Medicaid's Pandemic-Era Continuous Coverage Protections Helped Reduce Number of Uninsured Children by Joan Alker and Aubrianna Osorio Key Findings zz In response to the pandemic, states were temporarily zz Nationally, child uninsured rates fell across required to keep people covered by Medicaid enrolled demographic groups with children of nearly over the course of the COVID-19 public health emergency every age, race and ethnicity, and family in exchange for enhanced federal funding. This Medicaid income level seeing increased coverage. protection helped to reduce the number and rate of American Indian and Alaska Native children uninsured children; 3.9 million children were uninsured and children in low-income families saw the in 2022-tying 2017 for the second-lowest number biggest reductions in their uninsured rates, in recent memory. The only year with fewer uninsured likely reflecting the impact of the Medicaid children was 2016. The uninsured rate for children continuous coverage protection. However, declined to 5.1 percent in 2022 from 5.7 percent in 2019, this protection has now been lifted and the year before Medicaid's pandemic-era continuous coverage losses resulting from the current coverage protection took effect. Prior to the pandemic, the process of renewing eligibility for all number of uninsured children had been increasing. children threaten to reverse much of the zz Twenty-one states saw statistically significant declines progress seen over recent years. This in the rate and/or number of uninsured children, with unprecedented process of redetermining Wyoming, North Dakota, Utah, New Mexico, and eligibility for nearly everyone covered by Texas seeing the greatest improvements. Despite these Medicaid, otherwise known as "unwinding" of improvements, many of these states still had some of the the continuous coverage protection, will likely highest uninsured rates in the country in 2022. cause the uninsured rate for children to start moving in the wrong direction again as many zz Four states moved in the wrong direction, with Iowa, eligible children lose Medicaid coverage and Maryland, Pennsylvania, and Wisconsin seeing become uninsured. statistically significant increases in the number and rate of uninsured children from 2019 to 2022. Iowa saw the largest jump with a 27 percent increase in the number of uninsured children. More than one in five uninsured children live in Texas, which has far more uninsured children than any other state. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 1 9.7% 9.0%* Figure 1. Rate of Uninsured Children in 8.5%* the United States, 2008-2022 7.9%* 7.5%* 7.5% 6.3%* 5.7%* No 5.1%* 5.2%* Data** 5.4%* 5.0%* 5.1%* 4.7%* 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 * Change is significant at the 90% confidence level relative to the prior year indicated. ** Due to pandemic-related data quality issues, the U.S. Census Bureau did not release standard 1-year ACS estimates in 2020. See methodology for more information. Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. Data from the U.S. Census Bureau's American Community children had been rising 2 and it is likely to rise again, absent Survey (ACS) for 2022 finds that the number of uninsured very aggressive action by federal and state policymakers, children continued to decline over the pandemic period-most now that continuous coverage protections have been lifted likely as a consequence of the continuous coverage protection and states are reassessing eligibility for everyone covered by in Medicaid put in place by one of the first COVID-19 rescue Medicaid.3 packages, the Families First Coronavirus Relief Act of 2020 The number of uninsured children nationwide in 2022 was 3.9 (P.L. 116-127).1 The uninsured rate for children declined to 5.1 million, tying 2022 with 2017 for the second-lowest number in percent in 2022-a significant drop from the year before when recent memory-with the exception of 2016 when continued the uninsured rate was 5.4 percent (see Figure 1). Medicaid is implementation of the Affordable Care Act helped drive the the single largest source of coverage for children, and children number of uninsured children to its lowest level at 3.6 million were protected from administrative churning during the (see Figure 2). pandemic period. Prior to the pandemic the uninsured rate for Figure 2. Number of Uninsured Children in 7.6 7.1* the United States (in millions), 2008-2022 6.7* 6.2* 5.9* 5.9 4.9* 4.4* 4.0* 4.1* 4.2* 3.9* 3.9* 3.6* No Data** 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 * Change is significant at the 90% confidence level relative to the prior year indicated. ** Due to pandemic-related data quality issues, the U.S. Census Bureau did not release standard 1-year ACS estimates in 2020. See methodology for more information. Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 2 How are specific states doing? Most states (36) saw a decline in the number and rate Only four states saw significant growth in their number and rate of of uninsured children; twenty states saw a statistically uninsured children during the pandemic period (Iowa, Maryland, significant decline in number from 2019 to 2022, and 17 Pennsylvania, Wisconsin), with Iowa seeing the largest number states saw a statistically significant decline in rate over increase in the country in percentage terms. See Appendix Tables 3 the examined time period. Children in Texas saw the and 4 for a full list of state changes. greatest improvement in number by a considerable margin Despite improvement, Texas continues to be home to the largest (a 141,000 decline in the number of uninsured children); number of uninsured children by far, accounting for 22 percent of Wyoming saw the greatest improvement in its child all uninsured children. About 854,000 Texas children are uninsured. uninsured rate moving from 10.6 percent to 7.9 percent Florida and California follow with 336,000 and 287,000 respectively. in 2022. Tables 1 and 2 list the top ten states where the Together these states account for more than one-third of uninsured largest declines in the number and rate of uninsured children nationwide. children occurred. Table 1. Top 10 Largest Declines in the Number of Uninsured Children by State, 2019-2022 2019 Number 2022 Number 2019-2022 Change in 2019-2022 State Uninsured Uninsured Number of Uninsured Percent Change United States 4,375,000 3,932,000 -443,000* -10%* Texas 995,000 854,000 -141,000* -14%* California 334,000 287,000 -47,000* -14%* Georgia 197,000 166,000 -31,000* -16%* Indiana 119,000 91,000 -28,000* -24%* North Carolina 142,000 118,000 -24,000* -17%* Illinois 120,000 99,000 -21,000* -18%* Utah 82,000 61,000 -21,000* -26%* Arizona 161,000 142,000 -19,000* -12%* Michigan 78,000 60,000 -18,000* -23%* Oklahoma 86,000 73,000 -13,000* -15%* * Change is significant at the 90% confidence level relative to the prior year indicated. Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. Table 2. Top 10 Largest Declines in the Rate of Uninsured Children by State, 2019-2022 State 2019 Uninsured Rate 2022 Uninsured Rate Percentage Point Change United States 5.7% 5.1% -0.6* Wyoming 10.6% 7.9% -2.7* North Dakota 7.8% 5.5% -2.3* Utah 8.3% 6.1% -2.2* New Mexico 5.7% 3.8% -1.9* Texas 12.7% 10.9% -1.8* Indiana 7.1% 5.5% -1.6* South Dakota 7.8% 6.2% -1.6 Delaware 4.8% 3.4% -1.4 Oklahoma 8.6% 7.3% -1.3* Georgia 7.4% 6.2% -1.2* * Change is significant at the 90% confidence level relative to the prior year indicated. Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous Coverage 3 Table 3. Top 10 United States Metro Areas with Highest Uninsured Rates for Children, 2022 Metro Area State Uninsured Rate United States - 5.1% Lebanon Metro Area Pennsylvania 21.4% Lancaster Metro Area Pennsylvania 16.6% Sherman-Denison Metro Area Texas 13.9% Midland Metro Area Texas 13.8% McAllen-Edinburg-Mission Metro Area Texas 13.5% Abilene Metro Area Texas 12.7% Naples-Marco Island Metro Area Florida 12.0% Beaumont-Port Arthur Metro Area Texas 11.8% Elkhart-Goshen Metro Area Indiana 11.7% El Paso Metro Area Texas 11.6% Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2019-2021 American Community Survey (ACS), Table S2701. Six of the top ten metropolitan areas in the U.S. with the highest rates of uninsured children are in Texas (see Table 3). The map (see Figure 3) shows the 12 Texas metro areas where more than 10 percent of children are uninsured. Figure 3 Texas Metro Areas with Child Uninsured Rate of 10% or More, 2022 Child Uninsured Rate 10% 14% Figure 3. Texas Metro Areas with Child Uninsured Rate of 10 Percent or More, 2022 10% 14% Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2022 American Community Survey (ACS), Table S2701. Source: Georgetown University Center for Children and Families analysis of the US Census Bureau 2022 American Community Survey (ACS), Table S2701. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 4 While states in the Northeast tend to do better than the national average in terms of child uninsured rates, and states in the South and the Mountain West do worse, there is significant regional variation as Figure 4 shows. Figure 4. States with Higher and Lower Rates of Uninsured Children than the National Rate, 2022 Washington, D.C. has the lowest uninsured rate Higher than national rate (12 states) Lower than national rate (26 states including D.C.) No statistically significant Texas has difference (13 states) the highest uninsured rate Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous Coverage 5 What is the demographic profile of uninsured children? Uninsured rates in the U.S. fell for children of nearly every substantially higher than it is for other groups (see Figure 5). age, race and ethnicity, and income level. Young children Children of another race or multiple races were the only group under age 6 saw their uninsured rate fall from 4.7 percent to see a significant increase in their uninsured rate, but this in 2021 to 4.3 percent in 2022, and the uninsured rate for is likely related to recent demographic and survey changes school-aged children (ages 6 to 18) also fell from 6.1 percent that have meant that more children than ever are identified as in 2021 to 5.4 percent in 2022. "some other race" or as multiple races.4 By race, White children and American Indian and Alaska Uninsured rates for both Hispanic/Latino and non-Hispanic/ Native children saw the largest improvements in their Latino children also improved. Although Latino children saw uninsured rates, although the share of American Indian and larger coverage gains from 2019-2022, their uninsured rate is Alaska Native children who do not have coverage is still still nearly twice as high as for non-Latino children. Figure 5. Rate of Uninsured Children in the United States by Race and Ethnicity, 2019-2022 13.8% 2019 2022 10.9%* 9.2% 8.1%* 7.2%* 6.9% 5.6% 4.4% 4.2%* 4.6% 4.3%* 4.5% 3.8%* 4.1%* Asian/ White Black/African Other/American Not Hispanic/ Hispanic/ Native Hawaiian/American MultiracialIndian/Alaska Latino Latino Pacific Islander Native Native * Change is significant at the 90% confidence level relative to the prior year indicated. Note: Hispanic/Latino refers to a person's ethnicity, therefore Hispanic individuals may be of any race. The U.S. Census Bureau made changes to the ACS race and ethnicity questions beginning in 2020, which may affect the changes observed. Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2019-2022 American Community Survey (ACS), Tables C27001A-I. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 6 Children in lower-income families also saw the largest coverage during the pandemic (see Table 4). Citizen children improvements in uninsurance rates. Children in families at under 138 percent of the poverty line must be covered by the lowest end of the income spectrum earning less than 138 Medicaid in every state; 35 states cover lawfully residing percent of the Census Poverty Threshold (about $24,860 for children as well and 11 cover all children regardless of a family of 3) saw the largest improvement from 2019-2022, immigration status (CA, DC, IL, MA, ME, NJ, NY, OR, RI, VT, likely reflecting the protective effect of Medicaid continuous WA).5 coverage that kept low-income children enrolled in Medicaid Table 4. Rate of Uninsured Children in the United States by Poverty Threshold, 2019-2022 Percentage Point Poverty Threshold** 2019 2022 Change 2019-2022 0-137.99% of poverty 7.7% 6.6% -1.0* 138-249.99% of poverty 7.7% 6.9% -0.8* 250% of poverty or above 3.8% 3.7% -0.1* *Change is significant at the 90% confidence level relative to the prior year indicated. **Census poverty thresholds differ from the Department of Health and Human Services' (HHS) Federal Poverty Levels (FPL). See methology for more information. Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2019-2022 American Community Survey (ACS), Table B27016. Conclusion While the number of uninsured children declined over the termination rates have been high in many states;7 and since pandemic period, these gains are unlikely to be sustained children are more likely to be disenrolled while remaining given the current Medicaid renewal process that is underway. eligible 8 this does not bode well for child uninsured rates As of this writing there has been a net decline in child when data become available for 2023 next year. Medicaid enrollment of at least two million.6 Procedural Acknowledgments The authors would like to thank Cathy Hope, Edwin Park, and Emma Ford 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 at the McCourt School of Public Policy. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous Coverage 7 Appendix Table 1. Number of Uninsured Children by State, 2019-2022 2019 Number 2019 State 2022 Number 2022 State State Uninsured Ranking Uninsured Ranking United States 4,375,000 - 3,932,000 - Alabama 40,000 21 37,000 21 Alaska 18,000 12 15,000 12 Arizona 161,000 47 142,000 46 Arkansas 43,000 23 44,000 25 California 334,000 49 287,000 49 Colorado 73,000 33 62,000 35 Connecticut 27,000 17 25,000 17 Delaware 10,000 5 7,000 4 District of Columbia 3,000 1 2,000 1 Florida 343,000 50 336,000 50 Georgia 197,000 48 166,000 48 Hawaii 9,000 4 9,000 5 Idaho 24,000 16 28,000 19 Illinois 120,000 43 99,000 42 Indiana 119,000 42 91,000 41 Iowa 22,000 14 28,000 19 Kansas 43,000 23 38,000 22 Kentucky 45,000 25 46,000 27 Louisiana 50,000 28 39,000 23 Maine 15,000 8 12,000 10 Maryland 48,000 27 60,000 31 Massachusetts 22,000 14 22,000 15 Michigan 78,000 34 60,000 31 Minnesota 42,000 22 45,000 26 Mississippi 46,000 26 39,000 23 Missouri 95,000 39 83,000 38 Montana 15,000 8 17,000 13 Nebraska 28,000 18 23,000 16 Nevada 58,000 31 55,000 29 New Hampshire 10,000 5 9,000 5 New Jersey 88,000 38 82,000 37 New Mexico 29,000 19 18,000 14 New York 101,000 41 111,000 43 North Carolina 142,000 46 118,000 44 North Dakota 15,000 8 10,000 7 Ohio 131,000 45 122,000 45 Oklahoma 86,000 37 73,000 36 Oregon 38,000 20 27,000 18 Pennsylvania 128,000 44 145,000 47 Rhode Island 4,000 3 5,000 3 South Carolina 69,000 32 56,000 30 South Dakota 18,000 12 14,000 11 Tennessee 80,000 35 86,000 39 Texas 995,000 51 854,000 51 Utah 82,000 36 61,000 34 Vermont 3,000 1 3,000 2 Virginia 97,000 40 87,000 40 Washington 54,000 30 48,000 28 West Virginia 13,000 7 11,000 8 Wisconsin 51,000 29 60,000 31 Wyoming 15,000 8 11,000 8 Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 8 Appendix Table 2. Rate of Uninsured Children by State, 2019-2022 2019 2019 2022 2022 State Uninsured Rate State Ranking Uninsured Rate State Ranking United States 5.7 - 5.1 - Alabama 3.5 12 3.1 11 Alaska 9.4 49 8.4 49 Arizona 9.2 48 8.4 49 Arkansas 5.9 36 5.9 40 California 3.6 15 3.2 12 Colorado 5.5 29 4.8 30 Connecticut 3.5 12 3.2 12 Delaware 4.8 24 3.4 15 District of Columbia 2.0 3 1.4 1 Florida 7.6 42 7.4 46 Georgia 7.4 41 6.2 42 Hawaii 2.8 6 3.0 9 Idaho 5.0 27 5.7 38 Illinois 4.0 18 3.4 15 Indiana 7.1 40 5.5 35 Iowa 2.9 7 3.7 19 Kansas 5.8 33 5.2 32 Kentucky 4.3 20 4.3 23 Louisiana 4.4 22 3.5 18 Maine 5.6 30 4.6 27 Maryland 3.4 10 4.2 22 Massachusetts 1.5 1 1.5 2 Michigan 3.4 10 2.7 6 Minnesota 3.1 8 3.3 14 Mississippi 6.1 37 5.5 35 Missouri 6.5 39 5.8 39 Montana 6.2 38 6.9 44 Nebraska 5.7 31 4.6 27 Nevada 8.0 45 7.6 47 New Hampshire 3.7 16 3.4 15 New Jersey 4.3 20 3.9 21 New Mexico 5.7 31 3.8 20 New York 2.4 5 2.6 4 North Carolina 5.8 33 4.8 30 North Dakota 7.8 43 5.5 35 Ohio 4.8 24 4.5 25 Oklahoma 8.6 47 7.3 45 Oregon 4.1 19 3.0 9 Pennsylvania 4.6 23 5.2 32 Rhode Island 1.9 2 2.1 3 South Carolina 5.8 33 4.7 29 South Dakota 7.8 43 6.2 42 Tennessee 5.0 27 5.3 34 Texas 12.7 51 10.9 51 Utah 8.3 46 6.1 41 Vermont 2.1 4 2.6 4 Virginia 4.9 26 4.4 24 Washington 3.1 8 2.8 7 West Virginia 3.5 12 2.8 7 Wisconsin 3.8 17 4.5 25 Wyoming 10.6 50 7.9 48 Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous Coverage 9 Appendix Table 