Nation’s Youngest Children Lose Health Coverage at an Alarming Rate by Elisabeth Wright Burak, Maggie Clark, and Lauren Roygardner Key Findings z The nation’s rate and number of uninsured young children (under age 6) increased significantly between 2016 and 2018, following many years of steady decline. This reversal put the number of uninsured young children back above 1 million by 2018 for the first time since the full implementation of the Affordable Care Act in 2014. The rate of uninsured children under age 6 increased significantly between 2016 and 2018, from 3.8 percent in 2016 to 4.3 percent in 2018. z Coverage losses were widespread from 2016-2018, with 13 states showing statistically significant increases in the rate and/or number of young, uninsured children. Eleven states (Alabama, Florida, Georgia, Illinois, Kentucky, Missouri, Ohio, Tennessee, Texas, Washington, West Virginia) showed a significant increase in both the rate and number of uninsured children. Kansas and New York saw a significant rise in the rate alone. No state experienced a significant decrease in the rate of uninsured young children during the two-year period. Only Minnesota saw a significant decrease in the number of uninsured young children. z Young children are more likely to be uninsured in states that have not expanded Medicaid to parents and other adults under the Affordable Care Act, and the gap is growing. Between 2016 and 2018, non-expansion states saw an increase in the rate of uninsured children under age 6 that was more than double the growth in expansion states. Covering parents and caregivers is important for all children, but especially so for young children during their critical developmental years. States that expand Medicaid to parents and other adults can expect to see an improvement in their child coverage rates, as well. z Lack of health care coverage makes it more difficult for young children to get recommended check-ups, and families may miss out on opportunities for support. From birth to age 6, the American Academy of Pediatrics recommends that children have 15 well child check- ups. Access to this routine and necessary care is compromised when a child does not have health insurance. More frequent well-child visits for young children offer one of the best means to reach children and their families before school begins. In addition to providing needed immunizations and other preventive care, well- child visits are also increasingly seen as avenues to support and engage parents and other caregivers in their own health and successful parenting, since positive relationships are the foundation of healthy development for young children. CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 1 Introduction Until recently, the U.S. has experienced a consistent, annual The American Academy of Pediatrics (AAP) recommends decline in the number and rate of uninsured children in most 15 well-child visits before age 6, more heavily concentrated states.1 Beginning in 2016, however, the trend reversed and in a child’s first two years, when brain development the nation’s children experienced widespread coverage is most rapid.5 These frequent well-child visits also losses for the first time in many years. The youngest children provide an important opportunity to engage parents and were not spared from this inversion. As with all children, the other caregivers around positive parenting and healthy number and rate of uninsured children under age 6 grew development. Check-ups may be a means to identify parent between 2016 and 2018, reversing years of steady progress or family circumstances, such as parental depression,6 covering the nation’s infants, toddlers, and preschool-aged which, if left unaddressed, can negatively affect a child’s children. trajectory. For example, more than 33 states reimburse maternal depression screenings during a child’s well-child During the earliest months and years of life, children visit during the first year of life.7 Without coverage, paying experience rapid brain development and physical growth, out of pocket for these frequent visits puts parents of young making the period before kindergarten entry a critical children at particular financial risk if they are uninsured. window to address any developmental delays or health conditions before they escalate into greater challenges.2 The loss of health coverage experienced by children Health coverage is a crucial first step to ensure children under age 6 between 2016 and 2018 erases many of the receive regular check-ups to address health concerns as positive coverage gains made in the years following the early as possible and receive needed vaccinations and other Affordable Care Act’s (ACA) coverage expansions in 2014. preventive care. It also protects families from financial risk Children’s Medicaid expansions and the creation of the that can come from a baby or toddler’s unexpected injury Children’s Health Insurance Program (CHIP) drove dramatic or illness.3 Health insurance for children is also linked to declines in uninsured children in the decades prior to ACA better health, educational, and economic outcomes well into passage. The ACA accelerated this decline by increasing adulthood.4 the likelihood that more uninsured children—most of whom were eligible, but not enrolled in Medicaid or CHIP—would enroll as their parents signed up for newly available coverage through Medicaid or the ACA marketplaces in 2014. The ACA also included new requirements to streamline and simplify enrollment across programs, funded outreach and enrollment support, and required