2,596,917 3,289,608 692,691 26.7% 29 Oklahoma 716,566 1,248,544 531,978 74.2% 1 Oregon 1,002,190 1,343,029 340,839 34.0% 12 Pennsylvania 2,934,949 3,613,259 678,310 23.1% 38 Rhode Island 289,944 355,465 65,521 22.6% 42 South Carolina 1,036,982 1,269,307 232,325 22.4% 43 South Dakota 109,585 141,685 32,100 29.3% 24 Tennessee 1,447,919 1,746,101 298,182 20.6% 46 Texas 4,198,897 5,553,487 1,354,590 32.3% 18 Utah 313,899 469,333 155,434 49.5% 5 Vermont 151,167 190,063 38,896 25.7% 31 Virginia 1,426,912 1,945,680 518,768 36.4% 9 Washington 1,723,451 2,133,275 409,824 23.8% 37 West Virginia 506,857 635,927 129,070 25.5% 32 Wisconsin 1,050,981 1,391,275 340,294 32.4% 17 Wyoming 56,082 80,208 24,126 43.0% 6 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 9 Appendix Table 2. Child Enrollment Growth in Medicaid and CHIP by State February 2020 August 2022 Number Percent State Rank Childl Enrollment Child Enrollment Change Change United States 35,973,247 42,261,973 6,288,726 17.5% - Alabama 660,859 768,824 107,965 16.3% 25 Alaska 97,379 105,055 7,676 7.9% 50 Arizona 752,139 872,134 119,995 16.0% 27 Arkansas 370,840 436,612 65,772 17.7% 21 California 4,806,615 5,241,933 435,318 9.1% 47 Colorado 566,484 640,225 73,741 13.0% 39 Connecticut 331,656 362,198 30,542 9.2% 46 Delaware 105,630 121,590 15,960 15.1% 32 District of Columbia 90,421 100,287 9,866 10.9% 44 Florida 2,410,942 2,976,759 565,817 23.5% 13 Georgia 1,268,470 1,678,168 409,698 32.3% 5 Hawaii 138,826 157,877 19,051 13.7% 38 Idaho 175,309 205,916 30,607 17.5% 22 Illinois 1,347,284 1,536,583 189,299 14.1% 36 Indiana 716,646 1,037,575 320,929 44.8% 1 Iowa 337,748 381,600 43,852 13.0% 40 Kansas 263,184 343,858 80,674 30.7% 6 Kentucky 547,576 635,521 87,945 16.1% 26 Louisiana 717,338 796,152 78,814 11.0% 43 Maine 108,717 133,802 25,085 23.1% 14 Maryland 622,062 718,968 96,906 15.6% 29 Massachusetts 669,192 746,383 77,191 11.5% 42 Michigan 944,233 1,111,865 167,632 17.8% 20 Minnesota 530,743 630,323 99,580 18.8% 18 Mississippi 417,689 497,997 80,308 19.2% 17 Missouri 536,875 719,959 183,084 34.1% 4 Montana 114,894 130,957 16,063 14.0% 37 Nebraska 165,414 200,167 34,753 21.0% 16 Nevada 295,392 365,412 70,020 23.7% 12 New Hampshire 89,507 105,827 16,320 18.2% 19 New Jersey 811,342 946,208 134,866 16.6% 23 New Mexico 332,629 380,565 47,936 14.4% 34 New York 2,389,703 2,583,841 194,138 8.1% 49 North Carolina 1,189,125 1,372,286 183,161 15.4% 30 North Dakota 42,563 57,532 14,969 35.2% 3 Ohio 1,152,914 1,330,435 177,521 15.4% 31 Oklahoma 502,359 639,712 137,353 27.3% 8 Oregon 416,860 485,683 68,823 16.5% 24 Pennsylvania 1,383,641 1,563,140 179,499 13.0% 41 Rhode Island 116,420 126,694 10,274 8.8% 48 South Carolina 648,589 742,705 94,116 14.5% 33 South Dakota 77,955 98,679 20,724 26.6% 9 Tennessee 822,161 952,824 130,663 15.9% 28 Texas 3,301,272 4,172,430 871,158 26.4% 10 Utah 184,630 236,262 51,632 28.0% 7 Vermont 60,890 65,597 4,707 7.7% 51 Virginia 756,692 916,750 160,058 21.2% 15 Washington 826,585 904,229 77,644 9.4% 45 West Virginia 213,391 243,554 30,163 14.1% 35 Wisconsin 506,220 630,899 124,679 24.6% 11 Wyoming 374,242 51,421 14,179 38.1% 2 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 10 Appendix Table 3. Child Share of Enrollment Growth in Medicaid and CHIP by State Total Enrollment Number Change Child Enrollment Number Change Number State Rank (Feb 2020 – Aug 2022) (Feb 2020 – Aug 2022) Change United States 19,625,124 6,288,726 32.0% - Alabama 222,233 107,965 48.6% 7 