3. Change in the Number of Uninsured Children by State, 2019-2022 2019 Number 2022 Number Number Percent State Uninsured Uninsured Change Change United States 4,375,000 3,932,000 -443,000 * -10% * Alabama 40,000 37,000 -3,000 -8% Alaska 18,000 15,000 -3,000 * -17% * Arizona 161,000 142,000 -19,000 * -12% * Arkansas 43,000 44,000 1,000 2% California 334,000 287,000 -47,000 * -14% * Colorado 73,000 62,000 -11,000 * -15% * Connecticut 27,000 25,000 -2,000 -7% Delaware 10,000 7,000 -3,000 -30% District of Columbia 3,000 2,000 -1,000 -33% Florida 343,000 336,000 -7,000 -2% Georgia 197,000 166,000 -31,000 * -16% * Hawaii 9,000 9,000 0 0% Idaho 24,000 28,000 4,000 17% Illinois 120,000 99,000 -21,000 * -18% * Indiana 119,000 91,000 -28,000 * -24% * Iowa 22,000 28,000 6,000 * 27% * Kansas 43,000 38,000 -5,000 -12% Kentucky 45,000 46,000 1,000 2% Louisiana 50,000 39,000 -11,000 * -22% * Maine 15,000 12,000 -3,000 -20% Maryland 48,000 60,000 12,000 * 25% * Massachusetts 22,000 22,000 0 0% Michigan 78,000 60,000 -18,000 * -23% * Minnesota 42,000 45,000 3,000 7% Mississippi 46,000 39,000 -7,000 -15% Missouri 95,000 83,000 -12,000 * -13% * Montana 15,000 17,000 2,000 13% Nebraska 28,000 23,000 -5,000 -18% Nevada 58,000 55,000 -3,000 -5% New Hampshire 10,000 9,000 -1,000 -10% New Jersey 88,000 82,000 -6,000 -7% New Mexico 29,000 18,000 -11,000 * -38% * New York 101,000 111,000 10,000 10% North Carolina 142,000 118,000 -24,000 * -17% * North Dakota 15,000 10,000 -5,000 * -33% * Ohio 131,000 122,000 -9,000 -7% Oklahoma 86,000 73,000 -13,000 * -15% * Oregon 38,000 27,000 -11,000 * -29% * Pennsylvania 128,000 145,000 17,000 * 13% * Rhode Island 4,000 5,000 1,000 25% South Carolina 69,000 56,000 -13,000 * -19% * South Dakota 18,000 14,000 -4,000 * -22% * Tennessee 80,000 86,000 6,000 8% Texas 995,000 854,000 -141,000 * -14% * Utah 82,000 61,000 -21,000 * -26% * Vermont 3,000 3,000 0 0% Virginia 97,000 87,000 -10,000 -10% Washington 54,000 48,000 -6,000 -11% West Virginia 13,000 11,000 -2,000 -15% Wisconsin 51,000 60,000 9,000 * 18% * Wyoming 15,000 11,000 -4,000 * -27% * * Change is significant at the 90% confidence level relative to the prior year indicated. Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 10 Appendix Table 4. Change in the Rate of Uninsured Children by State, 2019-2022 State 2019 Uninsured Rate 2022 Uninsured Rate Percentage Point Change United States 5.7 5.1 - 0.6 * Alabama 3.5 3.1 - 0.4 Alaska 9.4 8.4 - 1.0 Arizona 9.2 8.4 - 0.8 Arkansas 5.9 5.9 0.0 California 3.6 3.2 - 0.4 * Colorado 5.5 4.8 - 0.7 Connecticut 3.5 3.2 - 0.3 Delaware 4.8 3.4 - 1.4 District of Columbia 2.0 1.4 - 0.6 Florida 7.6 7.4 - 0.2 Georgia 7.4 6.2 - 1.2 * Hawaii 2.8 3.0 0.2 Idaho 5.0 5.7 0.7 Illinois 4.0 3.4 - 0.6 * Indiana 7.1 5.5 - 1.6 * Iowa 2.9 3.7 0.8 * Kansas 5.8 5.2 - 0.6 Kentucky 4.3 4.3 0.0 Louisiana 4.4 3.5 - 0.9 * Maine 5.6 4.6 - 1.0 Maryland 3.4 4.2 0.8 * Massachusetts 1.5 1.5 0.0 Michigan 3.4 2.7 - 0.7 * Minnesota 3.1 3.3 0.2 Mississippi 6.1 5.5 - 0.6 Missouri 6.5 5.8 - 0.7 * Montana 6.2 6.9 0.7 Nebraska 5.7 4.6 - 1.1 * Nevada 8.0 7.6 - 0.4 New Hampshire 3.7 3.4 - 0.3 New Jersey 4.3 3.9 - 0.4 New Mexico 5.7 3.8 - 1.9 * New York 2.4 2.6 0.2 North Carolina 5.8 4.8 - 1.0 * North Dakota 7.8 5.5 - 2.3 * Ohio 4.8 4.5 - 0.3 Oklahoma 8.6 7.3 -1.3 * Oregon 4.1 3.0 -1.1 * Pennsylvania 4.6 5.2 0.6 * Rhode Island 1.9 2.1 0.2 South Carolina 5.8 4.7 -1.1 * South Dakota 7.8 6.2 -1.6 Tennessee 5.0 5.3 0.3 Texas 12.7 10.9 - 1.8 * Utah 8.3 6.1 - 2.2 * Vermont 2.1 2.6 0.5 Virginia 4.9 4.4 - 0.5 Washington 3.1 2.8 - 0.3 West Virginia 3.5 2.8 - 0.7 Wisconsin 3.8 4.5 0.7 * Wyoming 10.6 7.9 - 2.7 * * Change is significant at the 90% confidence level relative to the prior year indicated. Source: Georgetown University Center for Children and Families analysis of the 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 2022, Health Insurance Historical Tables. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous Coverage 11 Methodology Data Sources and Changes CCF uses the Census Bureau's Statistical Testing Tool to This report from the Georgetown University Center for Children determine statistical significance between estimates at a 90 and Families (CCF) analyzes data from the U.S. Census Bureau's percent confidence level. Differences between estimates should American Community Survey (ACS). The ACS randomly selects not be assumed to be statistically significant unless specifically about 3.5 million households each year to be surveyed and discussed or marked as such. conducts the survey year-round, with results published annually. CCF calculates coefficients of variation (CVs, also known as This report uses two ACS data products: 1) Health Insurance relative standard errors) to measure data reliability for each Historical Table HIC-5. Health Insurance Coverage Status and estimate. The CV measures the relative amount of error in an Type of Coverage by State-Children Under 19: 2008 to 2022; estimate by comparing how large its standard error is to the and 2) the 2022 1-Year ACS Estimates Detailed Tables published estimate itself, with the lower the CV, the more reliable the by the Census Bureau on data.census.gov. Please note that, estimate. CCF suppresses any estimate with a CV larger than 25 because of differences in sample size and data processing, percent. the estimates published in this report may differ from other estimates produced using either the 5-year ACS estimates Geographic Areas or ACS microdata (including the Census Bureau's Public Use The Census Bureau publishes 1-year ACS estimates for all Microdata Sample (PUMS) or the University of Minnesota's geographic areas with a population of 65,000 or more, which Integrated Public Use Microdata Series (IPUMS)), despite includes all regions, states (including the District of Columbia), the fact that all of these datasets are based on the American and some counties. Please note that 1-year estimates will Community Survey. differ from 5-year estimates, which CCF may use elsewhere for analyses of smaller geographic areas like counties or school Because of data quality issues related to the pandemic, the districts. CCF uses Census Bureau designations to report Census Bureau did not publish standard, comparable 1-year regional data. The HIC-5 table used throughout this report does estimates for 2020; CCF excludes 2020 ACS data from all of its not contain data for Puerto Rico or other territories; please see analyses. CCF's State Data Hub for additional data for Puerto Rico. In 2017, the Census Bureau updated the age categories to define children as individuals under age 19. (In previous years, children Poverty Status were classified as individuals under age 18). As a result, detailed Data on poverty thresholds only include individuals for whom table data from before and after 2017 should not be compared. the Census Bureau could determine poverty status for the past When examining longer-term trends, CCF instead uses the HIC-5 year. This population is slightly smaller than the total non- table, which harmonizes the age group to children under age 19 institutionalized population of the U.S. (the universe for all other before and after 2017. data used in this report). The Census Bureau determines an individual's poverty status by comparing that person's income Margin of Error, Data Reliability and in the past 12 months to Census Poverty Thresholds (CPTs). Suppression, and Statistical Significance Census Poverty Thresholds differ from the poverty guidelines The Census Bureau provides a margin of error (MOE) at a 90 (commonly known as the Federal Poverty Level or FPL) percent confidence level for each estimate it publishes. Because determined by the Department of Health and Human Services ACS data are based on a sample of the population (as opposed (HHS), and may differ considerably from the separate FPLs that to the full population), there is a level of uncertainty associated HHS determines for Alaska and Hawaii. Additionally, Census with each estimate. This uncertainty is captured by the MOE. Poverty Thresholds may include some income sources that When CCF calculates a new estimate with ACS data (such as state Medicaid and CHIP agencies do not count for purposes when we combine racial/ethnic groups or calculate percentages/ of determining income eligibility using Modified Adjusted Gross rates), we also calculate its margin of error, using formulas Income (MAGI). provided by the Census Bureau. CCF does not account for MOEs when ranking states by the number and percent of uninsured children by state. Although we do not publish MOEs in this report, they are available upon request. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 12 Health Insurance Coverage and Medicaid Demographic Characteristics Undercount "Children" are defined as individuals under age 19 (ages ACS data represents a "point-in-time" estimate of an individual's 0-18). insurance coverage, meaning that the survey collects information The ACS allows respondents to self-identify as the following on the respondent's coverage only at the moment they races: White, Black/African-American, American Indian/Alaska complete the form, not at another point during the year. (The Native, Asian, Native Hawaiian/Pacific Islander, "Some other ACS is conducted over the course of the year.) The ACS groups race," and "Two or more races." To improve sample sizes and coverage into the following categories: employer-based health data reliability, CCF combines estimates for Asian and Native insurance only, direct purchase health insurance only, Medicare Hawaiian or Other Pacific Islander and reports the calculations coverage only, Medicaid/means-tested public coverage only as "Asian, Native Hawaiian, or Other Pacific Islander" and also (including CHIP), TRICARE/military health coverage only, VA combines "Some other race" alone and "Two or more races" and health coverage only, two or more types of health insurance reports the calculations as "Other/Multiracial." Except for Other/ coverage, and no health insurance coverage. The Census Bureau Multiracial, all racial categories refer to individuals who reported does not consider access to Indian Health Service (IHS) services belonging only to one race. alone as a comprehensive form of health insurance coverage. Consequently, individuals who indicate that IHS is their only The Census Bureau recognizes and reports race and Hispanic source of coverage are designated as uninsured. Individuals can origin (i.e., ethnicity) as separate and distinct concepts and report more than one source of coverage. variables. "Hispanic or Latino" refers to individuals who self- identified as being Hispanic or Latino, while "non-Hispanic/ Please note that ACS estimates are not adjusted by the Census Latino" refers to individuals who indicated that they were not of Bureau (or by CCF) to address the "Medicaid undercount" Hispanic or Latino origin. CCF calculates estimates for non- observed when comparing the number of individuals covered by Hispanic or Latino populations by subtracting estimates for Medicaid and CHIP in surveys such as the ACS to the reported Hispanic or Latino individuals from the total population estimate numbers of individuals enrolled in Medicaid and CHIP using for children. As "Hispanic or Latino" refers to a person's ethnicity, federal and state administrative data. For example, ACS data Hispanic and non-Hispanic individuals may be of any race. show that 30.1 million children had Medicaid/CHIP coverage (either alone or in combination with another type of coverage) In 2020, the Census Bureau made changes to the ACS race in 2022, while administrative data show average enrollment and ethnicity questions, which may affect health coverage over the same period equaled about 41.9 million: a difference of comparisons related to race and ethnicity. These included nearly 12 million children. This undercount is not unique to the changes to the instructions and examples listed with some ACS, though the extent of the undercount varies among federal race and Hispanic origin response options, additional write-in surveys. Researchers attribute the Medicaid undercount to a response options for "White" and "Black or African American" combination of factors like sampling error and differences in categories, and changes to the way the Census Bureau demographic characteristics (for example, adults and individuals processes write-in responses. These changes may affect the with higher incomes are less likely to report Medicaid coverage); "Some Other Race" or multiple race categories in particular. reporting error, where individuals may respond that they do not For