Historic Gains in Health Coverage for Hispanic Children in the Affordable Care Act’s First Year by Sonya Schwartz, Alisa Chester, Steven Lopez, and Samantha Vargas Poppe Key Findings Introduction 1. Uninsurance rates for Hispanic children reached a All children should have the historic low in the first year that the Affordable Care opportunity to lead long and healthy Act’s (ACA) coverage provisions took effect. The lives. While many factors influence number of uninsured Hispanic children dropped by a child’s health, access to health approximately 300,000 children, from about 2 million coverage is a critical component in uninsured Hispanic children in 2013 to 1.7 million in 2014. setting them up for success. Federal The uninsurance rate for Hispanic children declined by and state efforts in the last two nearly 2 percentage points from 11.5 to 9.7 percent in the decades have cut the uninsurance same one-year time period. rate for low-income children in half.1 This reduction is due in large part 2. Hispanic children were much more likely to have to the success of Medicaid and the health coverage in states that have taken multiple Children’s Health Insurance Program steps to expand coverage for children and parents. (CHIP).2 More recently, the passage In 2014, 20 states had uninsurance rates for Hispanic and implementation of the Affordable children that were significantly below the national Care Act (ACA) has built upon this average. Of these, 16 states covered children in success by providing affordable Medicaid and the Children’s Health Insurance Program coverage for millions of adults. (CHIP) above 255 percent of the Federal Poverty Level (FPL, the median eligibility level for children), 18 states provided Medicaid and/or CHIP coverage to lawfully residing children in the five-year waiting period, and 17 The number of uninsured states extended Medicaid to low-income parents and Hispanic children other adults. dropped dramatically 3. Despite these gains, health coverage inequities for in the first year that the Hispanic children remained. Hispanic children accounted ACA took effect. for a much greater share of the uninsured child population (39.5 percent) than the child population at large (24.4 percent) in 2014. These inequities existed even though the vast majority of uninsured Hispanic children were eligible for Medicaid and CHIP, but unenrolled. January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 1 The ACA built on the success of Medicaid Figure 1. The Number of Uninsured Hispanic Children Declined While the Number of and CHIP by extending affordable Hispanic Children Grew, 2009-2014 coverage to more low-income adults and moderate-income children. Millions 2.8 Total Number of The ACA included some important changes in 2.6 Uninsured Hispanic Children 2.6 coverage that were expected to have an impact on 2.4 2.4 children’s health insurance coverage rates. Most of 2.2 2.2 the eligibility expansions under the ACA—including 2.1 2.0 2.0 the opportunity for states to extend Medicaid and 1.8 provide premium tax credits for coverage on the health 1.7 1.6 insurance marketplace—targeted adults. Prior to the enactment of the ACA, eligibility for Medicaid was 1.4 2009 2010 2011 2012 2013 2014 much more limited for adults than for kids, and adults’ insured rates lagged behind children’s for many years. Millions Total Number of Some moderate-income children also became eligible 18.0 Hispanic Children 17.9 for affordable coverage options through the health 17.8 17.7 insurance marketplaces and premium tax credits. 17.6 17.5 17.4 17.4 Hispanic adults had among the highest uninsured 17.2 17.2 rates in the nation with nearly two-fifths of Hispanic 17.0 adults uninsured before the ACA’s key coverage 16.8 16.7 expansions took effect in 2014.3 National surveys have 16.6 already identified a large decline—from 40 percent in 16.4 2012 to 34 percent in 2014—in uninsurance rates for 16.2 16.0 non-elderly Hispanic adults.4 2009 2010 2011 2012 2013 2014 Despite these significant gains, far too many children— more than 4.4 million, of which about 1.7 million are Figure 2. The The Uninsured Rate for Hispanic Children Declined More Quickly than the Hispanic—remain uninsured.5 (See Figure 1.) For too Uninsured Rate for All Children, 2009-2014 long, Hispanic children have been more likely than other children to be uninsured. In 2014, Hispanic children had 16.0% 15.8% Uninsured a higher rate of uninsurance than all children (9.7 percent Hispanic Children 15.0% 14.1%* compared to 6 percent respectively). (See Figure 2.) 14.0% 12.8%* While this inequity remains, the rate of uninsured 13.0% 12.1%* Hispanic children has decreased significantly. The 12.0% 11.5%* uninsurance rate for Hispanic children has been reduced 11.0% by half since 1997.6 This is largely due to a corresponding 10.0% 9.7%* All Uninsured increase in Medicaid and CHIP enrollment.7 Medicaid 9.0% Children 8.6%* and CHIP have also helped to reduce inequities in health 8.0% 8.0%* 7.5%* coverage rates between Hispanic children and other 7.2%* 7.1% 7.0% children. The difference between the uninsured rate for 6.0%* 6.0% Hispanic children and the uninsured rate for all children 5.0% has narrowed substantially from 7.2 percentage points in 20092010 2011 201220132014 2009 to 3.7 percentage points in 2014. (See Figure 2.) * Indicates change is significant at the 90% confidence level. 2 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 A majority of uninsured Hispanic children are eligible for Medicaid and CHIP but remain unenrolled due to many barriers. Two-thirds (66 percent) of uninsured Hispanic children were estimated to be eligible for Medicaid and CHIP but remained unenrolled in 2013.8 (See Figure 3.) Many Hispanic children are eligible for these public Figure 3. coverage programs because the majority of Hispanic children are U.S. Most Uninsured Hispanic Children Were citizens (93 percent) and live in low-income families (62 percent).9 As Eligible For Medicaid/CHIP of January 1, 2015, all but two states covered children at or above Coverage in 2013 200 percent of FPL through Medicaid and CHIP and 19 states covered children at or above 300 percent of the FPL.10 Two out of three However, many eligible Hispanic children remain unenrolled in uninsured health coverage because their families face barriers to enrollment. Hispanic children are eligible for These barriers include language access challenges, worries about public immigration-related consequences for family members, and the coverage. complexity of eligibility rules. More than half of all Hispanic children 66% in 2013 had at least one parent who was foreign born or who did not speak English well.11 State Medicaid and CHIP programs, as well as state and federal marketplaces, may not conduct adequate outreach in Spanish or offer an enrollment experience in high-quality Spanish. Eligible Hispanic children living with immigrant parents can also face barriers because their parents fear immigration-related consequences. Another barrier to enrollment is that parents may not know their children are eligible due to complex program rules that vary from state to state. Under the 2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA), states have the option to provide coverage to lawfully residing immigrant children using federal Medicaid and CHIP funds. Before CHIPRA, many immigrant children were subject to a five-year waiting period before federal Medicaid or CHIP funds could be used to provide health coverage. As of 2015, 28 states and D.C. had extended Medicaid and CHIP to lawfully residing children by lifting this five-year waiting period.12 However, some lawfully residing Hispanic children living in the 22 states that have not taken this CHIPRA option continue to be ineligible for coverage. Also, a small percentage of Hispanic children are unauthorized and not eligible for federally-funded coverage in Medicaid or CHIP except for limited-scope emergency Medicaid.13 January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 3 Providing health coverage to Hispanic National Trends children is not only important for their health and well-being, but it also benefits the Uninsurance rates for Hispanic social and economic fabric of the nation. children reached a historic low in the There are currently more than 17.5 million first year that the ACA’s coverage Hispanic children in the U.S., representing provisions took effect. one in every four children.14 Hispanic In 2014, when the full provisions of the ACA children are the fastest-growing segment went into effect, the number of uninsured of the child population in the U.S. and are Hispanic children dropped by approximately expected to represent nearly one in three 300,000 children (from 2 million in 2013 to 1.7 Hispanic children children by 2050.15 Consequently, it is million in 2014), a 14.6 