WASHINGTON — The number of U.S. children without health insurance has declined in the past few years, but that could change once the COVID-19 public health emergency (PHE) ends, according to a report released Wednesday by the Georgetown University Health Policy Institute’s Center for Children and Families.
“Prior to the pandemic, for the first time in many, many years, after President Trump took office, the number and rate of uninsured children began to rise,” Joan Alker, MPhil, executive director of the center, said during a telephone press conference. “After a historic low in 2016 of 4.7%, the number jumped up to 5.7% in 2019 — that was an increase of almost a million more children becoming uninsured during that period.”
In the early months of the pandemic, job losses led many people to believe that the number of uninsured children would continue to increase, said Alker, who wrote the report along with colleagues Aubrianna Osorio, MPP, and Edwin Park, JD. But the report actually contained some good news. “The rate and number of uninsured children stabilized and declined from 2019 to 2021, moving from 5.7% to 5.4%,” she said.
Why the reversal of fortune during this period? “For children, Medicaid provided a backstop to coverage loss on the employer side,” she noted. “And federal protections put in place by the Families First Act ensured that no one could be disenrolled from Medicaid during the federally declared COVID-19 public health emergency. These protections ensured that children and families didn’t lose coverage from what they call producible losses that are very common in ‘normal times’ — they occur when eligible children fall off of Medicaid because their coverage is removed due to administrative and paperwork barriers.”
In addition, Alker said, higher subsidies for those who signed up for health insurance through the Affordable Care Act marketplaces also helped decrease the rate of children who were uninsured.
Looking along socioeconomic lines, “children and families living below the poverty level — but especially children in low-wage working families with incomes between approximately $30,000 a year for a family of three to $55,000 a year — saw the biggest gains in coverage,” Alker continued. “In terms of race and ethnicity, American Indian/Alaska Native children — who have the highest uninsured rates in the country — saw the biggest drop, moving nationally from 13.8% to 11.8% uninsured. White children and Latino children also saw declines in their uninsured rates.”
The report analyzed data from the U.S. Census Bureau American Community Survey (ACS). The ACS randomly selects about 3.5 million households each year to be surveyed and conducts the survey year-round, publishing results annually. The researchers found that from 2019 to 2021, Texas had the biggest numerical decline in uninsured children at a drop of 65,000, followed by Illinois (25,000), Georgia (21,000), Indiana (19,000), and Arizona (15,000). But in terms of a percentage decrease, Oklahoma came out on top, with a decrease of 1.2%, followed by Connecticut and Indiana (both 1.1%) and Colorado and Texas (both 0.9%).
From a regional perspective, “States in New England continue to have the lowest uninsured rates for children,” the report said. “The South is a mixed picture, with Texas having the highest rate and number of uninsured children in the country, and Florida and Georgia continuing to have a large percentage of the uninsured children overall and relatively high rates in general. As a region, the Mountain West is falling most consistently behind the national average (with the exception of Colorado).”
Although the report is welcome news, “it may be short-lived, as millions of eligible children will likely fall through the cracks and become uninsured in states that are inattentive or ill-intentioned when the federal continuous coverage protection expires” at the end of the PHE, Alker said. Previous research from the center has found that 6.7 million children are at risk for a period of uninsurance at the end of the PHE, “so when you think about [the fact] that today’s report finds that there are more than 4.1 million children uninsured at the end of 2021 … you can see that massive potential increase” in the number of uninsured children.
What’s more, most of the children who will lose Medicaid when the PHE ends will actually still be eligible for Medicaid but will be kept off the rolls due to paperwork issues in their states, Alker said.
The country “can’t afford to lose” the coverage gains documented in the report, “especially at a time when children need as much support as possible,” during this period of increase in respiratory illnesses such as influenza and respiratory syncytial virus (RSV), said Deborah Greenhouse, MD, a pediatrician in Columbia, South Carolina, and a member of the government affairs committee at the American Academy of Pediatrics. “It’s critical that children and families continue to rely on the healthcare coverage to help them get the care and services they need … If our patients lose healthcare coverage, more and more will be forced to rely on [overcrowded] emergency departments as their only source of medical care.”
Anne Dunkelberg, MPA, a senior fellow at the public policy group Every Texan, said one of the problems in her state is that it won’t accept data to establish a child’s eligibility for Medicaid if the data are more than 2 months old. “That means that a huge percentage of the time, when the state goes to the database, it’s going to deem the information too old to use and start a mail-based process of reaching out to the family to get more updated income information.” She noted that the federal government has issued a toolkit for states to identify best practices in this area.