example, as noted above, 10.2 million children identified as have coverage or have a type of coverage other than Medicaid; another race or multiracial in 2019, representing 13 percent of and differences in how surveys and administrative data define the total child population. In 2022, this number increased to 21.3 coverage, such as estimates taken at a point in time versus over million or 28 percent of the child population. This increase, which the course of a year. In 2022, the Medicaid continuous coverage may be related to changes in question design, may also affect the provision may affect children's reported coverage source- distribution of children across other racial groups. As a result, the including uninsurance-if more misreported their coverage Census Bureau recommends caution in comparing 2019-2021 source including families who were unaware that they still had ACS estimates related to race and caution in comparing both Medicaid coverage. Moreover, previous research shows that the 2019-2021 and 2021-2022 ACS estimates related to ethnicity. Medicaid undercount has appeared to increase substantially since the start of the pandemic. Finally, recent research on the decennial Census shows that young children as a group are consistently and significantly undercounted, likely further worsening the Medicaid undercount among children. November 2023 CCF.GEORGETOWN.EDU Medicaid's continuous Coverage 13 Endnotes 1 T. Brooks and A. Schneider, "Families First Coronavirus Response Act 6 "How many children are losing Medicaid?" Georgetown University Medicaid and CHIP Provisions Explained" (Washington: Georgetown Center for Children and Families, https://ccf.georgetown.edu/2023/09/27/ University Center for Children and Families, March 2020), available how-many-children-are-losing-medicaid/. at https://ccf.georgetown.edu/2020/03/22/families-first-coronavirus- 7 See "What is happening with Medicaid renewals in each state?" response-act-medicaid-and-chip-provisions-explained/. Georgetown University Center for Children and Families, https:// 2 J. Alker and A. Corcoran, "Children's Uninsured Rate Rises By Largest ccf.georgetown.edu/2023/07/14/whats-happening-with-medicaid- Annual Jump In A Decade" (Washington: Georgetown University Center renewals/ and "Medicaid Enrollment and Unwinding Tracker" Kaiser for Children and Families, October 2020), available at https://ccf. Family Foundation, https://www.kff.org/medicaid/issue-brief/medicaid- georgetown.edu/2020/10/08/childrens-uninsured-rate-rises-by-largest- enrollment-and-unwinding-tracker/. annual-jump-in-more-than-a-decade-2/. 8 Assistant Secretary for the Office of Planning and Evaluation, 3 S. Federman and A. Coleman, "Protecting Kids From Coverage Losses "Unwinding the Medicaid Continuous Enrollment Provision: Projected During Medicaid Redeterminations and Beyond: Five Strategies for Enrollment Effects and Policy Approaches*" (Washington: August States" (Commonwealth Fund, July 17, 2023) available at https://www. 2022), available at https://aspe.hhs.gov/sites/default/files/documents/ commonwealthfund.org/blog/2023/protecting-kids-coverage-losses- dc73e82abf7fc26b6a8e5cc52ae42d48/aspe-end-mcaid-continuous- during-medicaid-redeterminations-and-beyond-five. coverage.pdf. 4 Beginning in 2020, the Census Bureau made changes to the race and ethnicity questions on the ACS which may affect health coverage comparisons related to race and ethnicity. These changes may affect the "Some Other Race" or multiple race categories in particular. For example, 10.2 million children identified as another race or multiracial in 2019, representing 13 percent of the total child population. In 2022, this number increased dramatically to 21.3 million or 28 percent of the child population. 5 T. Brooks, et al., "Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision" (Washington: Kaiser Family Foundation and Georgetown University Center for Children and Families, April 2023), available at https://www.kff.org/medicaid/report/medicaid-and-chip- eligibility-enrollment-and-renewal-policies-as-states-prepare-for-the- unwinding-of-the-pandemic-era-continuous-enrollment-provision/. Novermber 2023 CCF.GEORGETOWN.EDU Medicaid's continuous coverage 14