all Americans to have health insurance.8 Recent increases in uninsurance for the nation’s youngest children happened during a time of economic growth when more children should be gaining health care coverage. As detailed elsewhere, a number of factors may be contributing to this coverage reversal, likely driven by declines in Medicaid and CHIP among children—many of whom are likely eligible.9 After reaching the lowest levels on record in 2016, the rising number of uninsured children in 2017 and 2018 accompanied a host of national policy debates and decisions that have 2 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 started to undermine years of progress.10 The 2017 efforts Research shows that when adults have access to coverage, in Congress to repeal the ACA and severely cut Medicaid, their eligible children are more likely to be enrolled and access along with a months-long delay in extending CHIP, including preventive care.16 The latest example of this so-called “welcome critical outreach grants, undoubtedly sowed confusion mat” effect is in Virginia, where, since the state began Medicaid among parents and caregivers about whether coverage expansion enrollment in January 2019, more than 25,000 children would be available for their children. These delays were enrolled in Medicaid and CHIP.17 accompanied by Trump Administration cuts to outreach and enrollment programs dedicated to helping families navigate Given the importance of continuous, consistent coverage health coverage options.11 for children and their families during the early years, the reversal in coverage for young children is especially alarming. Declines in Medicaid and CHIP enrollment have also likely Younger children have historically had lower uninsured rates been influenced by the Trump Administration’s policies and compared to school-aged youth, and they still do, but this rhetoric targeting immigrant families, which has reportedly did not shield them from coverage losses affecting children deterred many parents from signing up eligible citizen of all ages in recent years. children in available Medicaid or CHIP coverage.12 Beyond immigrant families, years of work at the national and state Nationally, the number of uninsured infants, toddlers and levels to streamline Medicaid and CHIP enrollment and preschoolers increased by more than 114,000 between 2016 renewal processes have recently stalled, contributing to an and 2018, bringing the total back to more than 1 million unwelcoming climate that is less focused on enrolling and uninsured young children in the United States in 2018 (see retaining eligible children in Medicaid and CHIP.13 Figure 1), according to the U.S. Census American Community Survey.18 Children under age 6 make up 30 percent of State Medicaid expansion decisions also had a significant children under age 19 in the U.S.19 impact on a state’s uninsured rate for young children. Young children in non-Medicaid expansion states had uninsured rates The rate of uninsured children under age 6 increased that grew nearly three times as fast as their peers in expansion significantly between 2016 and 2018, from 3.8 percent in 2016 states between 2016 and 2018 (see Figure 6 on page 8). These to 4.3 percent in 2018 (see Figure 2). These reversals mirror uninsured young children in non-expansion states face doubly- the rising uninsured rate for all children, which grew from 4.7 difficult circumstances: Their uninsured parents are more percent in 2016 to 5.2 percent in 2018.20 Another Census likely to struggle with managing their own health and daily survey, the Current Population Survey, also shows an increase parenting challenges, and less likely to access treatment for in the uninsured rate for children under age 6 in just one year health conditions such as parental depression or substance (2017-2018)—from 4.5 percent to 5.3 percent—alongside a use disorder. Left untreated, these conditions can have decline in Medicaid/CHIP coverage for this age group.21 negative effects on their child’s development, weakening the essential relationships young children need for healthy social and emotional development throughout life.14 This challenge extends to all uninsured adult caregivers in a child’s life, including their early childcare educators who struggle to afford coverage in non-expansion states.15 December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 3 Figure 1. Number of Uninsured Children Under 6 in the United States, 2010-2018 (in millions) 1.54 1.43* 1.36* 1.37 1.16* 1.02* 0.95* 0.97* 0.90* 2010 20112012201320142015201620172018 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. * Change is significant at the 90% confidence level. Figure 2. Rate of Uninsured Children Under 6, 2010-2018 6.4% 5.9%* 5.7%* 5.7% 4.9%* 4.1%* 4.3%* 4.0%* 3.8%* 201020112012 2013 20142015 201620172018 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. * Change is significant at the 90% confidence level. 