Children’s Health Insurance Rates in 2014: ACA Results in Significant Improvements by Joan Alker and Alisa Chester Key Findings Children’s Uninsured Rate Is zz The rate of uninsurance among at Historic Low Thanks to the children dropped to a historic low of Affordable Care Act 6 percent following implementation of On January 1, 2014 many of the key provisions the Affordable Care Act in 2014. The of the Affordable Care Act (ACA) took effect. The improvement was widespread with 25 ACA created new pathways to coverage primarily states recording statistically significant for adults either through premium subsidies for declines in the number of uninsured those purchasing coverage in new federal or state children and no state reporting a significant marketplaces or by extending Medicaid eligibility, increase. Just under 4.4 million children which is now a state option. Most of the eligibility remain uninsured in 2014, and about half expansions were aimed at adults because their of these children live in six states—Texas, insured rates have lagged behind children’s for California, Florida, Georgia, Arizona, and many years; however, the ACA included some Pennsylvania. important policy changes for children that were zz Some states saw much greater expected to have both a direct and indirect impact improvements in children’s coverage than on children’s coverage rates.1 Health coverage others. States with the sharpest declines in for children leads to improved access to care, the rate of uninsured children were Nevada, better health outcomes, and stronger educational Colorado, West Virginia, Mississippi, achievement.2 and Rhode Island. Nevada’s decline was considerably larger than any other state. This year’s American Community Survey (ACS) zz States that extended Medicaid coverage data from 2014 provide a first look at how the to more uninsured adults saw nearly implementation of the ACA is affecting coverage double the rate of decline in uninsured rates for children – both nationwide and in all 50 children as compared to states that didn’t states and the District of Columbia. Our analysis accept the ACA’s Medicaid option. This is looks at the profile of uninsured children in 2014 and likely due to a robust “welcome mat” effect examines rates of change in coverage for children as parents enrolled their children when they from 2013 to 2014.3 The children’s uninsured rate signed up for newly available coverage. in the United States declined significantly from Even states that did not expand Medicaid 7.1 percent in 2013 to 6.0 percent in 2014. This appear to have experienced a welcome was welcome news, as 2013 data had shown no mat effect due to the ACA. significant decline in the children’s coverage rate for the first time in many years.4 October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 1 Figure 1: Rate of Uninsured Children from 2008-2014 10.0% 9.3% 9.0% 8.6%* 8.0% 8.0%* 7.5%* 7.2%* 7.0% 7.1% 6.0% 6.0%* 5.0% 2008 2009 20102011 20122013 2014 * Change is significant at the 90% confidence level. 2013 was the only year that did not show a significant one- year decline in the national rate of uninsured children. All income and racial groups and areas of coverage. In 2014, nearly half a million children the country reflected this national decline in (498,000) enrolled in marketplace coverage.5 uninsured children, with 25 states showing a Still, eligibility expansions are only part of the significant decrease in the number of uninsured story as most uninsured children (67.9 percent children and no state showing a significant in 2012) were already eligible for affordable increase. Most of the remaining states health care coverage prior to the ACA through showed declines in the number of uninsured Medicaid or CHIP but were not enrolled.6 children, but they were not large enough to be Reducing barriers to coverage and enhanced statistically significant. outreach and retention efforts are essential to This substantial decline is undoubtedly due in increasing participation rates for children and large part to changes in coverage as a result of reducing the uninsured rate. the ACA. Some of the policy changes affecting children could be expected to have a direct impact on their coverage levels—such as the availability of new tax credits to subsidize the purchase of newly available marketplace 2 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Figure 2: The Number of Uninsured Children in the United States Declined by 2.5 Million from 2008 to 2014 Number of 6.9 Uninsured 6.4* Children (in millions) 5.9* 5.5* 5.3* 5.2 4.4* 2008 2009 2010201120122013 2014 * Change is significant at the 90% confidence level. Other key changes brought about by the ACA coverage, many children were likely signed that likely contributed to the decline in uninsured up as their parents enrolled. The welcome children include the following provisions: mat effect appears to be strongest in those states that expanded Medicaid. zz The ACA’s “maintenance of effort” provision requires states to maintain their current zz In 2014, 18 states were required by the eligibility levels for children’s coverage in ACA to move children ages 6-18 with family Medicaid and CHIP through September incomes between 100 to 138 percent of 2019. Medicaid and CHIP are the primary the federal poverty level from their separate sources of health care coverage for children CHIP program to Medicaid.7, 8 As a result, living below 200 percent of the federal low-income families in seven states no poverty level. longer had to pay premiums to enroll their children in 2014.9 Imposing premiums on zz The ACA’s outreach and enrollment efforts low-income families has been shown to were primarily targeted to adults but likely suppress enrollment in coverage.10 resulted in a “welcome mat” effect for children who were previously eligible but not enrolled in Medicaid or CHIP. As parents learned about newly available affordable Figure 3: Uninsured Rates for Children and Other Age Groups 2012 2013 2014 Children (under 18) 7.2% 7.1% 6.0%* Young Adults (19-25) 26.5% 25.5%* 20.4%* Adults (18-64) 20.6% 20.3%* 16.3%* Seniors (65+) 1.0% 1.0% 0.9%* *Change is significant at the 90% confidence level. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 3 Which Children Are More Coverage Source by Income Likely to be Uninsured? Low-income children are more likely to be covered by their state Medicaid or CHIP The uninsured rate among children varies programs, while children at higher income levels based on demographic factors, including are more likely to rely on employer-sponsored income, race, ethnicity, age, and geographic insurance (see Appendix Table 5). Uninsurance location. School-aged children, those of rates for children at every income level Hispanic descent, and near-poor children significantly decreased as Figure 5 shows. Children in families are disproportionately represented among the uninsured. Children living in the South Despite a significant drop in the rate of child living on the brink and rural areas also face higher rates of poverty in 2014, more than one in five (21.7 of poverty (100 to uninsurance than those living in other parts percent), or 15.7 million children, live in poverty. 199 percent of FPL) of the country. Children below 100 percent of the Federal have the highest rate Poverty Level (FPL, $20,090 for a family of three Sources of Coverage in 2014) are more likely to be uninsured than of uninsurance. Nearly half of all children (46.7 percent) are children above 200 percent of the FPL ($40,180 covered through employer-sponsored health for a family of three). insurance, while more than one-third (34.9 Children in families living on the brink of percent) rely on Medicaid and CHIP coverage poverty (100 to 199 percent of FPL) are (see Figure 4). disproportionately uninsured. Children in In contrast to past trends of declining this income range have the highest rate of employer-sponsored insurance (ESI), the uninsurance by income level (9.0 percent) and number of children covered by ESI increased also saw the greatest decline in uninsurance (1.7 significantly between 2013 and 2014, percentage points). Despite the fact that children and the share of children covered by ESI in this income range constitute 22.4 percent of remained stable. Since 2013, the share of the child population, they represent 34.5 percent children with Medicaid coverage and direct- of the uninsured child population). Many of these purchase coverage has increased. “Direct- children may be eligible for public coverage but purchase” coverage includes new subsidized remain uninsured. Only children with incomes marketplace coverage.11 above 300 percent of the FPL have uninsurance rates lower than the national average (3.0 percent). Figure 4: Sources of Children’s Coverage, 2014 Employer- Direct- Un- sponsored Medicaid/CHIP Other* purchase insured 46.7% 34.9% 7.1% 5.2% 6.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% * Other includes Medicare, TRICARE, VA, and two or more types of coverage. See methodology section for more information. 4 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Figure 5: Percent of Uninsured Children by Poverty Level, 2013-2014 Children living near poverty have the highest uninsured rates. 10.7% 8.9% 9.0%* 8.1% 7.3%* 7.1%* 3.6% 3.0%* < 100% 100-199% 200-299% > 300% Percent of Federal Poverty Level (FPL) 2013 2014 * Change is significant at the 90% confidence level. Race and Ethnicity are disproportionately represented among With the exception of white non-Hispanic uninsured children. AIAN children account for children, all racial and ethnic groups experienced 2.3 percent of uninsured children, which is twice significant gains in health insurance coverage in their share (1 percent) of the child population. 2014. Still, disparities persist (see Figure 6). Hispanic children comprise less than a quarter (24.4 percent) of the total child population, but American Indian/Alaska Native (AIAN) children Hispanic children almost two-fifths (39.5 percent) of uninsured have the highest rate of uninsurance (13.9 children. An analysis of trends among Hispanic comprise less than a percent), followed by Hispanic children who children is forthcoming from Georgetown CCF quarter of the total can be of any race (9.7 percent). Both groups and the National Council of La Raza.12 child population, but almost two-fifths of Figure 6: Children’s Uninsured Rate by Race and Ethnicity, 2014 uninsured children. 13.9% 9.7% 7.5% 5.9% 5.5% 4.8% 4.6% Black White Asian/ Other American White, Hispanic* Native Hawaiian/ Indian/Alaska non- Pacific Islander Native** Hispanic* * For simplicity, racial and ethnic data are displayed in this chart, but Hispanic refers to a person’s ethnicity and these individuals may be of any race. See the methodology section for more information. ** Indian Health Service is not considered comprehensive coverage. See the methodology section for more information. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 5 As in past years, school-aged children (ages 6 to 17) are more likely than younger children (under age 6) to be uninsured. Both age groups saw a significant decline in percent uninsured in 2014 (Figure 7), but school-aged children still account for nearly three out of four uninsured children in the nation. Figure 7: Uninsurance Rates by Age, 2013 to 2014 7.8% Older children 6.5%* have higher 5.7% rates of 4.9%* uninsurance than their younger peers. Under 6 years old 6 to 17 years old 2013 2014 * Change is significant at the 90% confidence level. Where Do Uninsured Children Live? while children living in the South (7.4 percent) and West (6.3 percent) have higher than In 2014, both urban and rural populations average rates. saw significant reductions in the percent of The South accounts uninsured children. Compared to their urban Uninsured children are disproportionately for 38.2 percent of counterparts, children living in rural areas represented in Southern states (see Appendix the child population are disproportionately uninsured. Nationally, Table 7). The South accounts for 38.2 percent 18.1 percent of children live in rural areas yet almost half (47.3 but uninsured children that live in rural areas of the child population yet almost half (47.3 percent) of the nation’s uninsured children percent) of the nation’s comprise more than one fifth (20.8 percent) of live in the region. On the other hand, the uninsured children all uninsured children. Rural populations have Northeast accounts for 16.3 percent of the live in the region. higher rates of uninsurance (6.9 percent) than child population, but only 10.4 percent of the their urban counterparts (5.8 percent). nation’s uninsured children. See Appendix Table 6 for a list of the top twenty counties Geographic Region where uninsured children live. Children living in the Northeast (3.8 percent) and Midwest (4.7 percent) have lower uninsured rates than the national average, 6 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 How Are States Doing? In 2014, nearly half of all states (25 states) saw a significant decline in the number of uninsured children while no state saw a significant increase. Many of the remaining 26 states saw declines in the number of uninsured children but the declines were not large enough to be statistically significant. See Appendix Tables 1 through 4 for state tables on the number and percent of uninsured children and how they changed from 2013 to 2014. As the map in Figure 8 shows, 13 states have uninsured rates higher than the national average and these states tend to cluster in the West, particularly the Mountain West, and to some degree in the South. Figure 8: 13 States Had Higher Uninsured Rates for Children than the National Rate 4.7 8.2 2.2 6.3 6.9 4.4 4.6 3.8 1.5 7.8 5.7 4.4 3.3 5.9 3.3 3.8 3.7 3.2 5.2 4.6 9.6 5.3 4.8 3.2 9.4 3.3 7.2 5.7 5.6 3.0 2.1 5.4 5.5 7.2 5.7 4.3 5.2 5.2 10.0 7.3 8.7 4.8 5.5 5.3 3.8 7.6 11.0 5.2 No statistically significant 9.3 difference from the national average (10 states) 11.4 3.1 Uninsured rate lower than national rate (28 states including DC) Uninsured rate higher than national rate (13 states) October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 7 Figure 9 shows the five states with the lowest and highest rates of uninsured children nationwide. The states with the lowest uninsured rates remained stable from 2013 to 2014 except that West Virginia replaced New Hampshire. For the five states with the highest uninsured rates, Utah replaced Florida, which now ranks 46th. Figure 9: States with the Lowest and Highest Rates of Uninsured Children, 2014 States with Lowest Uninsured Rates States with Highest Uninsured Rates Massachusetts 1.5 Alaska 11.4 District of Columbia 2.1 Texas 11.0 Vermont 2.2 Arizona 10.0 West Virginia 3.0 Nevada 9.6 Hawaii 3.1 Utah 9.4 Because of differences in state size, demographics, and policy choices, a large share of the nation’s uninsured children remain clustered in a small number of states. Almost half of the nation’s uninsured children (48.9 percent) live in six states—Texas, California, Florida, Georgia, Arizona and Pennsylvania, while only 36.9 percent of all children live in these states. Figure 10: Half of the Nation’s Uninsured Children Reside in Six States State 2014 Number of As a Share of Total Uninsured Children Uninsured Children Texas 783,938 17.8% California 497,090 11.3% Florida 377,987 8.6% Georgia 189,035 4.3% Arizona 161,854 3.7% Pennsylvania 139,117 3.2% Six State Total 2,149,021 48.9% National Total 4,396,536 8 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Which States Saw the Greatest Declines in 2014? The five states with the highest percentage point decline in the rate of uninsured children from 2013 to 2014 were Nevada, Colorado, West Virginia, Mississippi, and Rhode Island (see Figure 11). Improvements in West Virginia and Rhode Island are especially impressive because their uninsured rate was already lower than the national average in 2013. Nevada’s decline was by far the largest in the country— moving the state from a rank of 51st in 2013 to 48th in 2014. Figure 11: States with the Greatest Decline in Rate of Uninsured Children, 2013-2014 State 2013 2014 2013-2014 Percent Percent Percentage Point Uninsured Uninsured Change in Uninsured Nevada 14.9 9.6 -5.3* Colorado 8.2 5.6 -2.6* West Virginia 5.3 3.0 -2.3* Mississippi 7.6 