Alaska 39,476 7,676 19.4% 45 Arizona 539,318 119,995 22.2% 37 Arkansas 216,293 65,772 30.4% 20 California 2,230,223 435,318 19.5% 44 Colorado 390,150 73,741 18.9% 47 Connecticut 140,846 30,542 21.7% 39 Delaware 61,394 15,960 26.0% 31 District of Columbia 46,310 9,866 21.3% 41 Florida 1,172,881 565,817 48.2% 8 Georgia 589,931 409,698 69.4% 1 Hawaii 109,834 19,051 17.3% 48 Idaho 113,440 30,607 27.0% 27 Illinois 865,501 189,299 21.9% 38 Indiana 768,978 320,929 41.7% 10 Iowa 156,152 43,852 28.1% 25 Kansas 126,473 80,674 63.8% 4 Kentucky 297,115 87,945 29.6% 22 Louisiana 371,018 78,814 21.2% 42 Maine 88,986 25,085 28.2% 24 Maryland 323,923 96,906 29.9% 21 Massachusetts 361,320 77,191 21.4% 40 Michigan 653,320 167,632 25.7% 33 Minnesota 297,931 99,580 33.4% 17 Mississippi 137,170 80,308 58.5% 6 Missouri 520,376 183,084 35.2% 15 Montana 62,637 16,063 25.6% 34 Nebraska 129,093 34,753 26.9% 28 Nevada 251,822 70,020 27.8% 26 New Hampshire 61,823 16,320 26.4% 30 New Jersey 458,010 134,866 29.4% 23 New Mexico 134,772 47,936 35.6% 14 New York 1,282,154 194,138 15.1% 50 North Carolina 524,747 183,161 34.9% 16 North Dakota 36,526 14,969 41.0% 11 Ohio 692,691 177,521 25.6% 35 Oklahoma 531,978 137,353 25.8% 32 Oregon 340,839 68,823 20.2% 43 Pennsylvania 678,310 179,499 26.5% 29 Rhode Island 65,521 10,274 15.7% 49 South Carolina 232,325 94,116 40.5% 12 South Dakota 32,100 20,724 64.6% 2 Tennessee 298,182 130,663 43.8% 9 Texas 1,354,590 871,158 64.3% 3 Utah 155,434 51,632 33.2% 18 Vermont 38,896 4,707 12.1% 51 Virginia 518,768 160,058 30.9% 19 Washington 409,824 77,644 18.9% 46 West Virginia 129,070 30,163 23.4% 36 Wisconsin 340,294 124,679 36.6% 13 Wyoming 24,126 14,179 58.8% 5 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 11 Appendix Table 4. Share of All Children Enrolled in Medicaid and CHIP by State 2021 August 2022 Share of Children with State Rank Child Population Child Enrollment Medicaid/CHIP Coverage United States 77,831,000 42,261,973 54.3% - Alabama 1,191,000 768,824 64.6% 6 Alaska 187,000 105,055 56.2% 17 Arizona 1,716,000 872,134 50.8% 29 Arkansas 743,000 436,612 58.8% 14 California 9,275,000 5,241,933 56.5% 16 Colorado 1,318,000 640,225 48.6% 37 Connecticut 775,000 362,198 46.7% 39 Delaware 222,000 121,590 54.8% 21 District of Columbia 134,000 100,287 74.8% 2 Florida 4,534,000 2,976,759 65.7% 5 Georgia 2,684,000 1,678,168 62.5% 9 Hawaii 318,000 157,877 49.6% 33 Idaho 498,000 205,916 41.3% 46 Illinois 2,968,000 1,536,583 51.8% 26 Indiana 1,680,000 1,037,575 61.8% 11 Iowa 782,000 381,600 48.8% 36 Kansas 746,000 343,858 46.1% 41 Kentucky 1,073,000 635,521 59.2% 13 Louisiana 1,138,000 796,152 70.0% 3 Maine 263,000 133,802 50.9% 28 Maryland 1,438,000 718,968 50.0% 31 Massachusetts 1,469,000 746,383 50.8% 30 Michigan 2,277,000 1,111,865 48.8% 35 Minnesota 1,383,000 630,323 45.6% 43 Mississippi 736,000 497,997 67.7% 4 Missouri 1,462,000 719,959 49.2% 34 Montana 248,000 130,957 52.8% 24 Nebraska 509,000 200,167 39.3% 47 Nevada 732,000 365,412 49.9% 32 New Hampshire 273,000 105,827 38.8% 48 New Jersey 2,129,000 946,208 44.4% 44 New Mexico 503,000 380,565 75.7% 1 New York 4,357,000 2,583,841 59.3% 12 North Carolina 2,451,000 1,372,286 56.0% 18 North Dakota 195,000 57,532 29.5% 50 Ohio 2,757,000 1,330,435 48.3% 38 Oklahoma 1,011,000 639,712 63.3% 8 Oregon 911,000 485,683 53.3% 22 Pennsylvania 2,847,000 1,563,140 54.9% 20 Rhode Island 227,000 126,694 55.8% 19 South Carolina 1,188,000 742,705 62.5% 10 South Dakota 232,000 98,679 42.5% 45 