4 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 Select Characteristics of Young, Uninsured Children Race and ethnicity Loss of coverage among children under 6 during the two-year period was most pronounced for white children, Hispanic children, and those whose parents identified them as “some other race alone” or “two or more races,” (see Figure 3). Overall, as with the rates for all children, American Indian and Alaska Native children have the highest uninsured rates, followed by Hispanic children. The uninsured rates for Black children and Asian/Pacific Islander children went up between 2016 and 2018, but not significantly, and remained lower overall than rates for white and Hispanic children. Figure 3. Uninsured Rate by Race and Ethnicity for Children Under 6, 2016-2018 11.6% 2016 2018 10.6% 5.8%* 5.3% 4.5%* 4.6%* 3.9% 4.0% 3.5% 3.1% 2.9% 2.7% Black or African White alone Asian/ Other American Hispanic American alone Native Hawaiian/ Indian/Alaska Pacific Islander Native Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. *Change is significant at the 90% confidence level for two-year trend (2016-2018). Note: Other combines the ACS categories “Some other race” and “Two or more races.” Except for “other”, all racial categories refer to respondents who indicated belonging to only one race. For more, see methodology for notes on demographic characteristics. December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 5 State of Residence Figure 4. More than Half of the Nation’s Uninsured More than half of the nation’s uninsured children Children Under 6 Reside in Seven States, 2018 under age 6 lived in just seven states in 2018. Texas had an overwhelming share, home to almost one out of every five uninsured young Texas 19.4% children in the nation. While large population Florida 7.5% size plays a role, Texas also had the second- Other States California 6.4% highest rate of uninsured young children in 49.6% the country, behind Alaska. With an estimated Georgia 5.4% 198,014 uninsured young children in 2018, Pennsylvania 4.1% Texas had more uninsured babies, toddlers and Ohio 4.1% preschool-aged children than California, Florida Arizona 3.5% and Georgia combined (see Figure 4). Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. Texas is also among the 14 states with rates of uninsured children significantly higher than the national average rate of 4.3 percent, as shown in the Figure 5 map (Alaska, Arizona, Florida, Georgia, Indiana, Missouri, Nevada, North Dakota, Ohio, Oklahoma, Pennsylvania, Texas, Utah and Wyoming). Alaska had the highest rate of uninsured children under age 6 in 2018, with 9.2 percent uninsured, followed by Texas (8.3 percent), Wyoming (7.7 percent) and Georgia (7.1 percent). (21 states) (16 states) (14 states) 6 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 Rates compared to school-aged Table 1: Seven States with a Higher Uninsured Rate for Children youth in 2018 Under 6 vs. School Age Children (ages 6-18), 2018 Young children tend to be uninsured at lower rates 2018 Uninsured 2018 Uninsured than their school-aged peers (4.3 percent compared State Rate for Rate for Children under 6 Children 6-18 to 5.6 percent nationally in 2018), with coverage rates declining as children age.22 These typically United States 4.3% 5.6% lower rates for young children are likely for a variety Kentucky 4.0% 3.7% of reasons, including historically higher levels of Nebraska 5.4% 5.2% North Dakota 6.6% 5.7% Medicaid/CHIP income eligibility for young children,23 Ohio 5.0% 4.7% requirements to automatically enroll newborns born Pennsylvania 5.0% 4.1% to low-income mothers in Medicaid,24 and more Rhode Island 2.5% 2.0% frequent well-child visits recommended during the Wyoming 7.7% 6.9% months and years following birth.25 In 2018, seven states appeared to counter this trend, showing Source: Georgetown University Center for Children and Families analysis of U.S. higher estimated rates of uninsured young children Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. compared to their school-aged peers (see Table 1).26 For these states, the inversion serves as potential warning sign that more could be done to reach uninsured young children. State-level Coverage Losses for Young Children Across the country, 11 states—Alabama, Florida, Table 2: 13 States with Significant Increase in Rate of Georgia, Illinois, Kentucky, Missouri, Ohio, Uninsured Children Under 6, 2016-2018 Tennessee, Texas, Washington and West Virginia— had statistically significant increases in both the Percentage Point State 2016 2018 Change rate and number of uninsured children under United States 3.8% 4.3% 0.5% age 6 (see Table 2). Kansas and New York saw Missouri 3.6% 5.3% 1.7% a significant rise in the rate of uninsured young West Virginia 1.9% 3.4% 1.5% children alone. Minnesota bucked the broader Ohio 3.6% 5.0% 1.4% trend, in part, showing a statistically significant Tennessee 2.9% 4.3% 1.4% improvement in the number, but not the rate, of Kentucky 2.7% 4.0% 1.3% uninsured young children. All other states and D.C. Georgia 6.0% 7.1% 1.1% had stagnant rates of coverage for young children Texas 7.3% 8.3% 1.0% over the two-year period. Kansas 3.9% 4.9% 1.0% Alabama 2.0% 3.0% 1.0% Illinois 2.0% 2.9% 0.9% Florida 4.7% 5.6% 0.9% Washington 1.8% 2.4% 0.6% New York 2.0% 2.4% 0.4% Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 7 In many states, the increases in the uninsured rate for young Table 3: 11 States with Significant Increase in Number of children appear to be growing faster than even the most Uninsured Children Under 6, 2016-2018 dramatic increases for children ages 0-18,27 adding a troubling 2016-2018 Change in 2016-2018 dimension to the coverage reversals. Among the states with State Number of Uninsured Percent significant increases in the number of uninsured children, West Children Under 6 Change Virginia, Alabama and Kentucky all experienced increases greater United States 114,963 12.7% than 50 percent between 2016 and 2018 (see Table 3). The West Virginia 1,584 69.8% growth in the uninsured rate for children under 6 appeared to Alabama 3,495 50.9% outpace the increase for all children in nine states—Alabama, Kentucky 4,365 50.7% Illinois, Kansas, Kentucky, Missouri, New