5.3 -2.3* Rhode Island 5.4 3.3 -2.1* * Change is significant at the 90% confidence level. The states with the largest decline in the number of uninsured children from 2013 to 2014 were California, Texas, Florida, Georgia, and Nevada (see Figure 12). The decline in uninsured children in these five states—431,326 children—accounted for more than half (51.5 percent) of the entire decline in uninsured children in the nation. Figure 12: States with the Greatest Decline in Number of Uninsured Children, 2013-2014 State 2013 2014 2013-2014 Number Number Change in Number Uninsured Uninsured of Uninsured California 673,208 497,090 -176,118* Texas 888,305 783,938 -104,367* Florida 445,035 377,987 -67,048* Georgia 238,051 189,035 -49,016* Nevada 98,509 63,732 -34,777* * Change is significant at the 90% confidence level. West Virginia had the largest percent decline in number of uninsured children from 2013 to 2014 (43.7 percent) followed by Rhode Island (38.5 percent), Nevada (35.3 percent), Minnesota (31.9 percent), and Colorado (31.4 percent). Vermont’s decline fell into this range but was not statistically significant. Percent change compares the decline in the number of uninsured children from 2013 to 2014 to the number of uninsured children in 2013. This measure is useful in analyzing the extent to which a state reduced its number of uninsured children – regardless of state size (see methodology section for more information). Refer to Appendix Table 3 for all states’ rate of decline in number of uninsured children. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 9 States that Expanded Medicaid Saw Greater Declines in the Number of the Uninsured Children States that extended Medicaid coverage to adults and parents in 2014 saw a larger decline in Expansion states had the number and percent of uninsured children than those states that did not.13 Prior research has nearly double the shown that covering parents increases the rate of coverage for their children as well.14 percent decline in the As Figure 13 shows, states that expanded Medicaid had lower rates of uninsured children prior to number of uninsured expansion, but despite having fewer uninsured children to begin with these states saw a sharper children compared to rate of decline in uninsured children.15 Figure 15 on page 11 shows a state-by-state comparison of children’s uninsured rates in expansion states and non-expansion states. non-expansion states. Figure 13: Children’s Uninsurance Rates by Medicaid Expansion Status, 2013 to 2014 8.5% 7.5%* Despite having lower rates of uninsured 5.9% children prior to expansion, states that 4.6%* expanded Medicaid had a larger decline in the rate of uninsured children compared to non-expansion states. Expansion states Non-expansion states 2013 2014 * Change is significant at the 90% confidence level. As Figure 14 shows, Medicaid expansion states saw a decline of nearly half a million (495,789) uninsured children while non-expansion states saw a decline of 342,007 in uninsured children. This translates to a 21.7 percent decline in expansion states, nearly double the 11.6 percent decline in non-expansion states. Figure 14: Expansion States Saw Nearly Double the Rate of Decline in Uninsured Children Compared to Non-expansion States Population Medicaid Expansion Non-Expansion States States 2013 Number of Uninsured Children 2,287,593 2,946,739 2014 Number of Uninsured Children 1,791,804 2,604,732 2013-2014 Change in Number of -495,789 -342,007 Uninsured Children Percent Change in Number of -21.7% -11.6% Uninsured Children 10 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Figure 15. Children’s Uninsurance Rates in Medicaid Expansion States and Non-Expansion States, 2014 Alaska* Texas Arizona Nevada Utah Florida Oklahoma Montana* Idaho Georgia New Mexico Indiana* Missouri North Dakota Maine United States Wyoming Delaware South Dakota Virginia Colorado Kansas South Carolina California Mississippi Nebraska Louisiana North Carolina Medicaid Pennsylvania* Expansion States Tennessee Arkansas Non-Expansion States Ohio Washington New Jersey Oregon New Hampshire Wisconsin Kentucky Alabama Michigan Minnesota Connecticut Illinois New York Rhode Island Iowa Maryland Hawaii West Virginia Vermont District of Columbia Massachusetts 0.0%2.0%4.0%6.0%8.0%10.0%12.0% * Alaska, Indiana, Montana, and Pennsylvania have or are in the process of expanding Medicaid in 2015. ** While Arizona expanded Medicaid, its CHIP program remains closed. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 11 Conclusion The Affordable Care Act contributed to a historic uninsured. Those children who remain uninsured decline in the number of America’s uninsured are more likely to be school-aged, Hispanic, children. States that took full advantage of the living in a family with income just over the ACA’s coverage options for parents and other poverty line, and live in rural areas. States adults saw sharper declines in the number that expanded Medicaid to cover parents of uninsured children. Nationwide, 6 percent saw the number of uninsured children decline of children—or 4.4 million children—remain considerably faster. Endnotes 1 G. Kenney, et al., “A First Look at Children’s 5 Assistant Secretary for Planning and Evaluation Health Coverage under the ACA in 2014,” Urban (ASPE), Department of Health and Human Services Institute Health Reform Monitoring Survey and “Health Insurance Marketplace: Summary Enrollment the Georgetown