Tennessee 1,623,000 952,824 58.7% 15 Texas 7,867,000 4,172,430 53.0% 23 Utah 998,000 236,262 23.7% 51 Vermont 126,000 65,597 52.1% 25 Virginia 2,000,000 916,750 45.8% 42 Washington 1,766,000 904,229 51.2% 27 West Virginia 381,000 243,554 63.9% 7 Wisconsin 1,352,000 630,899 46.7% 40 Wyoming 140,000 51,421 36.7% 49 Source: Georgetown University Center for Children and Families analysis of Centers for Medicare & Medicaid Services (CMS) State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Arizona does not report a child enrollment number in the CMS data, so CCF substitutes state administrative data, which Arizona releases quarterly. CCF also substitutes state administrative data for Indiana in August 2022. Child population totals from U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2021, Health Insurance Historical Tables. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 12 Endnotes 1 Centers for Medicare & Medicaid Services (CMS), "August 2022 12 Georgetown University Center for Children and Families analysis Medicaid and CHIP Enrollment Trends Snapshot," available at https:// of Centers for Medicare & Medicaid Services (CMS) State Medicaid www.medicaid.gov/medicaid/national-medicaid-chip-program- and CHIP Applications, Eligibility Determinations, and Enrollment information/downloads/august-2022-medicaid-chip-enrollment-trend- Data. CCF uses updated data whenever possible. Arizona does not snapshot.pdf. As CMS notes, this number reflects only 49 states and DC report a child enrollment number in the CMS data, so CCF substitutes and excludes Arizona, which does not report a child enrollment breakout. state administrative data for child enrollment in all months. CCF also substitutes Indiana state administrative data for both child and total 2 J. Alker and T. Brooks, "Millions of Children May Lose Medicaid: enrollment in August 2022 due to recent changes in the state's reporting What Can Be Done to Help Prevent Them from Becoming Uninsured?" to CMS. More information on data sources and methodology is available (Georgetown University Center for Children and Families: February 2022), online. available at https://ccf.georgetown.edu/2022/02/17/millions-of-children- may-lose-medicaid-what-can-be-done-to-help-prevent-them-from- 13 J. Alker, A. Osorio, and E. Park, "Number of Uninsured Children becoming-uninsured/. Stabilized and Improved Slightly During the Pandemic" (Georgetown University Center for Children and Families: December 2022), available at 3 Office of the Assistant Secretary for Planning and Evaluation (ASPE), https://ccf.georgetown.edu/2022/12/07/number-of-uninsured-children- "Unwinding the Medicaid Continuous Enrollment Provision: Projected stabilized-and-improved-slightly-during-the-pandemic-2/. Enrollment Effects and Policy Approaches" (Office of the Assistant Secretary for Planning and Evaluation, August 2022), available at https:// 14 A. Osorio and J. Alker, "Gaps in Coverage: A Look at Child Health aspe.hhs.gov/reports/unwinding-medicaid-continuous-enrollment- Insurance Trends" (Georgetown University Center for Children and provision. Families: November 2021), available at https://ccf.georgetown. edu/2021/11/22/gaps-in-coverage-a-look-at-child-health-insurance- 4 CMS, op. cit. CHIP enrollment has increased 4.7 percent during the trends/. same period; children in CHIP Medicaid programs are protected by the continuous coverage protection; children in "separate" state CHIP 15 M. Hawryluk, "Return To Sender? Just