York, Ohio, Washington, Tennessee 6,552 46.2% and West Virginia.28 Missouri 7,380 46.0% Illinois 7,540 41.0% Among the states with significant increases in the rate of Ohio 11,822 39.6% uninsured children during the two-year period, eight states Washington 3,558 37.7% had rates in 2018 that were either below (Alabama, Illinois, Florida 12,711 20.1% New York, Washington) or level with (Kansas, Kentucky, Georgia 7,727 16.4% Tennessee, West Virginia) the national average of 4.3 Texas 23,078 13.2% percent. While many of these states have historically had Source: Georgetown University Center for Children and Families analysis of U.S. some of the nation’s lowest uninsured rates for young Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. children, their rates are at risk of surpassing the U.S. average if current trends continue. Young children are increasingly likely to be uninsured in states that have Figure 6. Uninsured Rate for Children Under 6 by not expanded Medicaid. Medicaid Expansion Status, 2016-2018 Research is clear that children are more likely to be enrolled in 5.9%* 2016 available coverage when parents and other family members gain coverage.29 States that have not expanded Medicaid 5.1% 2018 to parents and other adults just above the poverty line 3.3%* have higher rates of uninsured children, with a growing 3.0% gap between states over time.30 These trends also extend to young children. As shown in Figure 5, the rate of uninsured, young children grew nearly three times as fast in non- expansion states as the rate among expansion states. In 2018, Non-expansion Expansion expansion states were more likely to have rates of uninsured, Source: Georgetown University Center for Children and Families analysis of young children at or below the national average (Figure 6). U.S. Census Bureau American Community Survey (ACS) data using 1-year Lack of health coverage for adults in non-expansion states estimates from Data.Census.Gov. is especially problematic for young children, whose early *Change is significant from the national average at the 90% confidence level. brain development is directly tied to the strength of their relationships with parents and caregivers.31 Without health Children under age 6 experience higher rates of poverty than coverage for themselves, parents’ struggles with their own older children, making families with young children especially unmet health needs can get in the way of their ability to fully financially vulnerable to surprise medical expenses that can arise bond and care for with their children, which can also impede without health coverage.33 their children’s development.32 Poverty and unexpected costs exacerbate stress on the parent-child relationship: 8 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 Figure 7. Uninsurance Rates for Children Under 6 in Medicaid Expansion States and Non-Expansion States, 2018 Alaska** 9.2 Texas 8.3 Wyoming 7.7 Georgia 7.1 Arizona 6.8 North Dakota 6.6 Utah*** 6.6 Nevada 6.5 Oklahoma 6.5 Indiana** 6.1 Florida 5.6 Nebraska *** 5.4 Missouri 5.3 South Dakota 5.2 Maine* 5.0 Montana** 5.0 Ohio 5.0 Pennsylvania** 5.0 Idaho*** 4.9 Medicaid Kansas 4.9 Expansion States Virginia* 4.5 New Mexico Non-Expansion 4.4 States United States 4.3 Tennessee 4.3 Colorado 4.0 Kentucky 4.0 North Carolina 4.0 *Maine and Virginia adopted the Medicaid expansion, South Carolina 3.9 but implementation was not Mississippi 3.7 in effect when the data was Arkansas 3.5 collected. Wisconsin 3.5 ** Five states (Alaska, West Virginia 3.4 Indiana, Louisiana, Oregon 3.3 Montana, and Pennsylvania) expanded Medicaid after Michigan 3.1 December 31, 2014. New Jersey 3.1 *** In Idaho, Utah and Alabama 3.0 Nebraska, voters approved Illinois 2.9 Medicaid expansion but Louisiana** 2.8 the expansions were not in Maryland 2.8 effect at the time the data Iowa 2.7 was collected. Hawaii 2.6 Connecticut 2.5 Minnesota 2.5 Source: Georgetown University Center for Children Rhode Island 2.5 and Families analysis of U.S. Delaware 2.4 Census Bureau American New York 2.4 Community Survey (ACS) data using 1-year estimates Washington 2.4 from Data.Census.Gov. California 2.2 New Hampshire 1.9 District of Columbia 1.6 Vermont 1.2 Massachusetts 1.0 0% 2.0% 4.0% 6.0% 8.0%10.0% December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 9 Conclusion The widespread coverage losses among the nation’s Medicaid and CHIP offer critical access to preventive care, youngest children are particularly troubling given the need immunizations and routine screenings that can identify for stable health care during the early years, when a child’s delays early, well before a child enters school. Addressing brain develops most rapidly. As the data show, ensuring preventable delays and conditions early is not only important young children have health coverage requires a whole- to school readiness, it can serve to set a child on the course family approach. Medicaid expansion states had lower rates to healthy lifelong development. Without coverage to of uninsured young children than non-expansion states, facilitate regular check-ups and screenings, small problems illustrating the inextricable link between parent and child can grow into bigger ones, and limit a child’s ability to be health. Ensuring parents are covered is an essential step successful in school and life. in making sure all children reach their fullest potential and that families are protected from the financial insecurity that comes with being uninsured. This brief was written by Elisabeth Wright Burak, Maggie Clark, and Lauren Roygardner. The authors would like to thank Allexa Gardner Dunakey and Lina Stolyar for their diligent research assistance and Joan Alker for her helpful review. 