percent decline. This are the fastest- projected that by 2050 nearly one-third of decline is roughly three times the size of the growing segment of the U.S. workforce will be Hispanic.16 prior year’s decline for Hispanic children. This decline occurred at a time when the overall the child population In order to reach their full potential, children Hispanic child population grew by 1.1 percent. in the U.S. need to be healthy. Research shows that (See Figure 1.) children with access to health coverage through Medicaid gain additional and In 2014, the uninsurance rate for Hispanic important long-term benefits, such as children also dropped at an unprecedented better educational outcomes as teenagers rate from 11.5 percent in 2013 to 9.7 percent and adults along with greater economic in 2014.18 This is three times the percentage success.17 Connecting these children to point drop from 2012 to 2013 (0.6 percentage coverage and care is essential to realizing points), and greater than any one-year our nation’s bright future. percentage point drop since 2009. (See Figure 2.) This brief provides a snapshot of uninsured Hispanic children in the U.S. in 2014, The uninsurance rate for Hispanic nationwide and in all 50 states and the children declined at a rate much District of Columbia (D.C.). Unless otherwise faster than the rate of decline for all noted, this report analyzes national children. and state data from the 2014 American From 2013 to 2014, the uninsurance rate for Community Survey (ACS) to profile Hispanic children fell by 1.8 percentage points, uninsured Hispanic children. The brief also faster than it fell for all children (1.1 percentage highlights the efforts of two states to reduce points). In the last five years, the uninsurance the number of uninsured children, and offers rate for Hispanic children fell 6 percentage recommendations to further reduce the points, more than double the percentage point number of uninsured children. drop for all children (2.6 percentage points). (See Figure 2.) 4 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Hispanic children are much more Figure 4. States that Expanded Medicaid likely to be insured in states that have Had a Larger Decline in the Rate of taken multiple steps to expand health Uninsured Hispanic Children Compared coverage to children and parents. to Non-Expansion States, 2013-2014 States that have uninsurance rates for Thousands 7.6% Hispanic children that are significantly below 1,100 1,084 decline the national average are much more likely to have taken multiple steps to expand affordable 1,001* 1,000 coverage, including: 952 zzraising Medicaid and CHIP income 900 22.6% eligibility levels for children; decline 800 zzcovering lawfully residing immigrant 737* children without a five-year waiting 700 period in Medicaid and CHIP; and zzextending Medicaid coverage to low- 600 income parents and other adults. 500 In 2014, 20 states had uninsurance rates for Hispanic children that were significantly 400 below the national average. Of these, 16 Expansion States Non-expansion States states covered children in Medicaid and the 2013 2014 Children’s Health Insurance Program (CHIP) * Indicates change is significant at the 90% confidence level. above 255 percent of the FPL (the median eligibility level for children), 18 states provided Medicaid and/or CHIP coverage to lawfully New coverage options for parents under residing children in the five-year waiting the ACA likely created a “welcome mat” period, and 17 states extended Medicaid to for Hispanic children. low-income parents and other adults. (See Most uninsured Hispanic children were already Appendix Table 5.) eligible for affordable health coverage through Medicaid or CHIP prior to the ACA, but were In addition, states that extended Medicaid not enrolled.20 Nonetheless, the ACA still had a to low-income adults had uninsurance rates positive impact on getting children connected for Hispanic children that were half the rate with coverage. It is likely that new eligibility and of states that did not expand Medicaid in enrollment opportunities for adults created a 2014 (7 percent compared to 13.7 percent “welcome mat” effect when parents enrolled respectively).19 States that expanded Medicaid their children in Medicaid or CHIP as they also had triple the rate of decline of uninsured signed themselves up for newly available ACA Hispanic children compared to non-expansion coverage. Research and state experience states between 2013 and 2014, despite the shows that covering parents increases the fact that most of them started off with fewer likelihood of children being enrolled in health uninsured Hispanic children. (See Figure 4 and coverage.21 For example, in Oregon, the odds Appendix Table 6.) of eligible children receiving Medicaid or CHIP coverage doubled if their parents enrolled in Medicaid.22 January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 5 Despite these gains, health coverage Figure 5. Hispanic Children Were Twice as inequities for Hispanic children Likely as Non-Hispanic White Children remained. to be Uninsured, 2014 Gaps in uninsurance rates between Hispanic Black 4.8% children and other children narrowed considerably between 2009 and 2014, but White 5.9% significant disparities remained. During this period, the gap in coverage between Asian/Native Hawaiian/ 5.5% Hispanic children and all children narrowed Pacific Islander from 7.2 percentage points to 3.7 points. Other 7.5% (See Figure 1.) The gap between Hispanic children and non-Hispanic white children American Indian/ narrowed from 9.9 percentage points to 13.9% Alaska Native* 5.1 points. (See Figure 5.) Although these coverage gaps were cut in half over a White, non-Hispanic** 4.6% five-year period, significant gaps remained in 2014, even after ACA’s first year of Hispanic 9.7% implementation. * Indian Health Service is not considered comprehensive coverage. See the In addition, Hispanic children continue methodology section for more information. to make up a disproportionate share of ** For simplicity, racial and ethnic data are displayed in this chart, but uninsured children. Hispanic children made Hispanic refers to a person’s ethnicity and these individuals may be of any race. See the methodology section for more information. up 39.5 percent of the uninsured child population, but only 24.4 percent of the overall child population. (See Figure 6.) Figure 6. Health Coverage Inequities Remain: The vast majority of uninsured Hispanic Children Were a Much Larger Share Hispanic children were eligible for of Uninsured Children Than They Were of Medicaid and CHIP but not enrolled. All Children, 2014 Two-thirds (66 percent) of uninsured Hispanic children were estimated to be eligible for Hispanic Children as a 24% Percent of the Total Child Medicaid and CHIP but not enrolled in 2013.23 Population, 2014 As discussed earlier, Hispanic children are often eligible for Medicaid and CHIP but not 76% Hispanic Children enrolled because their parents face barriers to All Other Children enrolling them. Uninsured Hispanic Children as a Percent of Uninsured 40% Children, 2014 60% Uninsured Hispanic Children Total Uninsured Children 6 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 State Trends times as high as New York’s. Texas, Florida, and Georgia have eligibility levels for children below the national In the ten states with the largest overall average, and Arizona is the only state in the country to number of Hispanic children, rates of have closed its CHIP program. Of these four states, only uninsured Hispanic children varied widely. Texas covers lawfully residing children in the five-year Of the ten states with the largest overall number of waiting period, and only Arizona has extended Medicaid Hispanic children, four states—California, New York, to low-income parents and other adults. (See Figure 7 and Illinois and New Jersey—had rates of uninsured Hispanic Appendix Table 5.) children that were significantly lower than the national Two states—Colorado and North Carolina—had average. (See Figure 7.) New York’s uninsurance rate uninsurance rates for Hispanic children that were on par for Hispanic children was the lowest by far of these ten with the national average. Colorado’s income eligibility states (3.8 percent). California, New York, Illinois, and levels for children in Medicaid and/or CHIP were above the New Jersey all cover children with incomes above 255 national median, but North Carolina’s levels were below percent of the FPL, cover lawfully residing immigrant the national median. Colorado began providing coverage children in the five-year waiting period, and have for lawfully residing children in the five-year waiting period extended Medicaid to low-income adults. (See Figure 7 in 2015 and North Carolina had already provided coverage and Appendix Table 