One Missed Letter Can programs are not. Be Enough To End Medicaid Benefits," National Public Radio, November 1, 2019, available at https://www.npr.org/sections/health- 5 For more information, see Edwin Park et al., "Consolidated shots/2019/11/01/774804485/return-to-sender-just-one-missed-letter- Appropriations Act, 2023: Medicaid and CHIP Provisions Explained" can-be-enough-to-end-medicaid-benefits. (Georgetown University Center for Children and Families: February 2022), available at https://ccf.georgetown.edu/2023/01/05/consolidated- 16 K. Wong, "Housing Insecurity and the COVID-19 Pandemic," appropriations-act-2023-medicaid-and-chip-provisions-explained/. (Consumer Financial Protection Bureau: March 2021), available at https:// files.consumerfinance.gov/f/documents/cfpb_Housing_insecurity_and_ 6 Georgetown University Center for Children and Families calculation the_COVID-19_pandemic.pdf. based on the 6.9 million children enrolled in CHIP as of August 2022 (CMS, op. cit). Approximately 61 percent of these children are in 17 CMS State Medicaid and CHIP Applications, Eligibility Determinations, CHIP-funded Medicaid, so we applied this ratio for an estimate. See and Enrollment Data, op. cit. MACPAC, "Exhibit 32. Child Enrollment in CHIP and Medicaid by State, 18 J. Haley et al., "Uninsurance Rose among Children and Parents in 2019: FY 2021 (thousands)", available at https://www.macpac.gov/wp-content/ National and State Patterns" (Urban Institute: July 2021), available at uploads/2022/12/EXHIBIT-32.-Child-Enrollment-in-CHIP-and-Medicaid- https://www.urban.org/sites/default/files/publication/104547/uninsurance- by-State-FY-2021-thousands.pdf. rose-among-children-and-parents-in-2019.pdf. 7 ASPE, op. cit. See also M. Buettgens and A. Green, "The Impact of the 19 Georgetown University Center for Children and Families, Children's COVID-19 Public Health Emergency Expiration on All Types of Health Health Care Report Card, available at https://kidshealthcarereport.ccf. Coverage" (Urban Institute: December 2022), available at https://www. georgetown.edu/states/indiana and https://kidshealthcarereport.ccf. urban.org/sites/default/files/2022-12/The%20Impact%20of%20the%20 georgetown.edu/states/wyoming. COVID-19%20Public%20Health%20Emergency%20Expiration%20 on%20All%20Types%20of%20Health%20Coverage_0.pdf; Alker and 20 Buettgens and Green, op. cit. Some children will be eligible for Brooks op. cit.; and E. Williams, R. Rudowitz, and B. Corallo, "Fiscal and employer-sponsored insurance or subsidized Marketplace coverage but Enrollment Implications of Medicaid Continuous Coverage Requirement this study does not break these numbers out by age. During and After the PHE Ends" (Kaiser Family Foundation: May 2022), available at https://www.kff.org/medicaid/issue-brief/fiscal-and- enrollment-implications-of-medicaid-continuous-coverage-requirement- during-and-after-the-phe-ends/. 8 ASPE, op. cit. 9 Alker and Brooks, op. cit. 10 R. A. Cohen and A. E. Cha, "Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January–June 2022" (National Center for Health Statistics: December 2022), available at https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202212.pdf. 11 C. Benson, "U.S. Poverty Rate Is 12.8% but Varies Significantly by Age Groups" (U.S. Census Bureau: October 2022), available at https://www. census.gov/library/stories/2022/10/poverty-rate-varies-by-age-groups. html. February 2023 CCF.GEORGETOWN.EDU child uninsured rate could rise sharply 13