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’s Health Policy Institute. 10 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 Methodology Data Sources and Historic Changes to 2017 American Community Survey (ACS) estimates for New Castle county and the state of Delaware, including the topic of Age Categories for Children health insurance. The Census indicates that “the 2017 ACS 1-year The data presented in this brief derive from the U.S. Census estimates for these topics (including health insurance) should not Bureau’s annual American Community Survey (ACS) as presented be compared with other ACS estimates.” Therefore, we are noting in the Census Bureau’s new data platform, Data.Census.Gov. the rate the Census data provides but this rate should not be The specific data sources include: 1) Table B27001, 2) Tables compared with any other data given this error in the data. B27001A-I, and 3) Table S2701. Where only number estimates are available, percent estimates were computed based on Demographic Characteristics formulas provided in the 2018 ACS’s “Instructions for Applying In this brief, “young children” are defined as those Statistical Testing to ACS 1-Year Data.” For this special report individuals under age 6 (0-5 years old). The ACS provides on “Children Under 6” and most previous similar annual ACS one-year health insurance coverage estimates for the reports, we have examined two-year trends in the ACS data (in following race/ethnicity categories in tables B27001A-I: this case, 2016-2018). On two occasions we have departed from (A-White alone, B-Black/African-American, C-AI/ AN, this methodology when a significant one-year change occurred D-Asian, E-Native Hawaiian/Pacific Islander, F-Some other (2013-2014) after the Affordable Care Act was implemented; race, G-More than 1 race, H-White, Non-Hispanic and and 2016-2017 when the number of uninsured children began I-Hispanic). The Census Bureau recognizes and reports race increasing as a result of efforts to pull back coverage and when and Hispanic origin (i.e. ethnicity) as separate and distinct Census also changed the age category for children in the ACS. concepts and variables. To report on an individual’s race, we merge the data for “Asian alone” and “Native Hawaiian or Margin of Error other Pacific Islander alone.” In addition, we report the ACS The published U.S. Census Bureau data provide a margin category “some other race alone” and “two or more races” of error (potential error bounds for any given estimate) at as “other.” Except for “other”, all racial categories refer to a 90 percent confidence level. All significance testing was respondents who indicated belonging to only one race. We conducted using the Census’ Statistical Testing Tool. Except report “Hispanic or Latino,” as “Hispanic.” As this refers to where noted, reported differences of percent or number a person’s ethnicity, Hispanic and non-Hispanic individuals estimates (either between groups, or across years) are may be of any race. For more detail on how the ACS statistically significant at a confidence level of 90 percent. defines racial and ethnic groups, see “American Community Where estimates were combined to produce new estimates, Survey and Puerto Rico Community Survey 2015 Subject margin of error results were computed following the U.S. Definitions.” Census’ formulas in their April 18, 2018, presentation entitled, “Using American Community Survey Estimates and Margins of Error” by Sirius Fuller. Geographic Location We report regional data as defined by the Census Bureau. The ACS produces single-year estimates for all geographic areas with a population of 65,000 or more, which includes all regions, states (including the District of Columbia), and country and county equivalents. The U.S. Census Bureau issued an Errata note 120 on Sept. 10, 2019 titled Data Collection Error in Delaware, which impacted December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 11 Appendix Table 1. Change in Number of Uninsured Children Under Age 6, 2016 and 2018 2016 Number 2018 Number 2016-2018 Change in 2016-2018 Percent State Uninsured Uninsured Number of Uninsured Change United States 904,417 1,019,380 114,963 * 12.7 Alabama 6,863 10,358 3,495 * 50.9 Alaska 4,984 5,803 819 16.4 Arizona 30,724 35,517 4,793 15.6 Arkansas 8,416 7,929 -487 -5.8 California 68,020 64,883 -3,137 -4.6 Colorado 13,369 16,213 2,844 21.3 Connecticut 7,163 5,285 -1,878 -26.2 Delaware 1,579 1,532 -47 -3.0 District of Columbia 1,168 820 -348 -29.8 Florida 63,322 76,033 12,711 * 20.1 Georgia 47,114 54,841 7,727 * 16.4 Hawaii 2,218 2,690 472 21.3 Idaho 4,838 6,841 2,003 41.4 Illinois 18,372 25,912 7,540 * 41.0 Indiana 27,990 30,734 2,744 9.8 Iowa 6,202 6,385 183 3.0 Kansas 9,230 10,820 1,590 17.2 Kentucky 8,608 12,973 4,365 * 50.7 Louisiana 9,423 10,298 875 9.3 Maine 3,191 3,896 705 22.1 Maryland 14,267 11,974 -2,293 -16.1 Massachusetts 4,938 4,455 -483 -9.8 Michigan 19,311 21,158 1,847 9.6 Minnesota 13,174 10,436 -2,738 * -20.8 Mississippi 9,917 8,021 -1,896 -19.1 Missouri 16,051 23,431 7,380 * 46.0 Montana 2,742 3,707 965 35.2 Nebraska 8,875 8,496 -379 -4.3 Nevada 11,995 14,288 2,293 19.1 New Hampshire 1,998 1,452 -546 -27.3 New Jersey 19,427 19,241 -186 -1.0 New Mexico 6,072 6,148 76 1.3 New York 27,477 32,491 5,014 18.2 North Carolina 24,679 28,389 3,710 15.0 North Dakota 5,045 4,126 -919 -18.2 Ohio 29,820 41,642 11,822 * 39.6 Oklahoma 19,644 20,191 547 2.8 Oregon 6,531 9,183 2,652 40.6 Pennsylvania 39,966 41,652 1,686 4.2 Rhode Island 1,472 1,697 225 15.3 South Carolina 13,110 13,465 355 2.7 South Dakota 3,180 3,756 576 18.1 Tennessee 14,189 20,741 6,552 * 46.2 Texas 174,936 198,014 23,078 * 13.2 Utah 16,330 19,624 3,294 20.2 Vermont 578 445 -133 -23.0 Virginia 25,378 27,337 1,959 7.7 Washington 9,435 12,993 3,558 * 37.7 West Virginia 2,268 3,852 1,584 * 69.8 Wisconsin 14,832 13,999 -833 -5.6 Wyoming 3,986 3,213 -773 -19.4 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. *Change is significant at the 90% confidence level. 