5.) to children in the five-year waiting period in 2014. Four states—Texas, Florida, Arizona, and Georgia— Colorado expanded Medicaid coverage to low-income had rates of uninsured Hispanic children that were adults in 2014, while North Carolina has not. (See Figure 7 significantly higher than the national average. Both and Appendix Table 5.) Georgia and Texas had uninsured rates that were four Figure 7. Of the 10 States with the Largest Overall Number of Hispanic Children, Only 4 States Had Uninsurance Rates Lower than the National Average, 2014 15.3% 15.3% 12.7% 12.1% 10.5% 9.6% 9.7% 6.8% 7.0% 4.5% 3.8% * Colorado and North Carolina had rates of uninsurance that are not statistically different than the national average. January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 7 The number and percentage of uninsured children fell in 11 states. Between 2013 and 2014, eleven states—Arizona, California, Colorado, Florida, Georgia, Nevada, New Jersey, New York, Oklahoma, Oregon and Texas—had significant decreases in both the number and percentage of uninsured Hispanic children. Some of the states that improved continued to have the largest number of uninsured Hispanic children in the nation, but showed among the greatest improvements in coverage. For instance, in Texas, a state with many uninsured Hispanic children, a 1.7 percentage point decline in the rate of uninsured Hispanic children translates to a decline of nearly 53,000 children. (See Figure 8.) Figure 8. The Number and Percentage of Uninsured Hispanic Children Fell in 11 States, 2013-2014 Number of Uninsured Percent of Uninsured Hispanic Children Hispanic Children State 2013 2014 2013-2014 2013 2014 2013-2014 Number Number Change in Number Percent Percent Percentage Uninsured Uninsured of Uninsured Uninsured Uninsured Point Change Arizona 105,377 89,143 -16,234* 15.1 12.7 -2.4* California 454,740 322,698 -132,042* 9.6 6.8 -2.8* Colorado 50,694 37,487 -13,207* 13.1 9.6 -3.5* Florida 167,917 143,831 -24,086* 14.4 12.1 -2.3* Georgia 64,489 52,113 -12,376* 19.2 15.3 -3.9* Nevada 53,142 35,736 -17,406* 20.0 13.3 -6.7* New Jersey 48,430 35,115 -13,315* 9.8 7.0 -2.8* New York 47,083 38,268 -8,815* 4.7 3.8 -0.9* Oklahoma 20,459 17,175 -3,284* 14.0 11.4 -2.5* Oregon 16,845 11,768 -5,077* 9.1 6.3 -2.8* Texas 585,498 532,615 -52,883* 17.0 15.3 -1.7* * Indicates change is significant at the 90 percent confidence level. 8 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 State Spotlight: Nevada Had the Greatest Decline in the Uninsurance Rate for Hispanic Children In Nevada, the uninsurance rate for Hispanic children fell from 20 percent in 2013 to 13.3 percent in 2014, the biggest drop in the nation.25 The number of uninsured Hispanic children in Nevada also declined dramatically from approximately 53,000 in 2013 to about 36,000 in 2014, a 33 percent decline. Despite this encouraging progress, Nevada still had the 9th largest number of uninsured Hispanic children in the nation and a rate that is significantly higher than the national average. State officials in Nevada took full advantage of coverage options under the ACA to bring down uninsured rates. At the end of 2012, Governor Sandoval announced that he would extend Medicaid coverage to low-income parents and other adults up to 138 percent of the federal poverty level. State officials in Nevada also decided to launch “Nevada Health Link,” a state health insurance marketplace.26 Nevada provides Medicaid and CHIP coverage to children up to 205 percent of the federal poverty level—lower than the national median—and has not provided Medicaid and/or CHIP to lawfully residing children in the five- year waiting period.27 Nevada used federal health insurance marketplace grants to develop a state marketplace website in Spanish and contracted with bilingual navigators who knew how to engage and enroll the Latino community.28 Despite early concerns that Hispanic enrollment numbers in Medicaid and the state marketplace were low, Nevada had a significant reduction in the number and rate of uninsured Hispanic adults. The number of uninsured non-elderly Hispanic adults in Nevada decreased by approximately 31,000 (from about 190,000 in 2013 to 159,000 in 2014) and the rate of uninsured non-elderly Hispanic adults in Nevada declined from 41.4 percent in 2013 to 33.4 percent in 2014.29 This likely resulted in a “welcome mat” effect where providing affordable health coverage options for parents—which could be through Medicaid expansion or the marketplace— increased the likelihood of their children being enrolled in health coverage.30 January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 9 State Spotlight: New York Continues to Keep its Uninsured Rate for Hispanic Children Low, Year after Year New York’s uninsurance rate for Hispanic children steadily declined in the last five years from 6.2 percent in 2009 to 3.8 percent in 2014. The state had a rate of uninsured Hispanic children in 2014 well below the national average, despite having the fourth largest Hispanic child population in the United States. New York has also made great strides in covering Hispanic adults. The uninsurance rate for Hispanic adults fell from 31.5 percent in 2009 to 24.5 percent in 2014. There are a few likely reasons for New York’s success. First, New York has had a long-standing commitment to affordable health coverage for children and adults in Medicaid and CHIP. New York has covered children in Medicaid and CHIP up to 400 percent of the federal poverty level, the highest level in the U.S., for nearly a decade. The state has covered all children regardless of immigration status since the 1990s.31 New York also provided Medicaid coverage to low-income parents up to 150 percent of FPL and childless adults up to 100 percent of FPL through a Medicaid waiver before the ACA took effect in 2014.32 Second, New York built on a vibrant infrastructure of trusted, community-based application assistance through its Facilitated Enrollment (FE) and Community Health Advocate (CHA) programs. Created in 1999, the FE program serves all counties across New York through state-administered contracts with nonprofit service organizations to facilitate enrollment into public health insurance programs.33 The CHA program also emerged in 1999 to provide enhanced support to consumers, communities, and social service organizations navigating New York’s healthcare systems and services. The federal marketplace grants provide additional resources that allowed the state to build on an already- organized and state-funded network of enrollment and renewal assisters that had existed for many years. Third, New York continues to eliminate administrative barriers in the enrollment and renewal process. The state has also worked to reduce disruptions in coverage—like movement from insured to uninsured or across Medicaid, CHIP and the marketplace—that occur due to small fluctuations in income. In particular, New York has adopted express lane eligibility and 12-month continuous eligibility for children in Medicaid and CHIP, which make it easier for children to be enrolled and stay enrolled regardless of changes in circumstance. 10 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Two-thirds of uninsured Hispanic children are its CHIP program in 2010. In effect, this enrollment concentrated in just five states. freeze limited eligibility for children in Medicaid to 152 percent of the FPL, the lowest income eligibility Two-thirds (66 percent) of all uninsured Hispanic children level in the country.36 Arizona also does not cover lived in just five states— Texas, California, Florida, Arizona, lawfully residing children in the five-year waiting and Georgia in 2014. (See Figure 9.) These five states were period. home to 1.1 million of the 1.7 million uninsured Hispanic children in 2014. zz The remaining three states, Texas, Florida, and Georgia, all had significantly higher rates of Taking a closer look at these five states provides a better uninsurance than the national average. Texas, understanding of why they might have such large numbers Florida, and Georgia cover children in Medicaid and of uninsured Hispanic children. (See Appendix Table 5 and CHIP below the national median eligibility levels Figure 9.) and have not extended Medicaid coverage to low- zz California’s rate of uninsured Hispanic children (6.8 income parents. Of these states, only Texas covers percent) was significantly below the national average. lawfully residing children in the five-year waiting However, California still drove up the national number period. Without improvements in eligibility levels of uninsured Hispanic children since it is such a large for parents and children, it will likely be difficult state. California’s rate was lower than the national for Texas, Florida, and Georgia to bring the rate of average for a few possible