Center for Children and Families Report for the Initial Annual Open Enrollment Period,” (September 2014), available at http://hrms.urban.org/ (May 1, 2014), available at http://aspe.hhs.gov/sites/ briefs/Childrens-Health-Insurance-Coverage-under- default/files/pdf/76876/ib_2014Apr_enrollment.pdf. the-ACA-in-2014.pdf. Note that this estimate provides enrollment from the initial annual open enrollment period (October 2 A. Chester & J. Alker, “Medicaid at 50: A Look at 1, 2013 through March 31, 2014) as well as the the Long-Term Benefits of Childhood Medicaid,” special enrollment period (through April 19, 2014). Georgetown University Center for Children and This number does not account for the final counts of Families (July 2015), available at http://ccf. effectuated enrollment which is likely lower. georgetown.edu/wp-content/uploads/2015/08/ Medicaid-at-50_final.pdf. 6 G. Kenney, et al., “Children Eligible for Medicaid or CHIP: Who Remains Uninsured, and Why?” Academic 3 Unless otherwise indicated, all data is from Pediatrics 15, no: 3: S36-S43 (2015). Georgetown CCF analysis of U.S. Census Bureau American Community Survey (ACS) data 2014 single 7 Four states moved children from CHIP to Medicaid year estimates. In previous years we have done prior to the change in law (California, Colorado, New a two-year look at coverage changes to account Hampshire, and New York). Some of the remaining 14 for longer trend impacts. This year, because of states moved children during 2014. the dramatic changes that occurred in 2014, we 8 W. Prater & J. Alker, “Aligning Eligibility For Children: compared 2013 to 2014. Except where noted, Moving the Stairstep Kids to Medicaid,” Kaiser reported differences for estimates are statistically Commission on Medicaid and the Uninsured and the significant at the 90 percent confidence interval. Georgetown Center for Children and Families (August 4 J. Alker & A. Chester, “Children’s Coverage at A 2013), available at http://ccf.georgetown.edu/wp- Crossroads: Progress Slows,” Georgetown University content/uploads/2013/08/stair-step.pdf. Center for Children and Families (October 2014), available at http://ccf.georgetown.edu/wp-content/ uploads/2014/10/Childrens-Coverage-at-a- Crossroads.pdf. 12 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 9 Florida had the highest premiums for children in this 14 L. Dubay & G. Kenney, “Expanding Public Health income range. For more information on premium levels Insurance to Parents: Effects on Children’s Coverage in 2013, see T. Brooks, et al., “Getting Into Gear for under Medicaid,” HSR: Health Services Research, vol. 2014: Findings From a 50-State Survey of Eligibility, 38: 1283-1302 (2003). Enrollment, Renewal and Cost-Sharing Policies in 15 The 27 states that expanded Medicaid have a Medicaid and CHIP, 2012-2013,” Kaiser Commission population of 38.7 million children and the 24 states on Medicaid and the Uninsured and the Georgetown that have not expanded Medicaid have a population of Center for Children and Families (January 2013), 34.8 million children. States that expanded Medicaid available at http://kff.org/medicaid/report/getting- also have a smaller population of uninsured children into-gear-for-2014-findings-from-a-50-state-survey- than non-expansion states (1.8 million compared to of-eligibility-enrollment-renewal-and-cost-sharing- 2.6 million). policies-in-medicaid-and-chip-2012-2013/. 10 Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services, “Financial Condition and Health Care Burdens of People in Deep Poverty,” (July 16, 2015), available at http://aspe.hhs.gov/basic-report/financial- condition-and-health-care-burdens-people-deep- poverty. 11 According to the Census Bureau, direct purchase is “insurance purchased directly from an insurance company.” There is no current option on the American Community Survey for respondents to select state- based or federally facilitated exchange coverage. 12 For last year’s report, please refer to S. Schwartz, et al., “Hispanic Children’s Coverage: Steady Progress, but Disparities Remain,” Georgetown Center for Children and Families and the National Council of La Raza (November 2014), available at http://ccf. georgetown.edu/wp-content/uploads/2014/11/ HispanicChildrensCoverage.pdf. 13 For the purpose of this analysis, the 27 states that expanded Medicaid are Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia. A few of these state covered adults before they began receiving the enhanced match in 2014. Wisconsin is not included as an expansion states as they don’t accept the enhanced match. Medicaid enrollment in Michigan (4/1/14) and New Hampshire (8/15/14) began after January 1, 2014. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 13 Methodology Data Source number of uninsured children. Percent change This brief analyzes single year estimates is useful to analyze the extent to which a state of summary data from the 2013 and 2014 reduced its number of uninsured children, American Community Survey (ACS). The U.S. regardless of their size. Compare this to the Census Bureau publishes ACS summary data percentage point change which measures the on American Fact Finder. Where only number change in the rate of uninsurance from 2013 estimates are available, percent estimates to 2014. For example, the United States saw and their standard errors were computed a 1.1 percentage point change in the rate of based on formulas provided in the 2014 ACS’s uninsured children, from 7.1 percent in 2013 to “Instructions for Applying Statistical Testing 6.0 percent in 2014. to ACS 1-Year Data.” All tests for statistical Geographic Location significance use 90 percent confidence intervals. Except where noted, reported We report regional data for the U.S. as defined differences of rate or number estimates (either by the Census Bureau. The ACS produces between groups, coverage sources, or years) single year estimates for all geographic areas are statistically significant. This year’s report with a population of 65,000 or more, which provides estimates over a 1-year time period, includes all regions, states (including D.C.), and as opposed to our previous reports, which county and county equivalents. Urban areas provided estimates over a 2-year time period. are territories with a population greater than 50,000 people or densely developed territories Margin of Error and State Rank with 2,500 to 50,000 people. Rural areas are all The Census provides the 90 percent margin of those territories outside urban areas. error (potential error bounds for any given data Poverty Status point). CCF does not take margin of error into account when ranking states by the number Data on poverty levels include only those and percent of uninsured children by state. individuals for whom the poverty status can be determined for the last year. Therefore, this Percent Change population is slightly smaller than the total Percent change measures differences relative non-institutionalized population of the U.S. (the to the size of what is being measured. In universe used to calculate all other data in the this report, percent change refers to change brief). The Census determines an individual’s in uninsured children from 2013 to 2014 poverty status by comparing their income in compared to the original population of the last 12 months to poverty thresholds that uninsured children in 2013. For example, from account for family size and composition, as 2013 to 2014, the number of uninsured children well as various types of income. in the United States declined by 838,000 Health Coverage children—from 5,234,332 in 2013 to 4,396,536 in 2014. To measure percent change, we take Data on sources of health insurance coverage the change (-837,796) and divide by the original are point-in-time estimates that convey population (5,234,332 uninsured children in whether a person has coverage at the time of 2013). The US saw a 16 percent decline in the the survey. Individuals can report more than 14 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 one source of coverage, as such totals may We report “Hispanic or Latino,” as “Hispanic.” add to more than 100 percent. Additionally, As this refers to a person’s ethnicity, Hispanic the estimates are not adjusted to address the and non-Hispanic individuals may be of any Medicaid undercount often found in surveys, race. We report data for both “white” children which may be accentuated by the absence of and “white non-Hispanic children.” The former state-specific health insurance program names refers to all children whose race is reported in the ACS. as white, without regard to their ethnicity; the latter category refers to children who reported We report children covered by “other” source their race as white and do not report their of health coverage as children covered by ethnicity as Hispanic. For more detail on how Medicare, TRICARE/military, VA, and two or the ACS defines racial and ethnic groups see more types of health insurance. The Census “American Community Survey and Puerto Rico Bureau provides the following categories of Community Survey 2014 Subject Definitions.” coverage for respondents to indicate source of health insurance: current or former employer, Medicaid Expansion Analysis purchased directly from an insurance company, For the purpose of this analysis, the 27 Medicare, Medicaid or means-tested (includes states that expanded Medicaid are Arizona, CHIP), TRICARE or other military health Arkansas, California, Colorado, Connecticut, coverage, VA, Indian Health Service (IHS), Delaware, District of Columbia, Hawaii, Illinois, or other. People who indicate IHS as their Iowa, Kentucky, Maryland, Massachusetts, only source of health coverage do not have Michigan, Minnesota, Nevada, New Hampshire, comprehensive coverage and are considered New Jersey, New Mexico, New York, North uninsured. Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia. A few of Demographic Characteristics these state covered adults before they began “Children” are defined as those under the age receiving the enhanced match in 2014. of 18. Wisconsin is not included as an expansion In the brief we report data for all seven race states as they don’t accept the enhanced categories and two ethnicity categories for match. which the ACS provides one-year health The rate of uninsurance in Medicaid expansion insurance coverage estimates. The U.S. states is calculated by dividing the number of Census Bureau recognizes and reports race uninsured children living in Medicaid expansion and Hispanic origin (i.e., ethnicity) as separate states by the number of children living in and distinct concepts. Medicaid expansion states. The same method To report on an individual’s race, we merge the is used to determine the rate of uninsurance in data for “Asian alone” and “Native Hawaiian 24 non-expansion states. 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. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 15 Appendix Table 1. Number of Uninsured 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 5,234,332 - 4,396,536 - Alabama 48,181 22 42,422 24 Alaska 21,842 13 21,252 13 Arizona 191,760 47 161,854 47 Arkansas 39,259 19 34,079 19 California 673,208 50 497,090 50 Colorado 102,149 39 70,084 32 Connecticut 33,655 17 28,870 17 Delaware 9,088 4 11,652 8 District of Columbia 2,630 1 2,385 1 Florida 445,035 49 377,987 49 Georgia 238,051 48 189,035 48 Hawaii 9,335 5 9,552 5 Idaho 38,017 18 33,777 18 Illinois 125,351 41 99,502 39 Indiana 130,004 42 113,495 42 Iowa 29,755 16 23,234 15 Kansas 44,130 21 39,411 23 Kentucky 59,530 26 43,298 26 Louisiana 63,312 28 57,531 28 Maine 15,386 10 16,292 11 Maryland 59,285 25 42,595 25 Massachusetts 21,079 12 21,311 14 Michigan 89,941 33 83,254 36 Minnesota 71,982 29 49,017 27 Mississippi 56,149 24 38,832 21 Missouri 97,546 36 99,972 40 Montana 22,495 14 18,421 12 Nebraska 25,379 15 24,795 16 Nevada 98,509 37 63,732 31 New Hampshire 10,261 6 11,701 9 New Jersey 112,117 40 91,842 38 New Mexico 43,105 20 36,402 20 New York 170,783 46 137,525 45 North Carolina 144,194 44 119,078 43 North Dakota 12,725 8 11,542 7 Ohio 141,368 43 126,139 44 Oklahoma 95,042 35 82,251 35 Oregon 50,172 23 39,033 22 Pennsylvania 147,303 45 139,117 46 Rhode Island 11,564 7 7,107 3 South Carolina 72,595 30 59,983 30 South Dakota 13,122 9 11,912 10 Tennessee 85,287 32 77,613 34 Texas 888,305 51 783,938 51 Utah 84,891 31 84,768 37 Vermont 3,882 2 2,640 2 Virginia 101,251 38 107,102 41 Washington 94,795 34 74,927 33 West Virginia 20,305 11 11,437 6 Wisconsin 61,288 27 57,611 29 Wyoming 7,934 3 8,137 4 Note: CCF does not take margin of error into account when ranking states by the number of uninsured children. 16 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Appendix Table 2. Percent of Uninsured Children Under 18, 2013 and 2014 2013 Percent 2013 State Ranking in 2014 Percent 2014 State Ranking in State Uninsured Percent of Uninsured Uninsured Percent of Uninsured United States 7.1 - 6.0 - Alabama 4.3 10 3.8 12 Alaska 11.6 48 11.4 51 Arizona 11.9 49 10.0 49 Arkansas 5.5 20 4.8 21 California 7.4 36 5.4 29 Colorado 8.2 39 5.6 32 Connecticut 4.3 10 3.7 11 Delaware 4.5 13 5.7 33 District of Columbia 2.4 2 2.1 2 Florida 11.1 47 9.3 46 Georgia 9.6 44 7.6 42 Hawaii 3.0 3 3.1 5 Idaho 8.9 42 7.8 43 Illinois 4.2 9 3.3 8 Indiana 8.2 39 7.2 39 Iowa 4.1 8 3.2 6 Kansas 6.1 31 5.5 30 Kentucky 5.9 28 4.3 15 Louisiana 5.7 24 5.2 23 Maine 5.9 28 6.3 37 Maryland 4.4 12 3.2 6 Massachusetts 1.5 1 1.5 1 Michigan 4.0 6 3.8 12 Minnesota 5.6 22 3.8 12 Mississippi 7.6 37 5.3 27 Missouri 7.0 35 7.2 39 Montana 10.1 46 8.2 44 Nebraska 5.5 20 5.3 27 Nevada 14.9 51 9.6 48 New Hampshire 3.8 5 4.4 16 New Jersey 5.6 22 4.6 18 New Mexico 8.5 41 7.3 41 New York 4.0 6 3.3 8 North Carolina 6.3 32 5.2 23 North Dakota 7.9 38 6.9 38 Ohio 5.3 15 4.8 21 Oklahoma 10.0 45 8.7 45 Oregon 5.8 27 4.6 18 Pennsylvania 5.4 17 5.2 23 Rhode Island 5.4 17 3.3 8 South Carolina 6.7 34 5.5 30 South Dakota 6.3 32 5.7 33 Tennessee 5.7 24 5.2 23 Texas 12.6 50 11.0 50 Utah 9.5 43 9.4 47 Vermont 3.1 4 2.2 3 Virginia 5.4 17 5.7 33 Washington 5.9 28 4.7 20 West Virginia 5.3 15 3.0 4 Wisconsin 4.7 14 4.4 16 Wyoming 5.7 24 5.9 36 Note: CCF does not take margin of error into account when ranking states by the percent of uninsured children.. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 17 Appendix Table 3. Change in the Number of Uninsured Children Under 18, 2013 and 2014 2013 Number 2014 Number 2013-2014 Change 2013-2014 State Uninsured Uninsured in Number of Uninsured Percent Change United States 5,234,332 4,396,536 -837,796* -16.0 California 673,208 497,090 -176,118* -26.2 Texas 888,305 783,938 -104,367* -11.7 Florida 445,035 377,987 -67,048* -15.1 Georgia 238,051 189,035 -49,016* -20.6 Nevada 98,509 63,732 -34,777* -35.3 New York 170,783 137,525 -33,258* -19.5 Colorado 102,149 70,084 -32,065* -31.4 Arizona 191,760 161,854 -29,906* -15.6 Illinois 125,351 99,502 -25,849* -20.6 North Carolina 144,194 119,078 -25,116* -17.4 Minnesota 71,982 49,017 -22,965* -31.9 New Jersey 112,117 91,842 -20,275* -18.1 Washington 94,795 74,927 -19,868* -21.0 Mississippi 56,149 38,832 -17,317* -30.8 Maryland 59,285 42,595 -16,690* -28.2 Indiana 130,004 113,495 -16,509* -12.7 Kentucky 59,530 43,298 -16,232* -27.3 Ohio 141,368 126,139 -15,229* -10.8 Oklahoma 95,042 82,251 -12,791* -13.5 South Carolina 72,595 59,983 -12,612* -17.4 Oregon 50,172 39,033 -11,139* -22.2 West Virginia 20,305 11,437 -8,868* -43.7 Pennsylvania 147,303 139,117 -8,186 -5.6 Tennessee 85,287 77,613 -7,674 -9.0 New Mexico 43,105 36,402 -6,703* -15.6 Michigan 89,941 83,254 -6,687 -7.4 Iowa 29,755 23,234 -6,521* -21.9 Louisiana 63,312 57,531 -5,781 -9.1 Alabama 48,181 42,422 -5,759 -12.0 Arkansas 39,259 34,079 -5,180 -13.2 Connecticut 33,655 28,870 -4,785 -14.2 Kansas 44,130 39,411 -4,719 -10.7 Rhode Island 11,564 7,107 -4,457* -38.5 Idaho 38,017 33,777 -4,240 -11.2 Montana 22,495 18,421 -4,074 -18.1 Wisconsin 61,288 57,611 -3,677 -6.0 Vermont 3,882 2,640 -1,242 -32.0 South Dakota 13,122 11,912 -1,210 -9.2 North Dakota 12,725 11,542 -1,183 -9.3 Alaska 21,842 21,252 -590 -2.7 Nebraska 25,379 24,795 -584 -2.3 District of Columbia 2,630 2,385 -245 -9.3 Utah 84,891 84,768 -123 -0.1 Wyoming 7,934 8,137 203 2.6 Hawaii 9,335 9,552 217 2.3 Massachusetts 21,079 21,311 232 1.1 Maine 15,386 16,292 906 5.9 New Hampshire 10,261 11,701 1,440 14.0 Missouri 97,546 99,972 2,426 2.5 Delaware 9,088 11,652 2,564 28.2 Virginia 101,251 107,102 5,851 5.8 * indicates that the percentage point change is significant at the 90% confidence level. 