12 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 Appendix Table 2. Change in Percent of Uninsured Children Under Age 6, 2016-2018 2016 Percent 2018 Percent 2016-2018 Percentage State Uninsured Uninsured Point Change US 3.8 4.3 0.5 * Alabama 2.0 3.0 1.0 * Alaska 7.9 9.2 1.3 Arizona 5.9 6.8 0.9 Arkansas 3.7 3.5 -0.2 California 2.3 2.2 -0.1 Colorado 3.3 4.0 0.7 Connecticut 3.2 2.5 -0.7 Delaware 2.4 2.4 0.0 District of Columbia 2.3 1.6 -0.7 Florida 4.7 5.6 0.9 * Georgia 6.0 7.1 1.1 * Hawaii 2.0 2.6 0.6 Idaho 3.5 4.9 1.4 Illinois 2.0 2.9 0.9 * Indiana 5.5 6.1 0.6 Iowa 2.6 2.7 0.1 Kansas 3.9 4.9 1.0 * Kentucky 2.7 4.0 1.3 * Louisiana 2.6 2.8 0.2 Maine 4.0 5.0 1.0 Maryland 3.3 2.8 -0.5 Massachusetts 1.1 1.0 -0.1 Michigan 2.8 3.1 0.3 Minnesota 3.1 2.5 -0.6 Mississippi 4.4 3.7 -0.7 Missouri 3.6 5.3 1.7 * Montana 3.7 5.0 1.3 Nebraska 5.6 5.4 -0.2 Nevada 5.5 6.5 1.0 New Hampshire 2.5 1.9 -0.6 New Jersey 3.1 3.1 0.0 New Mexico 4.0 4.4 0.4 New York 2.0 2.4 0.4 * North Carolina 3.5 4.0 0.5 North Dakota 7.7 6.6 -1.1 Ohio 3.6 5.0 1.4 * Oklahoma 6.2 6.5 0.3 Oregon 2.3 3.3 1.0 Pennsylvania 4.7 5.0 0.3 Rhode Island 2.2 2.5 0.3 South Carolina 3.8 3.9 0.1 South Dakota 4.3 5.2 0.9 Tennessee 2.9 4.3 1.4 * Texas 7.3 8.3 1.0 * Utah 5.4 6.6 1.2 Vermont 1.6 1.2 -0.4 Virginia 4.2 4.5 0.3 Washington 1.8 2.4 0.6 * West Virginia 1.9 3.4 1.5 * Wisconsin 3.7 3.5 -0.2 Wyoming 8.7 7.7 -1.0 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. *Change is significant at the 90% confidence level. December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 13 Appendix Table 3. Uninsurance Trend for Uninsured Children Under Age 6 by State, 2010-2018 State 2010 2011 2012 2013 2014 2015 2016 2017 2018 United States 6.4% 5.9%* 5.7%* 5.7% 4.9%* 4.0%* 3.8%* 4.1%* 4.3%* Alabama 4.8% 4.3% 3.3% 3.0% 3.4% 2.8% 2.0%* 2.6% 3.0% Alaska 9.3% 9.9% 11.7% 11.5% 9.8% 10.8% 7.9%* 9.2% 9.2% Arizona 9.9% 10.5% 10.8% 9.8%* 8.7% 6.8%* 5.9% 6.4% 6.8% Arkansas 4.6% 4.8% 4.8% 4.5% 4.2% 5.7%* 3.7%* 3.4% 3.5% California 6.4% 5.8%* 5.6% 5.2%* 3.9%* 2.4%* 2.3% 2.5% 2.2%* Colorado 8.3% 7.8% 6.5%* 5.7% 4.2%* 3.2%* 3.3% 3.2% 4.0%* Connecticut 2.4% 2.5% 3.3% 3.4% 3.3% 3.1% 3.2% 3.0% 2.5% Delaware ** 3.1% 3.6% 3.0% 3.6% 4.5% 2.5% 2.4% 5.6%* 2.4%* District of Columbia 1.0% 2.3% 1.9% 1.9% 1.8% 1.0% 2.3% 1.4% 1.6% Florida 9.9% 8.8%* 7.9%* 7.9% 7.0%* 5.1%* 4.7% 5.8%* 5.6% Georgia 7.7% 7.3% 7.0% 8.0% 5.8%* 5.5% 6.0% 6.2% 7.1% Hawaii 3.1% 2.2% 3.1% 2.8% 3.1% 0.8%* 2.0%* 1.4% 2.6% Idaho 10.1% 7.8%* 6.8% 7.8% 6.3% 4.3%* 3.5% 3.7% 4.9% Illinois 3.4% 2.6%* 2.7% 3.4%* 2.7%* 2.2%* 2.0% 2.3% 2.9%* Indiana 8.4% 7.8% 7.6% 7.7% 6.8%* 6.5% 5.5%* 6.2% 6.1% Iowa 2.9% 3.3% 3.3% 3.6% 2.7%* 3.4% 2.6% 3.3% 2.7% Kansas 6.7% 5.1%* 5.6% 4.8% 3.8% 4.5% 3.9% 4.5% 4.9% Kentucky 5.1% 5.4% 5.2% 5.2% 4.1%* 3.5% 2.7%* 3.5%* 4.0% Louisiana 4.2% 4.9% 3.9%* 4.8% 4.5% 3.7% 2.6%* 2.6% 2.8% Maine 2.8% 4.4%* 3.9% 4.9% 5.3% 6.1% 4.0% 4.0% 5.0% Maryland 4.1% 3.0%* 3.3% 3.7% 2.6%* 3.3% 3.3% 3.4% 2.8% Massachusetts 1.2% 1.9%* 1.4% 1.2% 1.6% 0.8%* 1.1% 1.5% 1.0% Michigan 3.6% 3.7% 3.6% 3.6% 3.4% 2.8%* 2.8% 2.6% 3.1% Minnesota 6.1% 5.7% 5.3% 5.0% 3.6%* 2.8%* 3.1% 3.0% 2.5% Mississippi 6.7% 6.9% 5.5% 6.4% 3.2%* 3.6% 4.4% 3.7% 3.7% Missouri 5.0% 5.2% 6.0% 6.6% 7.0% 5.3%* 3.6%* 4.5%* 5.3% Montana 13.5% 9.9%* 11.5% 8.9% 6.4%* 5.7% 3.7%* 5.4%* 5.0% Nebraska 4.6% 4.3% 4.7% 5.1% 4.1% 4.6% 5.6% 3.8%* 5.4%* Nevada 14.8% 14.1% 15.4% 11.4%* 8.4%* 6.3%* 5.5% 5.6% 6.5% New Hampshire 3.8% 2.9% 3.5% 3.1% 4.2% 2.4%* 2.5% 2.8% 1.9% New Jersey 4.6% 3.9%* 3.8% 4.5%* 3.1%* 3.1% 3.1% 3.0% 3.1% New Mexico 7.7% 6.7% 7.2% 6.1% 5.4% 3.0%* 4.0% 3.8% 4.4% New York 4.4% 3.6%* 3.5% 3.8% 3.0%* 2.3%* 2.0%* 2.7%* 2.4% North Carolina 5.6% 5.5% 4.9% 4.6% 4.0% 3.1%* 3.5% 3.3% 4.0% North Dakota 5.5% 5.5% 5.1% 9.4%* 5.7%* 7.3% 7.7% 6.5% 6.6% Ohio 4.9% 5.1% 4.6%* 5.1% 4.7% 4.4% 3.6%* 4.1% 5.0%* Oklahoma 7.2% 8.9%* 7.6%* 8.7%* 6.9%* 5.2%* 6.2%* 7.0% 6.5% Oregon 6.5% 6.6% 4.5%* 4.5% 4.3% 3.4% 2.3%* 2.8% 3.3% Pennsylvania 5.1% 5.6% 5.3% 5.5% 5.3% 4.3%* 4.7% 4.5% 5.0% Rhode Island 6.0% 2.5%* 4.1% 5.8% 2.7%* 2.9% 2.2% 1.3% 2.5% South Carolina 7.5% 6.4% 6.9% 4.9%* 4.2% 3.4% 3.8% 4.4% 3.9% South Dakota 7.4% 3.9%* 4.2% 6.1%* 5.5% 6.0% 4.3% 5.1% 5.2% Tennessee 4.2% 3.7% 5.1%* 5.2% 4.1%* 3.4%* 2.9% 3.9%* 4.3% Texas 10.7% 9.3%* 8.6%* 9.3%* 8.4%* 7.1%* 7.3% 7.5% 8.3%* Utah 9.7% 9.7% 8.6% 8.6% 8.3% 5.6%* 5.4% 5.9% 6.6% Vermont 1.9% 2.2% 1.5% 3.0% 2.7% 0.7%* 1.6%* 2.0% 1.2% Virginia 5.6% 4.2%* 4.5% 4.2% 4.4% 4.4% 4.2% 4.3% 4.5% Washington 5.0% 5.0% 4.7% 5.0% 4.1%* 2.6%* 1.8%* 2.0% 2.4% West Virginia 3.0% 3.8% 3.4% 3.8% 2.5% 2.3% 1.9% 2.5% 3.4% Wisconsin 4.8% 4.3% 4.3% 4.4% 4.2% 3.6% 3.7% 3.7% 3.5% Wyoming 7.2% 8.3% 6.1% 5.3% 6.9% 8.1% 8.7% 8.6% 7.7% Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau American Community Survey (ACS) data using 1-year estimates from Data.Census.Gov. * Change is significant at the 90% confidence level and is significant relative to the prior year. ** Because of an error in 2017 data collection noted by the U.S. Census Bureau, Delaware’s rate should not be compared to other estimates. 