reasons. California has more uninsured Hispanic children down to the national generous child eligibility levels (266 percent of the FPL) average. for Medicaid and CHIP than the other four states with The South had the largest share of the large numbers of uninsured Hispanic children, and nation’s uninsured Hispanic children and the has extended coverage to lawfully residing children in highest rate of uninsured Hispanic children. the five-year waiting period. Some California counties The South accounted for the largest share of the nation’s have extended coverage to all children regardless of uninsured Hispanic children in 2014 (51.5 percent), and immigration status.34 In addition, California extended had the highest rate of uninsured Hispanic children in Medicaid to low-income parents and other adults 2014 (13.8 percent). Only one Southern state, West under a Medicaid waiver approved in 2010.35 Arizona’s Virginia, had a lower rate of uninsured Hispanic children rate of uninsured Hispanic children (12.7 percent) than the national average. (See Figure 10.) Meanwhile, in remained significantly above the national average (9.7 the last decade, the nation’s Hispanic population grew at percent). Despite extending Medicaid to low-income the fastest rate in the South, including among Southern adults in 2014, Arizona limited eligibility for children states with historically small Hispanic populations.37 in CHIP from 2010 to 2014, by freezing enrollment for Figure 9. Two-thirds of Uninsured Hispanic Children Lived in 5 States, 2014 2014 Number and Rate of As a Share of State Uninsured Hispanic Children Total Uninsured Number Rate Hispanic Children Texas 532,615 15.3% 30.6% California 322,698 6.8% 18.6% Florida 143,831 12.1% 8.3% Arizona 89,143 12.7% 5.1% Georgia 52,113 15.3% 3.0% Five State Total 1,140,400 10.9% 65.6% National Total 1,738,230 9.7% 100% January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 11 Figure 10. States with Rates of Uninsured Hispanic Children Higher than the National Average Were Concentrated in the South and West, 2014 WA MT NH ND VT ME OR MN MA ID SD WI NY WY RI MI CT IA PA NJ NV NE MD OH UT IL DE IN CO WV DC CA KS MO VA KY NC TN AZ NM OK AR SC MS AL GA TX LA FL AK HI Uninsured rate higher than national rate (13 states) Uninsured rate lower than national rate (20 states including D.C.) No statistically significant difference from the national average (18 states) The Coverage Landscape for Hispanic Children What role do Medicaid and CHIP play A new body of research shows that Medicaid has in the health and long-term success of additional long-term benefits for children. Children Hispanic children and families? eligible for Medicaid had better health outcomes Medicaid and CHIP play a vital role in providing as adults and teenagers; better educational health coverage and health care services to low outcomes (they were less likely to drop out of high and moderate-income children. Medicaid and school and more likely to graduate from college); CHIP now cover more than half (55 percent) of and greater economic success.40 the nation’s Hispanic children.38 Children enrolled Which Hispanic children are more likely in Medicaid and CHIP have significantly better to remain uninsured? access to primary and specialty care and fewer Uninsured Hispanic children, like all uninsured cost barriers than those who are uninsured. children, are more likely to be school-aged. Furthermore, children enrolled in Medicaid Hispanic children under age 6 are less likely than are significantly less likely to have unmet or their older, school-aged peers (6 to 17 years delayed needs for medical care, dental care, and old) to be uninsured (6.9 percent compared to prescription drugs due to costs compared to low- 11.2 percent, respectively). However, Hispanic income uninsured children.39 uninsured children are more likely to live in 12 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 poverty than all uninsured children. Hispanic enrollment, such as removing asset tests and face- children living in poverty are more likely to be to-face interviews that made it harder for families to uninsured than those just above poverty (9.9 be determined eligible and enroll in coverage.45 percent uninsured below 100 percent of the FPL, compared to 8.7 percent at 100 to 125 percent of Conclusion the FPL).41 For nearly two decades, the number of uninsured How did the ACA support coverage children—including Hispanic children—has steadily gains for Hispanic children and families? declined. These gains in health coverage reflect years of concentrated efforts at the federal and On January 1, 2014, many of the key coverage state levels to ensure that more children have an provisions of the ACA took effect. The ACA opportunity to achieve good health and well-being created new pathways to coverage for adults through access to health insurance. While the by extending Medicaid eligibility to low-income number of uninsured children has fallen, certain Additional adults (which became optional for states as a result of the Supreme Court decision). In addition, racial and ethnic groups, especially Hispanics, efforts must continue to face inequities in health coverage levels. the ACA filled a gap in coverage for “lawfully continue to present” immigrants who do not meet a narrower While recent trends are promising, additional efforts educate, engage “qualified” immigrant definition for Medicaid. must continue to educate, engage and enroll the and enroll Lawfully present immigrants are now eligible for Hispanic community. The ACA has dramatically marketplace coverage and premium subsidies. the Hispanic increased the pace at which the uninsured rate is Given that more than half of Hispanic children falling for Hispanic children. Still, Hispanic children community. have a foreign-born parent, the expansion to are more likely to be uninsured than other children, lawfully present immigrants provided a new making them vulnerable to going without health care coverage option for parents of many Hispanic and leaving their families exposed to financial risk. children.42 Finally, some children also gained a path to coverage through premium subsidies for Given the high rates of uninsurance among purchasing health insurance in the new federal or Hispanic children, policymakers, program state marketplaces for children in families whose administrators, and other stakeholders should income is too high for Medicaid or CHIP. continue efforts to maximize health coverage for Hispanic children and remove barriers to As mentioned earlier, despite new coverage enrollment. Five particular strategies will support options under the ACA, most uninsured future progress: fully implementing the ACA’s Hispanic children were already eligible for coverage provisions; extending public coverage affordable health coverage through Medicaid to lawfully residing children; removing systemic or CHIP prior to the ACA, but were not enrolled.43 barriers to enrollment and support the application It is likely that new eligibility and enrollment process; supporting states and localities that opportunities for parents and other adults created want to expand coverage to children and families a “welcome mat” effect where parents enrolled regardless of immigration status; and encouraging their children as they signed themselves up for states to evaluate changing demographics and newly available ACA coverage.44 adopt strategies to maximize enrollment. Through these efforts, more Hispanic children will not The ACA also included a “maintenance of effort” only gain health coverage, but a more equitable provision requiring states to maintain their current opportunity for success in school, work, and as eligibility levels for children in Medicaid and participants in society at large. CHIP through September 2019. States were also required to remove administrative barriers to Recommendations for January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 13 Future Progress Fully Implement the ACA’s Coverage federal marketplaces should make the full outreach Provisions and enrollment experience available in high-quality To continue to make strong gains in coverage for Spanish. Additionally, education to clarify that Hispanic children and their families, states with large families can apply for health coverage programs populations of uninsured Hispanic children should without fear of immigration-related consequences accept federal funds and extend Medicaid to low- is needed. Together, these targeted efforts can help income parents and other adults. Research and ensure that a greater share of eligible children are experience has shown that coverage for parents enrolled in health coverage programs. has a “welcome mat” effect as parents enroll their Support States and Localities That Want to children when they sign themselves up