18 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Appendix Table 4. Change in the Percent of Uninsured Children Under 18, 2013 and 2014 2013 Percent 2014 Percent 2013-2014 2013-2014 State Uninsured Uninsured Percentage Point Change Ranking United States 7.1 6.0 -1.1* Nevada 14.9 9.6 -5.3* 1 Colorado 8.2 5.6 -2.6* 2 West Virginia 5.3 3.0 -2.3* 3 Mississippi 7.6 5.3 -2.3* 3 Rhode Island 5.4 3.3 -2.1* 5 Georgia 9.6 7.6 -2.0* 6 California 7.4 5.4 -1.9* 7 Arizona 11.9 10.0 -1.9* 7 Montana 10.1 8.2 -1.9 7 Minnesota 5.6 3.8 -1.8* 10 Florida 11.1 9.3 -1.7* 11 Texas 12.6 11.0 -1.6* 12 Kentucky 5.9 4.3 -1.6* 12 Oklahoma 10.0 8.7 -1.4* 14 Oregon 5.8 4.6 -1.3* 15 Washington 5.9 4.7 -1.3* 15 Maryland 4.4 3.2 -1.3* 15 New Mexico 8.5 7.3 -1.2 18 South Carolina 6.7 5.5 -1.2* 18 North Carolina 6.3 5.2 -1.1* 20 Idaho 8.9 7.8 -1.1 20 North Dakota 7.9 6.9 -1.0 22 Indiana 8.2 7.2 -1.0* 22 New Jersey 5.6 4.6 -1.0* 22 Vermont 3.1 2.2 -1.0 22 Iowa 4.1 3.2 -0.9* 26 Illinois 4.2 3.3 -0.8* 27 New York 4.0 3.3 -0.8* 27 Arkansas 5.5 4.8 -0.7 29 Kansas 6.1 5.5 -0.7 29 South Dakota 6.3 5.7 -0.6 31 Connecticut 4.3 3.7 -0.6 31 Ohio 5.3 4.8 -0.6* 31 Louisiana 5.7 5.2 -0.5 34 Alabama 4.3 3.8 -0.5 34 Tennessee 5.7 5.2 -0.5 34 District of Columbia 2.4 2.1 -0.3 37 Pennsylvania 5.4 5.2 -0.3 37 Michigan 4.0 3.8 -0.3 37 Wisconsin 4.7 4.4 -0.3 37 Alaska 11.6 11.4 -0.2 41 Nebraska 5.5 5.3 -0.2 41 Utah 9.5 9.4 -0.1 43 Massachusetts 1.5 1.5 0.0 44 Hawaii 3.0 3.1 0.1 45 Missouri 7.0 7.2 0.2 46 Wyoming 5.7 5.9 0.2 46 Virginia 5.4 5.7 0.3 48 Maine 5.9 6.3 0.4 49 New Hampshire 3.8 4.4 0.6 50 Delaware 4.5 5.7 1.3 51 * indicates that the percentage point change is significant at the 90% confidence level. Note: CCF does not take margin of error into account when ranking states by the percentage point change of uninsured children. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 19 Appendix Table 5: Children’s Coverage Source by Income Source of Coverage** Percent of federal Medicaid/CHIP Direct-purchase ESI Uninsured poverty level (FPL) 2013 2014 2013 2014 2013 2014 2013 2014 Under 100% FPL 79.8% 81.5%* 3.2% 3.4% 10.9% 10.8% 8.9% 7.3%* 100-199% FPL 55.5% 57.4%* 5.2% 5.5% 31.9% 31.4% 10.7% 9.0%* 100-137% FPL 66.5% 68.3%* 4.2% 4.7%* 22.0% 21.9% 10.7% 8.9%* 138-199% FPL 47.7% 49.8%* 5.9% 6.1% 39.0% 38.2%* 10.6% 9.0%* 200-299% FPL 25.8% 27.4%* 7.9% 8.3%* 60.2% 59.5%* 8.1% 7.1%* 300% FPL and above 7.8% 8.3%* 8.8% 8.9% 81.2% 81.2% 3.6% 3.0%* * Change is significant at the 90% confidence level. ** Individuals can report more than one source of coverage, as such totals may add to more than 100 percent. Appendix Table 6: Top Twenty Counties with the Highest Number of Uninsured Children, 2014* Geographic Number of County Rank by Highest Region Uninsured Children Number of Uninsured Children Harris County, Texas 143,320 1 Los Angeles County, California 131,339 2 Maricopa County, Arizona 92,551 3 Dallas County, Texas 90,103 4 Riverside County, California 54,554 5 Tarrant County, Texas 51,281 6 San Diego County, California 49,440 7 Miami-Dade County, Florida 48,192 8 Clark County, Nevada 47,679 9 Cook County, Illinois 43,118 10 Broward County, Florida 40,957 11 Hidalgo County, Texas 38,811 12 Bexar County, Texas 38,514 13 Orange County, California 36,094 14 San Bernardino County, California 32,622 15 Salt Lake County, Utah 32,003 16 Orange County, Florida 31,840 17 Palm Beach County, Florida 28,673 18 Travis County, Texas 27,770 19 Gwinnett County, Georgia 23,898 20 * One-fourth or 24.6 percent of all uninsured children live in these 20 counties. 20 CHILDREN’S HEALTH COVERAGE CCF.GEORGETOWN.EDU October 2015 Appendix Table 7: A Disproportionate Share of Uninsured Children Live in the South Region Child Share of the Number of Share of Nation’s Population Population Uninsured Children Uninsured Children Midwest 15,666,085 21.3% 739,884 16.8% Northeast 11,936,899 16.3% 456,405 10.4% South 28,029,138 38.2% 2,081,218 47.3% West 17,808,151 24.2% 1,119,029 25.5% Total 73,440,272 100.0% 4,396,536 100.0% Midwest - IA, IN, IL, KS, MI, MN, MO, NE, ND, OH, SD, WI Northeast - CT, ME, MA, NH, NJ, NY, PA, RI, VT South – AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV West – AZ, AK, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY The authors would like to thank Atlantic Center for Children and Families Philanthropies and the David and Lucile Health Policy Institute Packard Foundation for their support of our Georgetown University work. We would also like to thank Cathy Box 571444 Hope, Jordan Messner, Sarah Koslov and 3300 Whitehaven Street, NW, Suite 5000 Sean Miskell at CCF for their assistance with Washington, DC 20057-1485 this project. A very special thanks to Matt Phone (202) 687-0880 Broaddus from the Center on Budget and Email childhealth@georgetown.edu Policy Priorities for commenting on an earlier version of this paper. Design and layout assistance was provided by Nancy Magill. ccf.georgetown.edu/blog/ The Center for Children and Families (CCF) facebook.com/georgetownccf is an independent, nonpartisan policy and research center whose mission is to expand twitter.com/georgetownccf and improve health coverage for America’s children and families. CCF is based at Georgetown University’s McCourt School of Public Policy. October 2015 CCF.GEORGETOWN.EDU CHILDREN’S HEALTH COVERAGE 21