14 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019 Endnotes Their Coverage Amid Concerns About Changes to Public Charge Rules” (October 2019), available at https://www.kff.org/medicaid/press-release/ many-community-health-centers-report-that-immigrant-patients- 1 J. Alker and L. Roygardner, “The Number of Uninsured Children is on are-declining-to-enroll-in-medicaid-or-renew-their-coverage-amid- the Rise” (Washington: Georgetown University Center for Children and concerns-about-changes-to-public-charge-rules/. Families, October 2019), available at https://ccf.georgetown.edu/wp- content/uploads/2019/10/Uninsured-Kids-Report.pdf. 13 T. Brooks, “Improving State Administration and Procedures to Regain Medicaid/CHIP Enrollment Momentum for Kids” (Georgetown University 2 E. Burak, “Promoting Young Children’s Healthy Development in Center for Children and Families, October 2019), available at https:// Medicaid and the Children’s Health Insurance Program (CHIP)”, ccf.georgetown.edu/2019/10/29/improving-state-administration-and- (Washington: Georgetown University Center for Children and Families, procedures-to-regain-medicaid-chip-enrollment-momentum-for-kids/. October 2018), available at https://ccf.georgetown.edu/2018/10/17/ promoting-young-childrens-healthy-development-in-medicaid-and-the- 14 M. Clark, “Maternal Depression Costs Society Billions Each Year, New childrens-health-insurance-program-chip/. Model Finds” (Georgetown University Center for Children and Families, March 2019), available at https://ccf.georgetown.edu/2019/05/31/ 3 K. Wagnerman, “Medicaid: How Does It Provide Economic Security maternal-depression-costs-society-billions-each-year-new-model- for Families?” (Washington: Georgetown University Center for Children finds/. and Families, March 2017), available at https://ccf.georgetown.edu/wp- content/uploads/2017/03/Medicaid-and-Economic-Security.pdf. 15 E. Burak, “How Does Health Coverage for Adults Impact Children’s Healthy Development?” (Georgetown University Center for Children 4 K. Wagnerman, A. Chester, and J. Alker, “Medicaid is a Smart and Families, June 2019), available at https://ccf.georgetown. Investment in Children” (Washington: Georgetown University Center for edu/2019/06/12/how-does-health-coverage-for-adults-impact- Children and Families, March 2017), available at https://ccf.georgetown. childrens-healthy-development/. edu/wp-content/uploads/2017/03/MedicaidSmartInvestment.pdf. 16 E. Burak, “Parents’ and Caregivers’ Health Insurance Supports 5 American Academy of Pediatrics and Bright Futures, Children’s Healthy Development” (Washington: Society for Research “Recommendations for Preventative Pediatric Health” (Elk Grove, IL: in Child Development, June 2019), available at https://www.srcd.org/ American Academy of Pediatrics, February 2017). research/parents-and-caregivers-health-insurance-supports-childrens- 6 L. Murray and P. Cooper, “Effects of postnatal depression on infant healthy-development/. development,” Disease in Childhood 77, no. 2 (1997): 99-101.as cited 17 A. Searing, “Medicaid Expansion Connects 25,000 More Virginia Kids in Burak, E. (2018), available at https://ccf.georgetown.edu/2018/10/17/ and 110,000 Parents with Affordable Health Coverage” (Georgetown promoting-young-childrens-healthy-development-in-medicaid-and-the- University Center for Children and Families, November 2019), available childrens-health-insurance-program-chip/. at https://ccf.georgetown.edu/2019/11/26/medicaid-expansion- 7 S. Smith, M. Granja, U. Nguyen, and K. Rajani, “How States Use connects-25000-more-virginia-kids-and-110000-parents-with- Medicaid to Cover Key Infant and Early Childhood Mental Health affordable-health-coverage/. Services: Results of a 50-State Survey (2018 Update)” (National 18 Georgetown University Center for Children and Families analysis of Center for Children in Poverty, November 2018), available at http:// U.S. Census Bureau American Community Survey (ACS) data using nccp.org/publications/pdf/text_1211.pdf and “Maternal Depression 1-year estimates from Data.Census.Gov. Screening,” National Academy for State Health Policy, available at https://healthychild.nashp.org/screening/maternal-depression- 19 Georgetown University Center for Children and Families analysis of screening/#toggle-id-1. U.S. Census Bureau American Community Survey (ACS) data Table S2701 from Data.Census.Gov. 8 J. Alker and L. Roygardner, “The Number of Uninsured Children is on the Rise” (Washington: Georgetown University Center for Children and 20 J. Alker and L. Roygardner, “The Number of Uninsured Children is on Families, October 2019), available at https://ccf.georgetown.edu/wp- the Rise” (Washington: Georgetown University Center for Children and content/uploads/2019/10/Uninsured-Kids-Report.pdf. Families, October 2019), available at https://ccf.georgetown.edu/wp- content/uploads/2019/10/Uninsured-Kids-Report.pdf. 9 Haley, J. et al., “Improvements in Uninsurance and Medicaid/CHIP Participation among Children and Parents Stalled in 2017,” (Urban 21 United States Census Bureau, “Children’s Public Health Insurance Institute, May 2019). Coverage Lower Than in 2017,” September 10, 2019, available at https://www.census.gov/library/stories/2019/09/uninsured-rate-for- 10 J. Alker and L. Roygardner, “The Number of Uninsured Children is on children-in-2018.html. the Rise” (Washington: Georgetown University Center for Children and Families, October 2019), available at https://ccf.georgetown.edu/wp- 22 Ibid. content/uploads/2019/10/Uninsured-Kids-Report.pdf. 23 Congress required states to establish higher minimum eligibility 11 See T. Brooks, E. Park, and L. Roygardner, “Medicaid