for coverage. Expand Coverage to Children and Families States with large uninsured Hispanic child populations Regardless of Immigration Status that have not yet expanded Medicaid include Texas, The federal government should continue to allow Florida and Georgia. states flexibility to use state funds to fill in gaps for Extend Public Coverage to Lawfully children that exist because of immigration status. Residing Children Currently, some Hispanic children, including siblings Existing programs such as Medicaid and CHIP must of citizen children, are ineligible for Medicaid and be extended to lawfully residing children, including CHIP based on their immigration status.49 Many Hispanic children. The vast majority of Hispanic of these children are lawfully present, some have children are citizens, but some Hispanic children been granted deferred action under the Deferred who are lawfully residing immigrants are currently Action for Childhood Arrivals (DACA) program, ineligible for Medicaid and CHIP in their state based and others were brought here by their parents and on immigration status. As of 2015, 28 states and remain unauthorized.50 Over the years, a small D.C. have expanded Medicaid and CHIP to lawfully number of states and localities have successfully residing children who face a five-year waiting period used their own funds to maximize coverage options through a state option that became available in for children, regardless of immigration status or to 2009, while 22 states have not.46 Extending this subgroups of people ineligible for coverage, such as option would provide newly arrived lawfully residing those granted DACA status. children with an affordable health coverage option Encourage States, Particularly Those With that would cost states very little due to increased Emerging Hispanic Populations, to Evaluate federal CHIP matching rates.47 Changing Demographics and Adopt Remove Systemic Barriers to Enrollment Strategies to Maximize Enrollment and Support the Application Process States with high rates of uninsured Hispanic children The federal government and states should and fast-growing Hispanic populations—like those in maintain efforts to provide linguistically, culturally the South—should take steps to connect uninsured appropriate, and community based enrollment Hispanic children to health coverage. Initial steps assistance. Hispanic families face unique barriers to could include assessing where in the state Hispanic coverage programs. While most Hispanic children populations are most likely to live; ensuring that are U.S. citizens and speak English fluently, the applications for health coverage programs are majority of Hispanic children had at least one parent culturally competent and linguistically accessible; who was foreign-born or who did not speak English and partnering with community leaders and well.48 To overcome these unique barriers, state organizations to reach these populations. Medicaid and CHIP programs and the state and 14 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Methodology Data Source This brief analyzes single year estimates of summary data from We report “Hispanic or Latino,” as “Hispanic.” As this refers to a the 2013 and 2014 ACS. The U.S. Census Bureau publishes ACS person’s ethnicity, Hispanic and non-Hispanic individuals may be summary data on American Fact Finder. Where only number of any race. We report data for both “white” children and “white estimates are available, percent estimates and their standard non-Hispanic children.” The former refers to all children whose errors were computed based on formulas provided in the 2014 race is reported as white, without regard to their ethnicity; the ACS’s “Instructions for Applying Statistical Testing to ACS 1-Year latter category refers to children who reported their race as white Data.” and do not report their ethnicity as Hispanic. For more detail on how the ACS defines racial and ethnic groups, see “American Margin of Error Community Survey and Puerto Rico Community Survey 2014 The published Census Bureau data provide a 90-percent Subject Definitions.” margin of error (potential minimum and maximums for any given estimate, based on the sample size and sampling method of the Medicaid Expansion Analysis American Community Survey). Except where noted, reported For the purpose of this analysis, the 27 states (including D.C.) differences of rate or number estimates (either between groups, that expanded Medicaid are Arizona, Arkansas, California, coverage sources, or years) are statistically significant within a 90 Colorado, Connecticut, Delaware, District of Columbia, Hawaii, percent of margin of error. This year’s report provides estimates Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, over a 1-year time period, as opposed to last year’s report, which Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, provided estimates over a 2-year time period. CCF does not take New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, the 90-percent margin of error into account when ranking states Washington, and West Virginia. A few of these state covered by the number and percent of uninsured children by state, and adults before they began receiving the enhanced match in 2014. so minor differences in state rankings may not be statistically Wisconsin is not included as an expansion states as they don’t significant. accept the enhanced match. Geographic Location The rate of uninsurance in Medicaid expansion states is We report regional data for the U.S. as defined by the Census calculated by dividing the number of uninsured children living Bureau. The ACS produces single year estimates for all in Medicaid expansion states by the number of children living geographic areas with a population of 65,000 or more, which in Medicaid expansion states. The same method is used to includes all regions, states (including D.C.), and county and determine the rate of uninsurance in 24 non-expansion states. county equivalents. Health Coverage Data on sources of health insurance coverage are point-in-time estimates that convey whether a person has coverage at the time of the survey. Demographic Characteristics “Children” are defined as those under the age of 18. In the brief we report data for all seven race categories and two ethnicity categories for which the ACS provides one-year health insurance coverage estimates. The U.S. Census Bureau recognizes and reports race and Hispanic origin (i.e., ethnicity) as separate and distinct concepts. To report on an individual’s race, we merge the data for “Asian alone” and “Native Hawaiian or other Pacific Islander alone.” In addition, we report the ACS category “some other race alone” and “two or more races” as “Other.” Except for “Other,” all other racial categories refer to respondents who indicated belonging to only one race. January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 15 Appendix Table 1. Number of Uninsured Hispanic Children Under 18, 2013 and 2014 2013 Number 2013 State Ranking in 2014 Number 2014 State Ranking in State Uninsured Number of Uninsured Uninsured Number of Uninsured United States 2,035,787 - 1,738,230 - Alabama 7,068 19 7,694 19 Alaska 1,226 8 3,532 13 Arizona 105,377 48 89,143 48 Arkansas 7,428 20 8,799 21 California 454,740 50 322,698 50 Colorado 50,694 45 37,487 45 Connecticut 10,190 25 10,198 25 Delaware 1,385 11 3,596 14 District of Columbia 62 1 818 4 Florida 167,917 49 143,831 49 Georgia 64,489 47 52,113 47 Hawaii 1,310 10 1,349 8 Idaho 9,963 24 9,541 23 Illinois 37,373 41 32,982 40 Indiana 18,940 34 15,321 33 Iowa 4,749 16 3,212 12 Kansas 12,380 27 13,791 31 Kentucky 5,977 18 4,228 16 Louisiana 8,159 21 7,190 18 Maine 412 3 201 2 Maryland 13,639 29 15,152 32 Massachusetts 2,873 13 4,059 15 Michigan 9,875 23 8,319 20 Minnesota 14,407 30 12,712 29 Mississippi 4,658 15 4,782 17 Missouri 9,272 22 12,217 28 Montana 1,569 12 1,701 9 Nebraska 4,968 17 9,107 22 Nevada 53,142 46 35,736 42 New Hampshire 549 5 1,975 10 New Jersey 48,430 44 35,115 41 New Mexico 24,862 38 21,416 36 New York 47,083 43 38,268 46 North Carolina 41,802 42 36,402 44 North Dakota 709 6 1,107 7 Ohio 10,865 26 10,192 24 Oklahoma 20,459 35 17,175 34 Oregon 16,845 33 11,768 27 Pennsylvania 20,543 36 21,720 37 Rhode Island 3,860 14 2,292 11 South Carolina 13,081 28 10,316 26 South Dakota 1,222 7 825 5 Tennessee 16,584 32 19,079 35 Texas 585,498 51 532,615 51 Utah 33,551 40 36,005 43 Vermont 240 2 67 1 Virginia 23,167 37 31,311 39 Washington 24,982 39 23,943 38 West Virginia 531 4 443 3 Wisconsin 15,436 31 13,591 30 Wyoming 1,246 9 1,096 6 Note: CCF does not take margin of error into account when ranking states by the number of uninsured Hispanic children. The reported number of uninsured Hispanic children are estimates and should be interpreted as approximations of the population size rather than precise population counts. 16 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Appendix Table 2. Percent of Uninsured Hispanic Children Under 18, 2014 2014 Percent Rate Compared to State Uninsured National Average United States 9.7 Alabama 10.6 - Alaska 21.2 Greater than the national average Arizona 12.7 Greater than the national average Arkansas 11 - California 6.8 Less than the national average Colorado 9.6 - Connecticut 5.9 Less than the national average Delaware 12.1 - District of Columbia 4.9 Less than the national average Florida 12.1 Greater than the national average Georgia 15.3 Greater than the national average Hawaii 2.6 Less than the national average Idaho 12.2 - Illinois 4.5 Less than the national average Indiana 9.3 - Iowa 4.7 Less than the national average Kansas 10.6 - Kentucky 7.5 - Louisiana 10.8 - Maine 3.5 Less than the national average Maryland 8.4 - Massachusetts 1.7 Less than the national average Michigan 4.7 Less than the national average Minnesota 11.6 - Mississippi 17.4 Greater than the national average Missouri 14 Greater than the national average Montana 12.9 - Nebraska 11.9 Greater than the national average Nevada 13.3 Greater than the national average New Hampshire 13.7 - New Jersey 7 Less than the national average New Mexico 7.2 Less than the national average New York 3.8 Less than the national average North Carolina 10.5 - North Dakota 14.4 - Ohio 7 Less than the national average Oklahoma 11.4 Greater than the national average Oregon 6.3 Less than the national average Pennsylvania 7.4 Less than the national average Rhode Island 4.7 Less than the national average South Carolina 11.4 - South Dakota 7.1 - Tennessee 14.9 Greater than the national average Texas 15.3 Greater than the national average Utah 23.4 Greater than the national average Vermont 2.2 Less than the national average Virginia 13.3 Greater than the national average Washington 7.3 Less than the national average West Virginia 5 Less than the national average Wisconsin 9.3 - Wyoming 5.6 Less than the national average Note: “Greater than the national average” and “Less than the national average” indicate that the states’ rate of uninsured Hispanic children was statistically greater than or less than the national average of 9.7 percent. A “-” indicates that the states’ rate of uninsured Hispanic children was not statistically different than the national average of 9.7 percent. January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 17 Appendix Table 3. Change in the Number of Uninsured Hispanic Children Under 18, 2013 and 2014 2013 Number 2014 Number 2013-2014 Change Ranking 2013-2014 Change State Uninsured Uninsured in Number of Uninsured in Number of Uninsured United States 2,035,787 1,738,230 -297,557* - California 454,740 322,698 -132,042* 1 Texas 585,498 532,615 -52,883* 2 Florida 167,917 143,831 -24,086* 3 Nevada 53,142 35,736 -17,406* 4 Arizona 105,377 89,143 -16,234* 5 New Jersey 48,430 35,115 -13,315* 6 Colorado 50,694 37,487 -13,207* 7 Georgia 64,489 52,113 -12,376* 8 New York 47,083 38,268 -8,815* 9 North Carolina 41,802 36,402 -5,400 10 Oregon 16,845 11,768 -5,077* 11 Illinois 37,373 32,982 -4,391 12 Indiana 18,940 15,321 -3,619 13 New Mexico 24,862 21,416 -3,446 14 Oklahoma 20,459 17,175 -3,284* 15 South Carolina 13,081 10,316 -2,765 16 Wisconsin 15,436 13,591 -1,845 17 Kentucky 5,977 4,228 -1,749 18 Minnesota 14,407 12,712 -1,695 19 Rhode Island 3,860 2,292 -1,568 20 Michigan 9,875 8,319 -1,556 21 Iowa 4,749 3,212 -1,537 22 Washington 24,982 23,943 -1,039 23 Louisiana 8,159 7,190 -969 24 Ohio 10,865 10,192 -673 25 Idaho 9,963 9,541 -422 26 South Dakota 1,222 825 -397 27 Maine 412 201 -211 28 Vermont 240 67 -173 29 Wyoming 1,246 1,096 -150 30 West Virginia 531 443 -88 31 Connecticut 10,190 10,198 8 32 Hawaii 1,310 1,349 39 33 Mississippi 4,658 4,782 124 34 Montana 1,569 1,701 132 35 North Dakota 709 1,107 398 36 Alabama 7,068 7,694 626 37 District of Columbia 62 818 756* 38 Pennsylvania 20,543 21,720 1,177 39 Massachusetts 2,873 4,059 1,186 40 Arkansas 7,428 8,799 1,371 41 Kansas 12,380 13,791 1,411 42 New Hampshire 549 1,975 1,426* 43 Maryland 13,639 15,152 1,513 44 Delaware 1,385 3,596 2,211* 45 Alaska 1,226 3,532 2,306* 46 Utah 33,551 36,005 2,454 47 Tennessee 16,584 19,079 2,495 48 Missouri 9,272 12,217 2,945 49 Nebraska 4,968 9,107 4,139* 50 Virginia 23,167 31,311 8,144* 51 * indicates that the number change is significant at the 90% confidence level. Note: CCF does not take margin of error into account when ranking states by the number of uninsured Hispanic children. The reported number of uninsured Hispanic children are estimates and should be interpreted as approximations of the population size rather than precise population counts. 18 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Appendix Table 4. Number and Percent of Hispanic Children Under 18, 2013 and 2014 2013 Percent of 2014 Percent of 2013 Number of Hispanic Children 2014 Number of Hispanic Children State Hispanic Children (compared to total Hispanic Children (compared to total number of children) number of children) United States 17,693,070 24.1% 17,883,393 24.4% Alabama 70,509 6.4% 72,685 6.6% Alaska 16,453 8.8% 16,638 8.9% Arizona 698,981 43.3% 703,128 43.4% Arkansas 82,773 11.7% 79,667 11.3% California 4,753,124 51.9% 4,741,940 51.9% Colorado 386,423 31.2% 388,683 31.2% Connecticut 170,131 21.7% 171,933 22.2% Delaware 29,090 14.3% 29,776 14.6% District of Columbia 15,717 14.1% 16,805 14.6% Florida 1,166,603 29.0% 1,190,665 29.4% Georgia 335,782 13.5% 340,037 13.7% Hawaii 50,698 16.5% 52,444 17.0% Idaho 76,359 17.9% 77,967 18.1% Illinois 727,139 24.1% 725,926 24.4% Indiana 162,743 10.3% 164,108 10.4% Iowa 65,803 9.1% 68,318 9.4% Kansas 127,573 17.7% 129,684 18.0% Kentucky 56,179 5.6% 56,684 5.6% Louisiana 62,235 5.6% 66,417 6.0% Maine 6,658 2.6% 5,761 2.2% Maryland 170,561 12.7% 180,325 13.4% Massachusetts 227,392 16.4% 232,277 16.7% Michigan 176,244 7.9% 176,497 8.0% Minnesota 107,254 8.4% 109,761 8.6% Mississippi 27,172 3.7% 27,444 3.8% Missouri 86,196 6.2% 87,383 6.3% Montana 11,975 5.4% 13,142 5.9% Nebraska 73,399 15.9% 76,218 16.3% Nevada 265,850 40.2% 268,368 40.6% New Hampshire 14,259 5.3% 14,383 5.4% New Jersey 493,370 24.5% 503,586 25.1% New Mexico 299,266 59.0% 296,628 59.5% New York 999,710 23.6% 1,007,678 23.9% North Carolina 335,265 14.7% 347,036 15.2% North Dakota 5,751 3.6% 7,682 4.6% Ohio 141,923 5.4% 146,016 5.5% Oklahoma 146,331 15.5% 150,057 15.8% Oregon 184,511 21.5% 186,270 21.7% Pennsylvania 282,961 10.4% 292,170 10.8% Rhode Island 47,316 22.3% 49,144 23.2% South Carolina 88,969 8.3% 90,403 8.4% South Dakota 10,334 5.0% 11,571 5.5% Tennessee 119,254 8.0% 127,924 8.6% Texas 3,446,316 49.0% 3,487,097 49.1% Utah 151,050 16.9% 153,664 17.0% Vermont 2,907 2.3% 3,079 2.5% Virginia 225,658 12.1% 234,956 12.6% Washington 321,703 20.2% 328,847 20.5% West Virginia 8,760 2.3% 8,774 2.3% Wisconsin 142,736 10.9% 146,308 11.3% Wyoming 17,704 12.7% 19,439 14.2% January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 19 Appendix Table 5: State Policies Affecting Hispanic Children’s Coverage in 2014 Medicaid/CHIP Coverage of Medicaid/CHIP Upper Lawfully Residing Children in the Medicaid Expansion State Eligibility Limit a Five Year Waiting Period Status c (ICHIA Option) b United States Median eligibility level: Total: Total: 255% 27 states and D.C. 26 states and D.C. have expanded Medicaid for the purpose of this paper Alabama 317% - - Alaska 208% - -4 Arizona 205% (closed)1 - Expanded Arkansas 216% - Expanded California 266% Yes* Expanded Colorado 265% - 2 Expanded Connecticut 323% Yes Expanded Delaware 217% Yes Expanded District of Columbia 324% Yes* Expanded Florida 215% - - Georgia 252% - - Hawaii 313% Yes Expanded Idaho 190% - - Illinois 318% Yes* Expanded Indiana 255% - -4 Iowa 380% Yes Expanded Kansas 250% - - Kentucky 218% Yes Expanded Louisiana 255% - - Maine 213% Yes - Maryland 322% Yes Expanded Massachusetts 305% Yes* Expanded Michigan 217% - Expanded3 Minnesota 288% Yes Expanded Mississippi 214% - - Missouri 305% - - Montana 266% Yes -4 Nebraska 218% Yes - Nevada 205% - Expanded New Hampshire 323% - Expanded3 New Jersey 355% Yes Expanded New Mexico 305% Yes Expanded New York 405% Yes* Expanded North Carolina 216% Yes - North Dakota 175% - Expanded Ohio 211% Yes Expanded 20 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Appendix Table 5: State Policies Affecting Hispanic Children’s Coverage in 2014 (cont’d) Medicaid/CHIP Coverage of Medicaid/CHIP Upper Lawfully Residing Children in the Medicaid Expansion State Eligibility Limit a Five Year Waiting Period Status c (ICHIA Option) b Oklahoma 210% - - Oregon 305% Yes Expanded Pennsylvania 319% Yes -4 Rhode Island 266% Yes Expanded South Carolina 213% - - South Dakota 209% - - Tennessee 255% - - Texas 206% Yes - Utah 205% - - Vermont 318% Yes Expanded Virginia 205% Yes - Washington 305% Yes* Expanded West Virginia 305% Yes Expanded Wisconsin 306% Yes -5 Wyoming 205% - - Notes: States in bold indicates states and state policies that have uninsurance rates for Hispanic children that are significantly lower than the national average. * States have expanded coverage to all children, regardless of immigration status. California covers all children in some counties, and has passed a law to cover all children statewide to be implemented in 2016. 