and CHIP thresholds in Medicaid for children under age 6 in the 1980s and Enrollment Decline Suggest the Child Uninsured Rate May Rise Again” 1990s; minimum thresholds were phased in for school-aged children (Georgetown University Center for Children and Families, May 2019) as starting in 1990 but federal minimums for all children remained lower cited in J. Alker and L. Roygardner, “The Number of Uninsured Children for school-aged children until the Affordable Care Act changes in 2014. is on the Rise” (Washington: Georgetown University Center for Children The Kaiser Commission on Medicaid and the Uninsured, “Medicaid at and Families, October 2019), available at https://ccf.georgetown.edu/ 50” (Washington: The Kaiser Family Foundation, May 2015), available wp-content/uploads/2019/10/Uninsured-Kids-Report.pdf. at https://www.kff.org/report-section/medicaid-at-50-low-income- pregnant-women-children-and-families-and-childless-adults/. 12 Kaiser Family Foundation, “Many Community Health Centers Report That Immigrant Patients Are Declining to Enroll in Medicaid or Renew December 2019 CCF.GEORGETOWN.EDU YOUNGEST CHILDREN LOSING COVERAGE 15 24 Department of Health and Human Services Centers for Medicare and make up a portion of all children. Also see Alker, J. and Roygardner, Medicaid Services, Center for Medicaid and State Operations, “Letter L., “The Number of Uninsured Children is on the Rise” (Washington: to State Health Official,” August 31, 2009, available at https://www. Georgetown University Center for Children and Families, October 2019), medicaid.gov/federal-policy-guidance/downloads/sho-08-31-09b.pdf. available at https://ccf.georgetown.edu/wp-content/uploads/2019/10/ 25 American Academy of Pediatrics and Bright Futures, Uninsured-Kids-Report.pdf. “Recommendations for Preventative Pediatric Health” (Elk Grove, 29 E. Burak, “Parents’ and Caregivers’ Health Insurance Supports IL: American Academy of Pediatrics, February 2017), available at Children’s Healthy Development” (Washington: Society for Research https://aap.org/en-us/about-the-aap/aap-press-room/Pages/2019- in Child Development, June 2019), available at https://www.srcd.org/ Recommendations-for-Preventive-Pediatric-Health-Care.aspx. research/parents-and-caregivers-health-insurance-supports-childrens- 26 The currently released 2018 U.S. Census American Community healthy-development. Survey summary tables on Data.Census.Gov and the Census Statistical 30 Alker and Roygardner (2019), op. cit. Testing Tool affords us the ability to surmise that the uninsured rate 31 E. Burak, “Promoting Young Children’s Healthy Development for children under 6 is higher than the uninsured rate for school-aged in Medicaid and the Children’s Health Insurance Program (CHIP)” children in seven states (see Figure 6). However, additional data that (Washington: Georgetown University Center for Children and Families, could allow a determination of statistical significance of the difference October 2018), available at https://ccf.georgetown.edu/2018/10/17/ between the rate of change in uninsured groups between the two age promoting-young-childrens-healthy-development-in-medicaid-and-the- groups (young children under 6 vs. school age children) was unavailable childrens-health-insurance-program-chip/. as of December 2019. Also see Alker, J. and Roygardner, L., “The 32 E. Burak and K. Rolfes-Haase, “Using Medicaid to Ensure the Number of Uninsured Children is on the Rise” (Washington: Georgetown Healthy Social and Emotional Development of Infants and Toddlers” University Center for Children and Families, October 2019), available at (Washington: Georgetown University Center for Children and Families https://ccf.georgetown.edu/wp-content/uploads/2019/10/Uninsured- and Zero to Three, November 2018), available at https://ccf.georgetown. Kids-Report.pdf. edu/wp-content/uploads/2018/12/Medicaid-and-IECMH_FINAL.pdf. 27 J. Alker and L. Roygardner, “The Number of Uninsured Children is on 33 J. Pac et al. “Young child poverty in the United States: Analyzing the Rise” (Washington: Georgetown University Center for Children and trends in poverty and the role of anti-poverty programs using the Families, October 2019), available at https://ccf.georgetown.edu/wp- Supplemental Poverty Measure,” Children and youth services review content/uploads/2019/10/Uninsured-Kids-Report.pdf. vol. 74 (2017): 35-49, available at https://www.ncbi.nlm.nih.gov/pmc/ 28 Two separate data sources are used and referenced here to afford an articles/PMC5484166/. Also see “Children in poverty by age group in “at a glance” comparison between the ‘percent change in the number the United States”, Annie E. Casey Foundation, Kids Count Data Center, of uninsured children’ compared to the change for children under age 6. available at https://datacenter.kidscount.org/data/tables/5650-children- Table HIC-05, which rounds data, was used to analyze data on trends in-poverty-by-age-group?loc=1&loct=1#detailed/1/any/fale/37,871,870, for children under 19. The tables used to examine trends for children 573,869,36,868,867,133,38/17,18,36/12263,12264. under 6 (namely S2701), do not employ rounding. The children under 6 are, of course, included in the analysis of all children under 19 as they Georgetown University Center for Children and Families ccf.georgetown.edu/blog/ McCourt School of Public Policy Box 571444 facebook.com/georgetownccf 3300 Whitehaven Street, NW, Suite 5000 Washington, DC 20057-1485 twitter.com/georgetownccf Phone: (202) 687-0880 Email: childhealth@georgetown.edu 16 YOUNGEST CHILDREN LOSING COVERAGE CCF.GEORGETOWN.EDU December 2019