1 Arizona is the only state in the country to have closed its CHIP program. The state froze enrollment in its CHIP program in 2010 effectively limiting eligibility for children in Medicaid to 152 percent of the FPL, the lowest income eligibility level in the country. 2 Colorado expanded coverage to lawfully residing children in the five-year waiting period in July 2015. 3 Medicaid expansion coverage became effective on April 1, 2014 in Michigan and on August 16, 2014 in New Hampshire. 4 Four states (AK, IN, MT, and PA) have since expanded Medicaid coverage in 2015/2016. 5 Wisconsin covers adults up to 100 percent of FPL, but has not expanded Medicaid coverage through the ACA. Sources: a M. Heberlein, et al, “Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies Into Drive,” The Kaiser Commission on Medicaid and the Uninsured (November 2013), available at http://kff.org/medicaid/report/getting-into-gear-for-2014-shifting-new-medicaid- eligibility-and-enrollment-policies-into-drive/. b Center for Medicaid and CHIP Services (CMCS), “Medicaid and CHIP Coverage of Lawfully Residing Children and Pregnant Women,” Centers for Medicare & Medicaid Services (March 24, 2014), available at https://www.medicaid.gov/medicaid-chip-program-information/by- topics/outreach-and-enrollment/lawfully-residing.html. c Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, “Medicaid/CHIP Upper Income Eligibility Limits for Children, 2000-2015,” Kaiser Family Foundation State Health Facts, available at http://kff.org/medicaid/state- indicator/medicaidchip-upper-income-eligibility-limits-for-children-2000-2015/. January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 21 Appendix Table 6. Expansion States Saw Triple the Rate of Decline in Uninsured Hispanic Children Compared to Non-Expansion States Medicaid Expansion Non-Expansion Population States States 2013 Number of Hispanic Children 10,502,835 7,190,235 2014 Number of Hispanic Children 10,554,619 7,328,774 2013 Number of Uninsured Hispanic Children 952,177 1,083,610 2014 Number of Uninsured Hispanic Children 737,074 1,001,156 2013-2014 Change in Number of Uninsured Children -215,103 -82,454 Percent Change -22.6% -7.6% 22 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 Endnotes 1 Mathematica Policy Research, “CHIPRA Mandated at http://kff.org/health-reform/report/modern-era- Evaluation of the Children’s Health Insurance Program: medicaid-findings-from-a-50-state-survey-of-eligibility- Final Findings,” (August 2014), available at http:// enrollment-renewal-and-cost-sharing-policies-in- www.urban.org/sites/default/files/alfresco/publication- medicaid-and-chip-as-of-january-2015/ (accessed pdfs/413276-CHIPRA-Mandated-Evaluation-of-the- December 2, 2015). Children-s-Health-Insurance-Program-Final-Findings. 11 Eighty-seven percent of Hispanic children speak PDF (accessed December 2, 2015). English well but 53 percent of Latino children who live 2 The rate of low-income Hispanic children (under 200 with both parents have at least one parent who does percent of FPL) with Medicaid or CHIP coverage rose not speak English well; Op. cit. (9). from 42 percent in 1997 to 65 percent in 2012. Ibid. 12 Center for Children and Families, “CHIP and Health 3 Uninsured rates declined 6 percentage points from Coverage for Lawfully Residing Children,” (2015), 40 percent in 2012 to 34 percent in 2014 among available at http://ccf.georgetown.edu/wp-content/ Latinos age 19-64. The Commonwealth Fund, “Latinos uploads/2015/06/CCF-ICHIA-KIDS-1-pagerFINAL-1.pdf Have Made Coverage Gains but Millions Are Still (accessed Oct. 26, 2015). Note: this is as of 2015. The Uninsured,” (April 27, 2015), available at http://www. table provided in this report refers to health coverage for commonwealthfund.org/publications/blog/2015/apr/ lawfully residing children as of 2014 the year of the ACS latinos-have-made-coverage-gains (accessed October data this report analyzes. Colorado is the only state that 22, 2015). extended coverage to lawfully residing children in 2015. 4 Ibid. 13 A small number of states provide state-only funded 5 Unless otherwise indicated, all data is from a coverage to undocumented children who are ineligible Georgetown CCF and NCLR analysis of U.S. Census for federally funded full-scope Medicaid and CHIP. Bureau American Community Survey (ACS) data, 2014 Public Citizens for Children and Youth, “Fulfilling single year estimates. Data from outside sources is cited Pennsylvania’s Promise to Cover All Kids,” (June as authors report their findings (e.g., rounded to whole 2015), available at http://www.pccy.org/wp-content/ numbers). uploads/2015/06/PCCY-DreamCareReport-June2015. pdf (accessed December 18, 2015). 6 The rate of uninsurance for Hispanic children dropped from 34 percent in 1997 to 17 percent in 2012; Op. cit. (1). 14 Op. Cit. (9). 7 The rate of low-income Hispanic children (under 200 15 U.S. Census Bureau, “America’s Children in Brief: Key percent of FPL) with Medicaid or CHIP coverage rose National Indicators of Well-Being,” 2014, “Table POP3,”  from 42 percent in 1997 to 65 percent in 2012; Op. cit. (1). http://www.childstats.gov/americaschildren/tables/ pop3.asp (accessed May 2015). 8 Tabulations of the 2013 American Community Survey provided by Genevieve Kenny, Patricia Solleveld, and 16 J. S. Passel & D. Cohn, “U.S. Population Projections: Jason Gates, November 30, 2014. Urban Institute 2005-2050,” Pew Research Center (February 2008, tabulations from the Health Policy Center’s American available at http://www.pewhispanic.org/2008/02/11/ Community Survey Medicaid and CHIP Simulation us-population-projections-2005-2050/ (accessed Model based on 2013 data from the Integrated Public December 7, 2015). Use Microdata Series. Note that estimates for 2014 were 17 A Chester & J. Alker, “Medicaid at 50: A Look at not available at the time of publication of this report. the Long-Term Benefits of Childhood Medicaid,” 9 Low-income here means below 200 percent of the Georgetown University Center for Children and Families federal poverty level. D. Murphey, et al, “America’s (July 2015), available at http://ccf.georgetown.edu/ Hispanic Children: Gaining Ground, Looking Forward,” wp-content/uploads/2015/08/Medicaid-at-50_final.pdf Child Trends Hispanic Institute (September 2014), (accessed Oct. 26, 2015). available at www.childtrends.org/wp-content/ 18 The ACS first began recording health insurance uploads/2014/09/2014-38AmericaHispanicchildren. coverage data in 2008. Due to logical edits made to pdf (accessed May 2015). the 2008 single year estimates, data is not available 10 T. Brooks, et al, “Modern Era Medicaid: Findings on age, ethnicity, and health insurance status until from a 50-State Survey of Eligibility, Enrollment, 2009; V. Lynch, et al, “Applying and Evaluating Logical Renewal, and Cost-Sharing Policies in Medicaid and Coverage Edits to Health Insurance Coverage in the CHIP as of January 2015,” The Kaiser Commission on American Community Survey,” United States Census Medicaid and the Uninsured (January 2015), available Bureau (working paper, Washington, D.C.), available at http://www.census.gov/hhes/www/hlthins/publications/ coverage_edits_final.pdf. January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 23 19 For the purpose of this analysis, the 27 states 28 For more information, see “ Weekend enrollment fairs that expanded Medicaid are Arizona, Arkansas, slated for federal insurance mandate under ACA,” J. California, Colorado, Connecticut, Delaware, District of Robinson, available at http://www.reviewjournal.com/ Columbia, Hawaii, Illinois, Iowa, Kentucky, Maryland, business/weekend-enrollment-fairs-slated-federal- Massachusetts, Michigan, Minnesota, Nevada, New insurance-mandate-under-aca (accessed November 9, Hampshire, New Jersey, New Mexico, New York, 2015). North Dakota, Ohio, Oregon, Rhode Island, Vermont, 29 CCF calculations based on ACS 2013 and 2014 Washington, and West Virginia. A few of these state data. For more information, see J. Robinson, “Hispanic covered adults before they began receiving the enrollment in state health insurance exchange proves enhanced match in 2014. Wisconsin is not included as disappointing,” Las Vegas Review-Journal (April 2014), an expansion states as they do not accept the enhanced available at http://www.reviewjournal.com/business/ match. Medicaid enrollment in Michigan (4/1/14) and hispanic-enrollment-state-health-insurance-exchange- New Hampshire (8/15/14) began after January 1, 2014. proves-disappointing (accessed November 9, 2015). The 27 states that have expanded Medicaid have a 30 Op. cit. (21). population of 10.6 million Hispanic children and the 24 states that have not expanded Medicaid with a 31 Note that children above 200 percent of FPL do pay population of 7.3 million children. States that expanded premiums (on a sliding scale based on income) for Medicaid also have a smaller population of uninsured coverage. New York also launched the Basic Health children than non-expansion states (0.7 million compared Program in 2015, which provides affordable health to 1 million). coverage to citizen adults with incomes above the Medicaid income level to 200 percent of FPL, and 20 Op. cit. (8). lawfully present adults, who are ineligible for Medicaid 21 Georgetown Center for Children and Families, from zero to 200 percent of FPL. S. Schwartz, “Two “Medicaid Expansion: Good for Parents and Children,” States on the Path to the Basic Health Program,” Center (January 2014), available at http://ccf.georgetown.edu/ For Children and Families, (April 2014), available at wp-content/uploads/2013/12/Expanding-Coverage-for- http://ccf.georgetown.edu/all/two-states-on-the-path- Parents-HelpsChildren-2013.pdf. to-the-basic-health-program-2/ (accessed December 2, 22 J. DeVoe, et al., “Effect of Expanding Medicaid for 2015). Parents on Children’s Health Insurance Coverage: 32 M. Heberlein, et al, “Getting into Gear for 2014: Lessons From the Oregon Experiment,” JAMA Shifting New Medicaid Eligibility and Enrollment Policies Pediatrics 169 (January 2015). Into Drive,” The Kaiser Commission on Medicaid and the 23 Op. cit. (8). Uninsured (November 2013), available at http://kff.org/ 24 There is no statistically significant difference in medicaid/report/getting-into-gear-for-2014-shifting-new- Colorado’s rate of uninsurance (9.6 percent) than medicaid-eligibility-and-enrollment-policies-into-drive/. the national rate. There is no statistically significant 33 L. Gonzalez-Camastra, “Children’s Defense Fund NY, difference in North Carolina’s rate of uninsurance (10.5 Creating a Child and Family Friendly Health Insurance percent) than the national rate. Exchange in New York-An Issue Briefing,” (presentation, 25 Nevada also had the largest percentage point decline January 2013). of all uninsured children (5.3 percentage points from 34 E. Lewit, “Major Transition with Minor Disruption: 2013 to 2014) which was far greater than any other Moving Undocumented Children from Healthy Kids state. to Full-Scope Medi-Cal” The California HealthCare 26 Nevada Office of the Governor, Governor Sandoval Foundation (November 2015), available at http:// Statement of Medicaid Expansion, Statement www.chcf.org/publications/2015/11/major-transition- (December 11, 2012), available at http://gov.nv.gov/ undocumented-children (accessed January 1, 2016). News-and-Media/Press/2012/Governor-Sandoval- 35 For information about California’s Bridge To Reform Statement-on-Medicaid-Expansion/ (accessed 1115 waivers and California’s Medi-Cal eligibility , November 9, 2015). see California Department of Health Care Services, 27 The median Medicaid/CHIP Income eligibility “California Bridge To Reform: A Section 1115 Waiver thresholds for children are 305 percent of FPL for states Fact Sheet,” (November 2010), available at http://www. adopting the Medicaid expansion, and 215 percent of dhcs.ca.gov/Documents/1115%20Waiver%20Fact%20 FPL for states not adopting the expansion as of January Sheet%2011.2.10.pdf. 2015; Op. cit. (10) 36 On January 31, 2014, an estimated 14,000 Arizona children lost their health coverage under KidsCare II, a temporary extension of the state’s CHIP; T. Brooks, et al, “Dismantling CHIP in Arizona: How Losing KidsCare Impacts a Child’s Health Care Costs,” Georgetown 24 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016 University Center for Children and Families (May 2014), 47 Center for Children and Families, “Medicare Access available at http://ccf.georgetown.edu/wp-content/ and CHIP Reauthorization Act of 2015: Summary of Key uploads/2014/05/Dismantling-CHIP-in-Arizona.pdf Provisions Impacting Children,” (May 2015), available (accessed December 2, 2015). Note Arizona also does at http://ccf.georgetown.edu/ccf-resources/medicare- not cover lawfully residing children in the five-year access-chip-reauthorization-act-2015-summary-key- waiting period. provisions-impacting-children/ (accessed December 2, 37 From 2000 to 2013, the percent change of the 2015). Hispanic population was 70.8 percent in the South as 48 Op. cit. (9). compared to 58.7, 43.6 and 42.2 percent in the Midwest, 49 J. Hudson & S. Abdus, “Coverage and Care Northeast and West respectively. Pew Research Center Consequences For Families in Which Children Have Hispanic Trends, “Statistical Portrait of Hispanics in the Mixed Eligibility For Public Insurance,” Health Affairs, United States, 1980-2013,” (March 18, 2015) available 34, no.8 (August 2015), available at http://content. at http://www.pewhispanic.org/2015/05/12/statistical- healthaffairs.org/content/34/8/1340.full.html. portrait-of-hispanics-in-the-united-states-1980-2013- 50 DACA grantees are ineligible for Medicaid, CHIP trends/ph_2015-03_statistical-portrait-of-hispanics-in- and the marketplace coverage and premium subsidies the-united-states-2013-trend-54/ (viewed November 12, under federal guidance. For more information, see 2015). Dinah Wiley, “For DACA youth, Health Insurance is 38 Unlike the ACS, which are “point in time” estimates of (Only) a Dream,” available at http://ccf.georgetown.edu/ health coverage, the Current Population Survey Annual all/for-daca-youth-health-insurance-is-only-a-dream/ Social and Economic Supplement (CPS ASEC) asks (accessed Oct. 26, 2015). respondents if they were covered at any point during the year. The CPS ASEC finds that 9.3 percent of Hispanic children are uninsured in 2014 and the ACS finds that 9.7 percent of Hispanic children are uninsured in 2014. Current Population Survey, “Table HI04_9: Health Insurance Coverage Status and Type of Coverage by Selected Characteristics for Near Poor People in the Poverty Universe: 2014 (Income-to-Poverty Ratio is between 100 and 125 percent),” U.S. Census Bureau, 2015 Annual Social and Economic Supplement (September 2015), available at http://www.census.gov/ hhes/www/cpstables/032015/health/hi04_9.xls. 39 Center for Children and Families, “Medicaid and CHIP provide needed access to children and families,” (April 2014), available at http://ccf.georgetown.edu/ wp-content/uploads/2013/11/access-factsheet.pdf (accessed November 10, 2015). 40 Op. cit. (17). 41 Current Population Survey, “Table HI03_9: Health Insurance Coverage Status and Type of Coverage by Selected Characteristics for Poor People in the Poverty Universe: 2014 (Income-to-Poverty Ratio is below 100 percent),” U.S. Census Bureau, 2015 Annual Social and Economic Supplement (September 2015), available at http://www.census.gov/hhes/www/cpstables/032015/ health/hi03_9.xls. 42 Op. cit. (9). 43 Op. cit. (8). 44 Op. cit. (21). 45 Op. cit. (10). 46 Op. cit. (12). January 2016 CCF.GEORGETOWN.EDU HISPANIC CHILDREN’S HEALTH COVERAGE 25 Authors: Sonya Schwartz, Alisa Chester, Center for Children and Families Steven Lopez, and Samantha Vargas Poppe Health Policy Institute, Georgetown University Box 571444, 3300 Whitehaven Street, NW, Suite 5000 Many members of the Georgetown CCF Washington, D.C. 20057-1485 Phone (202) 687-0880 team supported the work of this analysis. Email childhealth@georgetown.edu Cathy Hope guided the communications strategy. Joan Alker, Sean Miskell, and Sarah ccf.georgetown.edu/blog/ Koslov reviewed the paper. John Allison and Jordan Messner provided essential research facebook.com/georgetownccf assistance. Design and layout provided by Nancy Magill. twitter.com/georgetownccf Special thanks to Randy Capps at the Migration Policy Institute for his review of this National Council of La Raza analysis. 1126 16th Street, NW, Suite 600 Washington, D.C. 20036-4845 The Center for Children and Families (CCF) Phone (202) 785-1670 is an independent, nonpartisan policy and research center whose mission is to expand and improve health coverage for America’s blog.nclr.org/ children and families. CCF is based at facebook.com/Nationalcounciloflaraza Georgetown University’s McCourt School of Public Policy. For more information, contact twitter.com/NCLRHealth (202) 687-0880 or childhealth@georgetown. edu. The National Council of La Raza (NCLR)— the largest national Hispanic civil rights and advocacy organization in the United States— works to improve opportunities for Hispanic Americans. For more information, please visit www.nclr.org. 26 HISPANIC CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU January 2016